Surgical method
EC surgical staging including pelvic and paraaortic LND can be conducted
by minimally invasive surgery (MIS) or open
laparotomy(49). MIS has been associated with less
complications with a reported overall rate of 7%(49).
However, extent of LND was unreported in all arms of this study, a
potentially significant confounder(49). The other
benefits of MIS are well documented such as shorter hospital stay and
faster recuperation than laparotomy(46,50), as
recommended by ESMO-ESGO-ESTRO 2016 (Table 3) and further supported by a
recent RCT(46). Open laparotomy now tends to be used
in EC patients with increased complexity including obese patients, G3
and G4 tumours and higher uterine weight(51).
MIS is inclusive of robotic and laparoscopic surgery. Despite the safety
and feasibility of robotic surgery becoming widely accepted, it
represents a recent technology with reduced user
experience(52). Looking at various parameters of
patient outcome, there are limitations such as increased cost and
operative time(51,52), a factor very much dependent on
the surgeon’s experience.
Robotic surgery is found to have a significantly reduced learning curve
compared to laparoscopy and improved intraoperative and major
complications(50). This is however opposed by multiple
studies displaying no difference in complications between the different
surgical techniques(52,53). A retrospective cohort
study did demonstrate however, reduced urinary tract injuries in the
robotic patient group despite the same overall rate of intra- and
postoperative complications(52). Despite these
findings, the study did not place enough attention on long-term health
parameters such as return to work, quality of life and
OS(52). Comparing robotic and laparoscopic conversion
to open laparotomy, there are mixed findings. Some studies find a lower
rate of conversion for robotic(50,52,54) but other
retrospective studies found laparoscopy to have lower
rates(51) or no difference between the surgical
methods(53).
Thirty-day readmissions rates between methods were
similar(51,52). However, readmission rates outside of
the primary hospital were unknown(51). Robotic surgery
is widely associated with shorter hospital stay and blood
loss(50,52,55). Reduced pain may factor into the lower
hospital stay allowing patients to be mobilised
faster(55). In multiple studies, the reduced blood
loss was not clinically significant because blood transfusion rates were
unaffected(50,52,55). Yet one of these studies
suggested that the reduced blood loss could reflect decreased
complications and increased ability to deal with difficult
anatomy(55).
In summary due to the variations in morbidity(49),
further review of minimally invasive LND surgical methods is needed.