Page 27 - Journal of Laparoscopic Surgery

WJOLS

Advances in Minimal Access Surgery in the Surgical Staging of Carcinoma Endometrium

Lowe et al report that the learning curve for robotic N = 23) were compared with historical controls selected from
hysterectomy with pelvic and aortic node dissection lies between consecutive women who have had staging with conventional
9 and 20 cases. 19 laparoscopy (N = 80).
No difference was found in demographics and preoperative
Cost Analysis
variables between the two groups. Conversion from
With regard to costs, there has been one article to date microlaparoscopy to a conventional laparoscopic technique
comparing robotic, open and laparoscopic procedures to occurred in two cases (9.7%), while there was no conversion to
surgically stage endometrial cancer. In that report, the cost of open surgical staging in either group. There were no significant
the robotic system was included in the cost analysis for robotic differences between the microlaparoscopy group and the control
surgery. Interestingly, there was no statistically significant group with regard to estimated blood loss [100 (10-400) vs
difference in costs between robotic and laparoscopic approach 100 (10-400), p = 0.09], number of pelvic lymph nodes (19.2 ±
(p < 0.06). Both minimally invasive approaches cost significantly 7.4 vs 18. 6 ± 7.2, p = 0.79) and complication rate (intraoperative:
less than an open approach (p < 0.001). However, robotics was 0 vs 2.5%, p = 1.0; postoperative: 8.7 vs 13.7%, p = 0.73). Operative
associated with less perioperative morbidity and quicker return time was similar between groups when analysis was restricted
to normal activity. 38 to the last 20 conventional procedures performed period prior
to beginning of the microlaparoscopy trial [155 (110-300) vs
Uterine Manipulation 160 (115-295), p = 0.17]. The median length of hospital stay was
Regarding uterine manipulation in laparoscopic hysterectomy, 2 (1-10) days for women undergoing microlaparoscopic
there are conflicting reports. procedures compared to 3 (1-15) days for those undergoing
Querleu et al reported three patients with stage I, noninvasive conventional laparoscopy (p = 0.001).
or superficially invasive endometrial cancer with vaginal cuff These preliminary results suggest that microlaparoscopy is
recurrence within 9 months of treatment. They raised the concern a safe and adequate surgical option for endometrial cancer
that the obligatory use of a vaginal manipulator at the time of staging with the potential to further decrease invasiveness of
surgery may lead to antegrade and retrograde dispersal of tumor the conventional laparoscopic approach. 43
cells with subsequent vaginal cuff and peritoneal metastasis.
No evidence exists to link vaginal recurrence with the use of DISCUSSION
uterine manipulators or with the omission of tubal occlusion. 39 The role of minimally invasive surgical staging in the
Sonoda et al showed that the treatment of low-risk management of patients with apparent early endometrial cancer
endometrial cancer by laparoscopy is associated with a continues to evolve. From the above-mentioned review of
significantly higher incidence of positive peritoneal cytology literature, it is evident that comprehensive surgical staging of
when compared with patients operated by laparotomy. The use endometrial cancer can be performed using laparoscopy without
of an intrauterine manipulator is not necessarily required to increased intraoperative injuries, with fewer postoperative
perform an adequate laparoscopic-assisted procedure and could complications, and with shorter hospital stay. This makes
prevent the retrograde dissemination of cancer cells into the attempting laparoscopy, when assumed to be feasible, worth
peritoneal cavity during uterine manipulation. 40 the extraoperative time and surgeon training. The long-term
Gamal H Eltabakh et al in a prospective study of laparoscopic results comparing recurrence-free survival, overall survival and
surgical staging of clinical stage 1 endometroid endometrial quality of life are also promising. With the advent of robotic
carcinoma using Pelosi uterine manipulator have reported that surgery, the limitations of the laparoscopic approach is presumed
it does not increase the incidence of positive peritoneal to be overcome.
cytology. 41 The conversion rate to laparotomy is less frequent for those
patients undergoing the robotic approach when compared to
Portsite Metastasis laparoscopy, despite a significantly higher BMI. In addition,
The incidence of portsite metastasis treated by total the operating room times, length of hospital stay, blood loss
laparoscopic hysterectomy is low. Andreas Obermair et al have and transfusion rates were significantly reduced in the robotic
reported that on a median follow-up of 29.4 months, no port- cohort. Therefore, it appears that the robotics platform may
site metastasis was seen in 215 patients treated with laparoscopy. offer significant advantages over laparoscopy in the
The disease-free survival was statistically comparable to comprehensive surgical management of endometrial cancer. The
284 laparotomy treated controls. 42 three-dimensional, magnified images combined with wristed
instrumentation, tremor filtration and motion scaling allow the
Microlaparoscopy in Surgical Staging of surgeon to recapitulate open surgery. The counterintuitive
Carcinoma Endometrium motions encountered in conventional laparoscopy are
Consecutive patients undergoing surgical staging of eliminated and these advantages are readily apparent even to
endometrial cancer using exclusively 3 mm working ports and a the advanced laparoscopic gynecologic oncologist. The
3 or 5 mm laparoscope at the umbilicus (microlaparoscopy group; robotics platform is associated with a shorter learning curve.

World Journal of Laparoscopic Surgery, September-December 2011;4(3):149-155 153