Could Robotic-Assisted Surgery Reduce Complications for Endometrial Cancer Patients?

A national introduction of minimally invasive robotic surgery (MIRS) for hysterectomy for the treatment of endometrial cancer in Denmark greatly increased the proportion of women opting for a minimally invasive procedure, according to the results of a study.

Use of minimally invasive surgery (MIS) resulted in significantly reduced risk for severe complications, according to study researcher Siv Lykke Jørgensen, MD, of Odense University Hospital in Denmark, and colleagues. These results were published in JAMA Surgery.

“The reduction in the number of severe complications was observed despite a higher proportion of women with an older age, a high American Society of Anesthesiologists score, high-risk histopathologic characteristics, and intra-abdominal adhesions being offered MIS and a higher proportion of women undergoing staging lymphadenectomy,” they wrote.

The study took advantage of the national introduction of MIRS in Denmark. It included 5,654 women with early-stage endometrial cancer who had undergone surgery before the introduction of MIRS to their region (group 1, n = 3,091), and those who underwent surgery after the introduction of MIRS (group 2, n = 2,563).

“Minimally invasive laparoscopic surgery [MILS] was accessible throughout the study period, whereas MIRS was gradually implemented between 2008 and 2013 in all cancer centers,” the researchers noted.

Nationwide use of MIS increased from 3% in 2005 to 95% in 2015. Prior to the introduction of robotic surgery, 14.1% of women had opted for a minimally invasive approach. Among patients in group 2, 22.2% opted for MILS, and 50% opted for MIRS.

Among patients in group 2, the use of a total abdominal hysterectomy increased the odds of severe complications more than twofold compared with MILS (odds ratio [OR], 2.58; 95% CI, 1.80–3.70) and more than threefold compared with MIRS (OR, 3.87; 95% CI, 2.52–5.93). No differences in severe complications were found between the two minimally invasive approaches.

Women who underwent surgery as part of group 1 had about a 40% increased risk for severe complications compared with women in group 2 (OR, 1.39; 95% CI, 1.11–1.74).

In an editorial that accompanied the study, Jason D. Wright, MD, of Columbia University College of Physicians and Surgeons, Fady Khoury-Collado, MD, of Herbert Irving Comprehensive Cancer Center at Columbia University, and Alexander Melamed, MD, MPH, of Massachusetts General Hospital, pointed out caveats to consider alongside the results of this study.

First, the study does not answer if robotically assisted surgery is required to increase the use of MIS.

“To determine the association of a robotic platform with the use of MIS, an experimental group in which robotically assisted surgery was introduced should be compared with a control group in which robotically assisted surgery was not adopted,” they wrote.

Second, care for patients with endometrial cancer was centralized in Denmark to only 6 centers, suggesting that the improvement in outcomes could also be related to “regionalizing care to experienced surgeons in high-volume centers as opposed to the rollout of a surgical robot,” they noted.

“Regardless, Jørgensen and colleagues have demonstrated that increasing the rate of minimally invasive hysterectomy can improve outcomes for women undergoing hysterectomy for early-stage endometrial cancer,” they wrote. “Going forward, the use of MIS for early-stage endometrial cancer should be an important quality metric. Programs to promote access to MIS, whether laparoscopic or robotically assisted, should be a priority for women with endometrial cancer.”