What you need to know about laparoscopic surgery for endometrial cancer

February 1, 2007
Brian M. Slomovitz, MD

DR. SLOMOVITZ is Assistant Professor, Obstetrics and Gynecology, Division of Gynecologic Oncology, Weill Medical College of Cornell University, New York Presbyterian Hosital, New York, N.Y.

,
Pedro T. Ramirez, MD

DR. RAMIREZ is Associate Professor and Director of Minimally Invasive Surgical Research and Education, Department of gynecologic Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Tex.

A laparoscopic procedure is an option for many women with endometrial cancer. Here, two expert gynecologic oncologists tell you what the surgery involves and how to select patients for referral.

By the time you read this, endometrial cancer will have claimed the lives of more than 7,000 women in the United States in 2006 and more than 41,000 will have been diagnosed with the disease.1 It's the most common gynecologic malignancy in this country. The good news is that most patients present with early-stage disease, and the 5-year overall survival rate is about 85%.

Laparoscopic surgery is an emerging option, and one that offers appropriately selected patients with endometrial cancer a less invasive procedure, shorter hospitalization, earlier return of bowel function and resumption of a normal diet, and a faster recovery. This article will review the evidence for taking a laparoscopic approach to endometrial cancer, give you a look at the procedure itself, and help you understand for which patients it's best suited, based on potential risks, outcomes, and costs.

It's been more than a decade since Childers and colleagues published the first report of laparoscopic treatment of endometrial cancer in the US.7 They used the technique on 59 women whose disease was deemed to be confined to the uterus based on clinical evaluation. Six of the patients were found to have intraperitoneal disease and did not undergo laparoscopic staging. All but one of the 53 remaining women underwent laparoscopic-assisted vaginal hysterectomy (LAVH). Of that group, 29 patients also underwent laparoscopic lymphadenectomy, and it was successful in 27 (93%). The authors reported a mean estimated blood loss of less than 200 mL and a mean hospital stay of 2.9 days. Since that first report, several other centers have reported success with laparoscopic surgery in patients with endometrial cancer.8-11

Considerations in patient selection

Several newer studies have examined the impact of patient characteristics on outcomes after laparoscopic surgery for endometrial cancer. [Some physicians may feel that laparoscopy is inappropriate for women who are older, obese, or nulliparous. Recent data, however, tell a different story.

Age. Older women who undergo laparotomy for endometrial cancer are more likely to have surgical and medical complications that require extended hospitalization and other procedures than are younger women who have the surgery.12 The same is not true, however, for laparoscopic hysterectomy,] as demonstrated by O'Hanlan and colleagues with a retrospective study.13 They evaluated the impact of age on surgical outcomes in young, middle-aged, and senior patients. Blood loss, mean lengths of hospital stay, and complication rates after total laparoscopic hysterectomy (TLH) were similar in the three groups.

Obesity. Being overweight is the predisposing factor associated with the greatest risk for developing endometrial cancer, so it traditionally has been considered a potential contraindication to laparoscopic surgery. But two recent studies suggest that obese patients can safely undergo laparoscopic surgery for endometrial cancer.

The first study, by Heinberg and colleagues, was a retrospective estimation of risk of operative and postoperative complications for obese and nonobese patients undergoing TLH.14 The authors found no statistically significant difference between the rate of successful completion of TLH in obese patients (90%) versus those who were not obese (96%). The surgery was 60% more likely to take at least 2 hours and involve blood loss of more than 500 mL in obese patients. Yet the risks of major and minor complications, hospital readmission, and reoperation were similar for the two groups.