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Minimally invasive comprehensive surgical staging for endometrial cancer:
Robotics or laparoscopy?

Leigh G.Seamon
a
,David E.Cohn
a
,Melissa S.Henretta
a
,Kenneth H.Kim
a
,Matthew J.Carlson
a
,
Gary S.Phillips
b
,Jeffrey M.Fowler
a,

a
The Division of Gynecologic Oncology,Department of Obstetrics and Gynecology,The Ohio State University College of Medicine,Columbus,OH,USA
b
Center for Biostatistics,The Ohio State University College of Medicine,Columbus,OH,USA
a b s t r a c ta r t i c l e i n f o
Article history:
Received 1 November 2008
Available online xxxx
Keywords:
Robotic surgery
Laparoscopy
Hysterectomy
Lymph node dissection
Endometrial cancer
Gynecology
Objective.To compare outcomes between robotic versus laparoscopic hysterectomy and lymphadenect-
omy in patients with endometrial cancer.
Methods.A cohort study was performed by prospectively identifying all patients with clinical stage I or
occult stage II endometrial cancer who underwent robotic hysterectomy and lymphadenectomy from2006–
2008 and retrospectively comparing data using the same surgeons'laparoscopic hysterectomy and
lymphadenectomy cases from 1998–2005,prior to our robotic experience.Patient demographics,operative
times,complications,conversion rates,pathologic results,and length of stay were analyzed.
Results.181 patients (105 robotic and 76 laparoscopic) met inclusion criteria.There was no significant
difference between the two groups in median age,uterine weight,bilateral pelvic or aortic lymph node
counts,or complication rates in patients whose surgeries were completed minimally invasively.Despite a
higher BMI (34 vs.29,Pb0.001),the estimated blood loss (100 vs.250 mL,Pb0.001),transfusion rate (3% vs.
18%,RR 0.18,95%CI 0.05–0.64,P=0.002),laparotomy conversion rate (12% vs.26%,RR 0.47,95%CI 0.25–0.89,
P=0.017),and length of stay (median:1 vs.2 nights,Pb0.001) were lower in the robotic patients compared to
the laparoscopic cohort.The odds ratio of conversion to laparotomy based on BMI for robotics compared to
laparoscopy is 0.20 (95% CI 0.08–0.56,P=0.002).The mean skin to skin time (242 vs.287 min,Pb0.001) and
total room time (305 vs.336 min,Pb0.001) was shorter for the robotic cohort.
Conclusion.Robotic hysterectomyandlymphadenectomyfor endometrial carcinomacanbe accomplishedin
heavier patients and results in shorter operating times and hospital length of stay,a lower transfusion rate,and
less frequent conversion to laparotomy when compared to laparoscopic hysterectomy and lymphadenectomy.
© 2008 Elsevier Inc.All rights reserved.
Introduction
Of approximately 40,100 newcases of endometrial cancer that are
diagnosed this year,the majority will present with apparently early
stage disease [1,2].Surgical management is the mainstay of initial
treatment for most patients and is usually curative.When feasible,
comprehensive surgical staging of endometrial cancer patients has
been shown to define the biology of disease and guides the use of
post-operative adjuvant therapy [3–5].
Since Childers and Surwit first proposed laparoscopy as an option
for apparently early stage endometrial cancer (1993),several others
have published their experience on the feasibility of this approach
[6–17].The reported benefits of a laparoscopic approach are lower
blood loss and transfusion rates,shorter hospital stay,faster post-
operative recovery [3–19],and superior short-term quality of life
[10,11],albeit at the expense of longer operative times.However,
certain surgeon and patient factors contribute to many potential
disadvantages,especially if the goal is comprehensive surgical staging.
Surgeon experience,training and limitations of laparoscopy that
include counterintuitive motion,non-wristed instrumentation and a
heavy reliance on skilled surgical assistance contribute to a difficult
and long learning curve.Comprehensive laparoscopic surgical staging
is more difficult in the morbidly obese and other patient factors such
as associated co-morbidities,adhesive disease,large uteri,fatty
mesentery,and inability to tolerate steep Trendelenberg have limited
widespread use of this approach in endometrial carcinoma [20,21].
Since the da Vinci surgical system(Intuitive Surgical
®
,Sunnydale,
CA) was approved for gynecology in April 2005,the role of robotic-
assisted surgery in gynecologic oncology continues to evolve.While
still in its infancy,the published literature on robotic application to
Gynecologic Oncology xxx (2009) xxx–xxx

Presented in part at the 39th Annual Meeting on Women's Cancer™ Society of
Gynecologic Oncologists,Tampa,Florida and at the 3rd International Congress of the
Minimally Invasive Robotic Association 2008,Rome,Italy.
⁎ Corresponding author.The Ohio State University College of Medicine,M-210
Starling-Loving,320 West Tenth Avenue,Columbus,Ohio 43210-1228,USA.Fax:+1614
293 3078.
E-mail address:jeffrey.fowler@osumc.edu (J.M.Fowler).
YGYNO-972998;No.of pages:6;4C:
0090-8258/$ – see front matter © 2008 Elsevier Inc.All rights reserved.
doi:10.1016/j.ygyno.2008.12.005
Contents lists available at ScienceDirect
Gynecologic Oncology
j our nal homepage:www.el sevi er.com/l ocat e/ygyno
Please cite this article as:Seamon LG et al.Minimally invasive comprehensive surgical staging for endometrial cancer:Robotics or
laparoscopy?.Gynecol Oncol (2009),doi:10.1016/j.ygyno.2008.12.005
ARTICLE IN PRESS
endometrial cancer is minimal [22–28].The objective of this study
was to compare the surgical and pathologic outcomes for two
minimally invasive treatment modalities for endometrial cancer–
robotics and laparoscopy.
Materials and methods
A cohort study was performed by prospectively identifying all
patients with clinical stage I endometrial cancer who underwent
robotic hysterectomy and lymphadenectomy fromJanuary 2006–April
2008 and retrospectively comparing consecutive laparoscopic hyster-
ectomy and lymphadenectomy cases fromJanuary 1998 to December
2005,prior to our robotic experience.All minimally invasive cases
were performed by one of two primary surgeons (J.M.F.and D.E.C.).
The surgical teamconsisted of the primary surgeon,bedside assistant
(fellow or resident),vaginal assistant,and a dedicated minimally
invasive surgical scrub technician and circulating nurse.The protocol
and video for our robotics room set-up,patient positioning,instru-
mentation and port placement are previously described [29].
Regardless of pre-operative grade,our management goal in
endometrial cancer is comprehensive staging either laparoscopically
or robotically with the da Vinci surgical system (Intuitive Surgical
®
,
Sunnydale,CA),when feasible,to include pelvic washings,hyster-
ectomy±bilateral salpingo-oophorectomy,and pelvic±aortic lympha-
denectomy.The boundaries of the pelvic and para-aortic lymph node
dissection are previously described and include to the duodenum on
the right side and to the inferior mesenteric artery on the left [28,29].
The hysterectomies were completed via total robotic,laparoscopic,or
laparoscopic-assisted vaginal approach.
Operative times for all minimally invasive surgeries were recorded
and defined in Table 1.Length of stay was defined as the number of
nights the patient spent in the hospital.Conversionwas defined as any
laparotomy other than extension of a port to remove the specimen.All
operative and post-operative complications were recorded.
The data was analyzed using STATA 10
®
(Stata Corporation,College
Station,Texas) statistical software.Using a normal probability plot,we
assessedthe distributions of the dependent variables.Continuous data
was analyzed using either a two-sample t-test or Wilcoxon rank-sum
test depending on whether or not the data was normally distributed.
Associations across categorical data were tested using either Pearson's
chi-squared or Fisher's exact test depending of the number of
observations in the table cells.Results for continuous data are
shown as medians or means along with the data range and categorical
data are displayed as counts and percentages.Logistic regression was
used to model probability of conversion to laparotomy where the
main risk factor was procedure (laparoscopic vs.robotic) and was
adjusted for subject's body mass index (BMI).Sequence of operation
was included in the model as it confounds the relationship between
conversion and BMI,since the women with lower BMIs were treated
Table 1
Operativetime(minutes) definitions for hysterectomy,pelvicandaorticlymphadenectomy
for endometrial cancer
Patient
entry
The time the patient entered the operating room as recorded on the
OR record
Incision After the patient was prepped and draped,the time recorded on the
OR record as the beginning of the procedure,either with vaginal
instrumentation or incision with a scalpel.
Roomto
incision
Incision (defined above) minus patient entry (defined above)
Completion After all ports are removed and the incisions are closed,the completion
time is the time recorded on the OR record at termination of the
procedure.
Patient exit The time the patient leaves the OR as recorded on the OR record.
Room Patient exit (defined above) minus patient entry (defined above).
Skin Completion (defined above) minus incision (defined above).
OR:Operating room.
Table 2
Patient demographics and pathologic factors for robotic versus laparoscopic hysterectomy and pelvic-aortic lymphadenectomy for endometrial cancer
Robotic N=105 Laparoscopic N=76 P-value
a
Age years,mean (sd) 59 (8.9) 57 (11) 0.098
BMI (kg/m
2
),mean (sd) 34.2 (9) 28.7 (6.9) b0.001
Categorical BMI,%
b30 40 62
30–40 32.4 35.5 b001
b
N40 27.6 2.6
BSA (m
2
),mean (sd) 2 (0.29) 1.8 (0.19) b0.001
Number of previous vaginal deliveries,median (range) 2 (0–6) 2 (0–9) 0.26
c
Number of previous surgeries,%
0 53 55
1 29 27 0.98
b
≥2 18 18
≥2 significant co-morbidities,% 26 17 0.15
b
≥3 significant co-morbidities,% 12 6 0.13
b
Pre-operative grade,%
Grade 1 66 77
Grade 2 22 12 0.242
b
Grade 3 12 11
Tumor size (cm),mean (sd) 3.8 (1.8) 3 (1.5) 0.009
Uterine weight (grams),mean (sd) 132 (64) 133 (60) 0.97
#Aortic lymph nodes,mean (sd) 10 (4.8) 11 (5.3) 0.097
Right 5 (2.9) 5 (3.6)
Left 5 (2.9) 6 (3.8)
#Pelvic lymph nodes,mean (sd) 21 (7.6) 22 (8.4) 0.862
Stage,%
I 87 86
II 3 5 0.814
b
III and IV 10 9
BMI:body mass index,BSA:body surface area,sd:standard deviation.
a
P value based on the two-sample t-test.
b
P value based on Pearson's chi-squared statistic.
c
P value based on Wilcoxon rank-sumtest.
2 L.G.Seamon et al./Gynecologic Oncology xxx (2009) xxx–xxx
Please cite this article as:Seamon LG et al.Minimally invasive comprehensive surgical staging for endometrial cancer:Robotics or
laparoscopy?.Gynecol Oncol (2009),doi:10.1016/j.ygyno.2008.12.005
ARTICLE IN PRESS
earlier in the sequence of robotic operations where the likelihood of
conversion is expected to be higher.
Results
One hundred eighty one patients (105 robotic,76 laparoscopic)
met inclusion criteria and formed the cohort for this study.Of these,
there were 92 patients (88%) in the robotics group and 56 (74%) in the
laparoscopic group whose surgeries where completed without
conversion to laparotomy.Ninety-five percent of the patients in the
robotic group underwent some element of surgical staging which
includes;79 robotic hysterectomy±bilateral salpingo-oophorectomy
(BSO) pelvic and aortic lymphadenectomy,6 robotic hysterectomy±
BSO pelvic lymphadenectomy,2 robotic hysterectomy±BSO pelvic
lymph node sampling and 5 robotic hysterectomy±BSO.All of the
patients in the laparoscopic cohort underwent surgical staging
including 55 laparoscopic hysterectomy±BSO pelvic and aortic
lymphadenectomy,and 1 laparoscopic hysterectomy±BSO pelvic
lymphadenectomy.
There was no significant difference between two groups in median
age,uterine weight,lymph node counts,surgical stage,or complica-
tion rate in patients whose surgeries where completed minimally
invasively (Tables 2,3).The median body mass BMI for patients in the
robotics group was significantly higher than patients undergoing
laparoscopy (34 vs.29,Pb0.001).In addition,the median length of
stay was shorter (1 night vs.2 nights,Pb0.001),estimated blood loss
(100 vs.250 mL,Pb0.001) and transfusion rate (3 vs.18%,RR 0.18,95%
CI 0.05–0.64,P=0.002) was lower for robotics compared to laparo-
scopy.Operative times are significantly shorter in the robotic cohort
and summarized in Table 4.
The conversion rate was lower for robotic compared with
laparoscopic procedures (12% vs.26%,RR 0.47,95%CI 0.25–0.89,
P=0.017).Probability curves for conversion were generated using a
sequence number equal to the third quartile in each procedure
(sequence=59 for laparoscopic and sequence=79 for robotic).As
shown in Fig.1,the probability of conversion based on BMI was
significantly lower for robotic surgery compared with laparoscopy.
The odds ratio is 0.20 (95%CI 0.08–0.56,P=0.002) indicating that the
odds of having a conversion to laparotomy are 80% less for robotic
compared to laparoscopy.Poor exposure was the major indication
(70%of the time) for conversion to laparotomy (Table 5).No patients in
the robotics cohort were converted for bleeding.However,six patients
in the laparoscopic group were converted due to inability to control
bleeding;four of these were related to pelvic sidewall hemorrhage,
one patient for an inferior vena cava injury and another for excessive
bleeding during a left aortic dissection.Although there were no
conversions for equipment failure,3 patients were opened for
technical difficulties (one robotic and 2 laparoscopic).One patient in
the laparoscopic cohort had a large aortic aneurysm and there was
difficulty skeletonizing the inferior mesenteric artery and another
patient had a fixed obturator node that could not be safely dissected
laparoscopically.One robotic patient was opened for difficult dissec-
tion secondary to robotic armcollisions in addition to the presence of
extensive pelvic adhesions.Another patient in the robotics group
underwent mini-laparotomy at the end of the procedure for a lost
Ray-Tec,which was used to maintain a clean operative field during the
procedure.The overall complication rates were similar and are listed
in Table 3 [30].
Table 3
Transfusion rates,length of stay,and complications for robotic versus laparoscopic
hysterectomy and pelvic-aortic lymphadenectomy for endometrial cancer
Robotic
(N=92)
Laparoscopic
(N=56)
Relative Risk
(95%CI)
P-value
a
Length of stay (nights),
median (range)
1 (1–46) 2 (1–9) ⁎ b0.001
Estimated blood loss
(mL)
88 (20–500) 200 (50–650) ⁎ b0.001
Transfusion patient#(%) 3 (3%) 10 (18%) 0.18 (0.05–0.64) 0.002
b
Major vessel injury 1 0
Nerve injury 0 1
Gastrointestional injury

3 0
Urinary tract injury 0 1
Venous thomboembolic
events
0 1
Cardiac events 1 1
Pulmonary events 1 0
Neurologic events 0 1
Other 5 3
Total events 11/85 (13%) 8/58 (14%) 0.84 0.681
There were no post-operative gastrointestional or urinary events.

1 grade 4 bowel injury,1 grade 3 small bowel obstruction due to trocar hernia from
robotic port [29].

Not applicable.
a
P value based on Wilcoxon rank-sum test.
b
P value based on Pearson's chi-squared statistic.
Table 4
Mean operative time in minutes (standard deviation) for robotic versus laparoscopic
hysterectomy and pelvic-aortic lymphadenectomy for endometrial cancer
Robotic Laparoscopic P value
Roomto incision time⁎ 44 (13.6) 38 (8.3) 0.009
Roomtime

305 (61) 336 (55) b0.001
Skin time

242 (53) 287 (55) b0.001

Incision time or vaginal instrumentation minus patient roomentry time.

Patient operating roomexit time minus patient entry time.

Completiontime(all incisions closed) minus first incisionor vaginal instrumentation.
Fig.1.The probability of conversion to laparotomy based on a logistic regression model
was performed on the robotic surgeries (solid line) and the laparoscopic surgeries
(dashed line).The model was adjusted for sequence of operation since women with
lower BMIs were treated in the earlier robotic operations.The probability curves were
generated using a sequence number equal to the third quartile in each procedure
(sequence=59 for laparoscopic and sequence=79 for robotic).The odds ratio is 0.20
indicating that the odds of having a conversion to laparotomy are 80% less for robotic
compared to laparoscopy and is significantly different (P=0.002,95%CI shaded in grey
surrounding each line).
Table 5
Indications for conversion to laparotomy fromrobotic versus laparoscopic hysterectomy
and pelvic-aortic lymphadenectomy for endometrial cancer
Robotic Laparoscopic
Total number of cases 105 76 Relative risk (95% CI) P value
Poor exposure 11 12
Bleeding 0 6
Technical difficulty 1 2
Equipment failure 0 0
Other⁎ 1 0
Conversions 13 (12.4%) 20 (26.3%) 0.47 (0.25–0.89) 0.017

Lost Ray-Tec.
3L.G.Seamon et al./Gynecologic Oncology xxx (2009) xxx–xxx
Please cite this article as:Seamon LG et al.Minimally invasive comprehensive surgical staging for endometrial cancer:Robotics or
laparoscopy?.Gynecol Oncol (2009),doi:10.1016/j.ygyno.2008.12.005
ARTICLE IN PRESS
Discussion
The role of minimally invasive surgical staging in the management
of patients with apparent early endometrial cancer continues to
evolve [31];however the role of robotic surgery in endometrial cancer
is even less defined.In this cohort study,we have demonstrated that
in patients undergoing minimally invasive surgery with the intention
of comprehensive surgical staging,the conversion rate to laparotomy
was less frequent for those patients undergoing the robotic approach,
despite a significantly higher BMI,when compared to laparoscopy.In
addition,the operating roomtimes,length of hospital stay,blood loss
and transfusion rates were significantly reduced in the robotic cohort.
Therefore,it appears that the robotics platform may offer significant
advantages over laparoscopy in the comprehensive surgical manage-
ment of endometrial cancer.
Manyof the limitations of laparoscopyareovercomebythe robotics
platform.The three-dimensional,magnified images combined with
wristed instrumentation,tremor filtration and motion scaling allow
the surgeon to recapitulate open surgery.The counter-intuitive
motions encountered in conventional laparoscopy are eliminated
and these advantages are readily apparent even to the advanced
laparoscopic gynecologic oncologist.The robotics platform more
closely mimics open procedures and in our experience is associated
with a shorter learning curve [28].While a skilled robotic bedside
assistant is essential,therobotic surgeonhas theadditional advantages
of a stable camera anddirect control of endoscope movement.Robotics
also reduces the poor ergonomics associated with laparoscopy,which
leads to surgeon discomfort and risk of chronic musculoskeletal
occupational injury,particularly during longer procedures.Although
robotics offers many potential advantages for endometrial staging
procedures,there are many unknown entities surrounding this new
technology.Robotic surgery for gynecology was approved in April
2005,thus limited published data exists regarding application to
endometrial cancer and survival data is lacking [22–28].
In this cohort of patients selected for minimally invasive surgery
withthe goal of comprehensive surgical staging,patients inthe robotic
group were half as likely (12% vs.26%,RR 0.47,95%CI,0.25–0.89,
P=0.017) to need a laparotomy to complete the case.The need to
convert from a minimally invasive procedure to laparotomy is
influenced not only by level of exposure and/or occurrence of an
intra-operative complication,but also by the priority a surgeon places
on the requirement of comprehensive surgical staging for the patient.
The clinical impact of this difference is even more important
considering the significantly higher BMI (34 vs.29,Pb0.001) in the
robotic group.While our rate of laparoscopic conversions (25.6%) may
seem high compared with other robotics series that included
laparoscopic patients [25–27],it is consistent with the 23% conversion
rate seen in the GOG Lap-2 protocol (Walker et al.,Society of
Gynecologic Oncologists 37th Annual Meeting 2006,abstract 22,
Gynecol Oncol 2006;101:S11–12),a large prospective randomized trial
in which comprehensive surgical staging was mandated.This is
particularly true for the obese patient where the conversion rate is as
high as 36% for laparoscopic staging [20,21].The primary reason for
need of laparotomy in our experience was exposure;however,it is
interesting that 6 patients in the laparoscopic cohort were converted
for factors limiting the ability to control bleeding with conventional
instrumentation.We believe the advantages offered by the robotic
platform,including additional retraction and improvements in
dexterity that allows the ability to perform complex dissection,
significantly,contributes to decreased conversion to laparotomy in
this cohort.
In our study,overall operative room time (305 vs.336 min,
Pb0.001) and skin opening to closure time (242 vs.287 min,Pb0.001)
were significantly less for the patients undergoing robotic surgery
when compared to laparoscopy.Gehrig et al.and Boggess et al.also
note shorter operative times even in the obese population [26,27].
While it is difficult to compare operative times between most
minimally invasive studies considering heterogeneous data (either
lack of the definition of “operative time” in the publication or data
collection bias,retrospective vs.prospective),our robotic times are
comparable with Veljovich et al.(302 min) [25].Gehrig et al.
demonstrated significantly reduced robotic operative times
(189 min) compared to laparoscopic procedures (215 min) in obese
patients while still accomplishing complete staging in 92% of the
robotic patients and 84% of laparoscopic cohort [26],however length
of time in the operating roomwas not defined.Even more compelling,
other authors reporting equivalent laparoscopic times (range:135–
192 min) did not perform comprehensive surgical staging and these
patients had lower mean BMIs (range:25–30 kg/m
2
) [15–18].
We attributed our decreased operative times to many factors.
Although the two surgeons in this study did have prior laparoscopic
experience,there were many aspects that were likely related to the
robotics platform.The procedure is quickly adaptable,particularly for
the advanced laparoscopic gynecologic oncologist.While the
robotics data was prospectively collected for each portion of the
comprehensive staging procedure,we do not have comparative data
for the laparoscopic cohort.Acknowledging this limitation,we
attributed most of the decrease in time to the superiority of the
robotic platform and the increased autonomy of the primary
surgeon.In addition,a previously skilled laparoscopic surgeon and
a consistent and well-trained bedside assistant were also essential to
proficiency and may be potential factors accounting for shorter
operative times in the robotic cohort.We also believe that the
decreased blood loss and lower transfusion rates were due to
advantages afforded by the robotic platform including improved
optics and surgeon dexterity.
Several investigators have demonstrated the ability to safely
performadequate open lymphadenectomy in morbidly obese patients
[32–34].Although laparoscopic staging for gynecologic malignancies
in obese patients is technically possible with 100–40% of the patients
undergoing at least pelvic lymphadenectomy [20,26,34–36],morbid
obesity is one of the limiting factors for widespread application of
minimally invasive surgery in the comprehensive staging of endo-
metrial cancer.In the current study,none of our morbidly obese
patients were converted for anesthesia reasons and all tolerated steep
Trendelenberg without difficulty.Our data demonstrates that robotic
comprehensive staging in obese women is feasible with a potential
lower rate of conversion to laparotomy when compared to laparo-
scopy.While still considered a limitation to minimally invasive
surgery,obesity may be less of a factor for robotic surgery when
compared to conventional laparoscopy for endometrial cancer
patients.Our data supports this hypothesis (Fig.1).
Minimally invasive surgery is associated with less complications
compared to laparotomy.As with any surgical procedure,particularly
a new technology,complications are seen if enough procedures are
performed.While the robotics group experienced a lower estimated
blood loss that translated into a lower transfusion rate,the overall
complication rate was similar between the two groups.Our post-
operative management philosophy was identical throughout the time
period of the study therefore the decreased length of stay may be
secondary to less overall tissue trauma attributed to the robotics
platform.Gerhig et al.also noted a decreased length of stay with their
robotic cohort compared to laparoscopy and in their overall series
demonstrated a significant decrease as compared to laparotomy
[26,27].Recently,Gil-Moreno et al.reviewed the literature on
laparoscopic vs.laparotomy for early-stage endometrial carcinoma
and reported a laparoscopic complication rate of 15% vs.22% for
laparotomy [19],which is consistent with the data presented in the
current study.
With the emphasis trending towards more gynecologic oncolo-
gists performing complete surgical staging and advanced fellowship
training programs,minimally invasive surgery is playing a more
4 L.G.Seamon et al./Gynecologic Oncology xxx (2009) xxx–xxx
Please cite this article as:Seamon LG et al.Minimally invasive comprehensive surgical staging for endometrial cancer:Robotics or
laparoscopy?.Gynecol Oncol (2009),doi:10.1016/j.ygyno.2008.12.005
ARTICLE IN PRESS
predominate role in the primary treatment of endometrial cancer.In
a 2005 survey of the Society of Gynecologic Oncologists,approxi-
mately 49% of the respondents performed laparoscopy for endome-
trial cancer;however only 8% estimated that minimally invasive
surgery was the preferred procedure for the surgical management of
endometrial carcinoma [37].This number represented an absolute
increase of 13% since the initial 1999 survey [38].Similarly,a 12-year
Memorial Sloan Kettering experience of surgical management of
endometrial cancer reveals an increase in use of minimally invasive
surgery and an increase in lymph node sampling regardless of the
surgical approach [39].Although endoscopic techniques for lympha-
denectomy have evolved from pelvic nodes to right aortic lympha-
denectomy to bilateral aortic lymph node dissection [29],many
fellowship-training programs perform a limited number of these
cases annually and carefully select candidates for a minimally
invasive approach.While any retrospective comparison such as the
current study is at risk for bias,the rapid adaptation of the robotic
platformhas greatly increased the portion of patients in our practice
undergoing comprehensive staging via a minimally invasive
approach.This is demonstrated by the almost 10-year time-span at
our institution to obtain the 76 patients in the attempted laparo-
scopic group versus 2.5 years for 105 attempted robotic staging
procedures by the same two gynecologic oncologists.As such,we
believe the robotic approach can help overcome many of the factors
(obesity and steeper learning curve) limiting the wide application of
minimally invasive surgery to endometrial cancer patients and that
more gynecologic oncologists will be able to more quickly adapt the
procedure.
While the current study and others demonstrates advantages of
robotic surgery over laparoscopy and laparotomy for the surgical
management of endometrial cancer [26,27],we acknowledge several
limitations including the usual biases of retrospective studies-use of
historical controls and lack of randomization.Due to the prospective
nature of data collection in the robotics versus retrospective reviewin
the laparoscopic group,ascertainment bias may be introduced.We
also acknowledge that these two robotic surgeons were advanced
minimially invasive surgeons prior to their robotic experience and this
could have lead to additional bias either toward or away fromthe null.
For example,the differences seen in conversions,complications,and
transfusions could be due to the previous laparoscopic experience of
the two surgeons.On the other hand,if the two surgeons were not
adept in minimally invasive surgery and the study was performed in a
randomized fashion with a laparoscopic and robotic arm,the absolute
differences may even be higher in favor of the robotics arm.Although
the sequential study design is a limitation,it serves as “real world”
application — as most gynecologic oncologists who now perform
robotic surgery have experience in advanced laparoscopy.
In conclusion,we report one of the first studies comparing robotic
and laparoscopic hysterectomy and lymphadenectomy for endome-
trial cancer and conclude that robotic surgery results in shorter
operating times,lower transfusion rates and less frequent conversion
to laparotomy when compared to a laparoscopic approach.It has been
established that minimally invasive surgery offers improved out-
comes to patients with endometrial cancer compared to laparotomy
[36,40].The obese patient with associated co-morbidities has the
most to gain from a successfully completed minimally invasive
procedure,but also offers the surgeon the greatest challenges to
complete the case.We feel it is safe to conclude that the robotic
platform allows the gynecologic oncologist to offer minimally
invasive surgery,with the goal of comprehensive surgical staging,
to a significantly larger portion of women diagnosed with endome-
trial cancer.Additionally,the surgeon benefits from the significantly
improved robotic ergonomics compared with traditional laparoscopy.
Expanded outcome measures,such as quality of life for the patient,
total disability and cost will need to be measured to evaluate the true
impact of this technology.
Conflict of interest statement
The authors declare that there are no conflicts of interest.
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Please cite this article as:Seamon LG et al.Minimally invasive comprehensive surgical staging for endometrial cancer:Robotics or
laparoscopy?.Gynecol Oncol (2009),doi:10.1016/j.ygyno.2008.12.005
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