Laparoscopy versus laparotomy for the management of presumed early stage endometrial cancer

Background
Worldwide, cancer of the womb or 'endometrial cancer' is the fifth most common cancer among women up to 65 years of age and has a higher incidence in high income countries than in low and middle income countries. For women with cancer of the womb, removal of the womb (hysterectomy) and removal of both fallopian tubes (tubes along which eggs travel from the ovaries to the womb) and ovaries (which produce eggs) is considered current standard treatment. Other treatments include radiotherapy and chemotherapy. Traditionally, surgery for cancer of the womb is performed through a laparotomy (open cut in the abdomen).

Review question
This review compared overall survival (length of time that the woman remained alive) and disease free survival (length of time that the women remained disease-free) for laparoscopic (keyhole) surgery with laparotomy in women with presumed early endometrial cancer.

Key results
Results from six trials where women were randomly put into one of two treatment groups showed no difference in the risk of death between women who had laparoscopy and women who had laparotomy. In addition, results from five randomised trials confirmed no difference in the risk of cancer recurrence between women who had laparoscopy and women who had laparotomy. Notably, laparoscopy was associated with less blood loss and earlier discharge from hospital.

Certainty of the evidence
The certainty of the evidence for overall and recurrence free survival was moderate. Certainty for side effects was low.

What were the conclusions?
This review update confirms the findings of the previous review that laparoscopy (keyhole) is an effective and viable alternative to laparotomy (open surgery) in the treatment of early stage endometrial cancer. With regards to long term survival outcomes, treatment by laparoscopy is comparable to laparotomy.

Authors' conclusions: 

This review found low to moderate-certainty evidence to support the role of laparoscopy for the management of early endometrial cancer. For presumed early stage primary endometrioid adenocarcinoma of the endometrium, laparoscopy is associated with similar OS and DFS. Furthermore, laparoscopy is associated with reduced operative morbidity and hospital stay. There is no significant difference in severe postoperative morbidity between the two modalities.

The certainty of evidence for OS and RFS was moderate and was downgraded for unclear risk of bias profiles and imprecision in effect estimates. However, most studies used adequate methods of sequence generation and concealment of allocation so studies were not prone to selection bias. Adverse event outcomes were downgraded for the same reasons and additionally for low event rates and low power thus these outcomes provided low-certainty evidence.

Read the full abstract...
Background: 

This is an update of a previous Cochrane Review published in 2012, Issue 9.

Surgery for endometrial cancer (hysterectomy with removal of both fallopian tubes and ovaries) is performed through laparotomy. It has been suggested that the laparoscopic approach is associated with a reduction in operative morbidity. Over the last two decades there has been a steady increase of the use of laparoscopy for endometrial cancer. This review investigated the evidence of benefits and harms of laparoscopic surgery compared with laparotomy for presumed early stage endometrial cancer.

Objectives: 

To compare overall survival (OS) and disease free survival (DFS) for laparoscopic surgery versus laparotomy in women with presumed early stage endometrial cancer.

Search strategy: 

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 5) in the Cochrane Library, MEDLINE via Ovid (April 2012 to June 2018) and Embase via Ovid (April 2012 to June 2018). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies. The trial registers included NHMRC Clinical Trials Register, UKCCCR Register of Cancer Trials, Meta-Register and Physician Data Query Protocol.

Selection criteria: 

Randomised controlled trials (RCTs) comparing laparoscopy and laparotomy for early stage endometrial cancer.

Data collection and analysis: 

We independently abstracted data and assessed risk of bias. We used hazard ratios (HRs) for OS and recurrence free survival (RFS), risk ratios (RR) for severe adverse events and mean differences (MD) for continuous outcomes in women who received laparoscopy or laparotomy with 9% confidence intervals (CI). These were pooled in random-effects meta-analyses.

Main results: 

We identified one new study in this update of the review. The review contains nine RCTs comparing laparoscopy with laparotomy for the surgical management of early stage endometrial cancer.

All nine studies met the inclusion criteria and assessed 4389 women at the end of the studies. Six studies assessing 3993 participants with early stage endometrial cancer found no significant difference in the risk of death between women who underwent laparoscopy and women who underwent laparotomy (HR 1.04, 95% 0.86 to 1.25; moderate-certainty evidence) and five studies assessing 3710 participants found no significant difference in the risk of recurrence between the laparoscopy and laparotomy groups (HR 1.14, 95% CI 0.90 to 1.43; moderate-certainty evidence). There was no significant difference in the rate of perioperative death; women requiring a blood transfusion; and bladder, ureteric, bowel and vascular injury. However, one meta-analysis of three studies found that women in the laparoscopy group lost significantly less blood than women in the laparotomy group (MD –106.82 mL, 95% CI –141.59 to –72.06; low-certainty evidence). A further meta-analysis of two studies, which assessed 3344 women and included one very large trial of over 2500 participants, found that there was no clinical difference in the risk of severe postoperative complications in women in the laparoscopy and laparotomy groups (RR 0.78, 95% CI 0.44 to 1.38). Most studies were at moderate risk of bias. All nine studies reported hospital stay and results showed that on average, laparoscopy was associated with a significantly shorter hospital stay.

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