Editorial: Minimally Invasive Hysterectomy Improves Outcomes in Women with Early Endometrial Cancer

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In JAMA Surgery, Danish researchers recently described the nationwide introduction of minimally invasive robotic surgery for gynecologic conditions. This changed the country's approach to the treatment of early-stage endometrial cancer from open surgery to minimally invasive surgery (MIS). The researchers determined that the change in approach was associated with a significantly reduced risk of severe complications.

Journal editors invited Alexander Melamed, MD, MPH, a fellow in the Center for Gynecologic Oncology at Massachusetts General Hospital, and colleagues to comment on the study in the same issue of JAMA Surgery. In their editorial, they present some caveats while agreeing that access to MIS should be a priority for women with endometrial cancer.

Highlights of the Danish Study

As the editorialists say, the Danish researchers were able to leverage a unique natural experiment to assemble a large prospective cohort (n=5,654 women with early-stage endometrial cancer) in the country. At each hospital in Denmark, researchers determined the timing of the introduction of robotically assisted gynecologic surgery (2008–2013), and then examined before and after rates of MIS and severe surgical complications.

The rate of MIS was 14% before the introduction of robotically assisted surgery and 72% afterward. Serious complications occurred less frequently in women who underwent MIS than in those who underwent a total abdominal hysterectomy. Thus, the adjusted risk of complications decreased after the introduction of robotically-assisted surgery.

Limitations of the Study

What the study doesn't demonstrate conclusively, the editorialists say, is that a robotically assisted surgical program is required to increase the use of MIS or improve outcomes. Related to this issue they point out two limitations of the study design:

1. No true control group. All hospitals in the analysis adopted robotically assisted surgery between 2008 and 2013, a period when there was already rapid uptake and diffusion of MIS in gynecology. To determine the association of a robotic platform with the use of MIS, it would be necessary to compare an experimental group of hospitals in which robotically assisted surgery was introduced with a control group where robotically assisted surgery had not been adopted
2. Consolidation of care to high-volume centers. The analysis is confounded by the fact that endometrial cancer care in Denmark was consolidated from 28 hospitals to only six, and this change coincided with the introduction of robotically assisted surgery. Therefore, what seems to be an impressive uptake of minimally invasive hysterectomy with improvement in outcomes might actually reflect the centralization of care to experienced surgeons in high-volume centers

Disentangling the effects of centralization, trends in the performance of MIS and the introduction of the robotic platform is not possible with the present study, Dr. Melamed and his colleagues conclude.

They do concur, however, that increasing the rate of MIS can improve outcomes for women undergoing hysterectomy for early-stage endometrial cancer. The editorialists recommend that access to minimally invasive hysterectomy, whether laparoscopic or robotically assisted, should be a priority for women with endometrial cancer.

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