Is robotic surgery equivalent to laparoscopy in the treatment of stage I endometrial cancers? (544)

Abstract

Objectives: The LAP2 trial demonstrated that short-term outcomes for patients undergoing minimally invasive surgery (MIS) for endometrial cancer are similar to those undergoing laparotomy. However, recent reports in both cervical and uterine cancer suggest that route of surgery had an unanticipated impact on the long-term clinical outcomes of patients, including recurrence and death. Given an increasing use of robotic surgery since LAP2, we undertook to determine if outcomes following robotic surgery are similar to those of laparoscopy during intermediate and long-term follow-up. Methods: We performed a retrospective review of patients from a single, large, academic, urban practice who underwent either laparoscopic or robot-assisted MIS (RA-MIS) for the treatment of stage I endometrial carcinoma and had at least five years of potential followup. Comparisons of recurrence-free (RFS) and overall survival (OS) by route of surgery were conducted using Cox regression models adjusting for stage, grade, use of adjuvant therapy, and age at surgery. Results: We identified 1,138 patients treated in the study window; 482 in the laparoscopy group and 656 in the RA-MIS group. The groups were similar in age, stage, grade, completeness of staging, and adjuvant therapy. There was a steady increase in the use of RA-MIS surgeries during the study window. Traditional risk factors, such as increasing age, stage, and grade, were associated with poorer outcomes. After controlling for these, RA-MIS was associated with poorer RFS (HR: 1.55, 95% CI: 1.12-2.16) and OS (HR: 1.57, 95% CI: 1.06-2.33). Disease-specific death risk was also higher in the RA-MIS group (competing risks analysis; HR: 3.48, 95% CI: 1.79-6.77). Among those who recurred, the median time to the first recurrence was shorter in the RA-MIS group than in the laparoscopy group (16.3 vs 29.3 months, p=0.046). Fifty-three percent of recurrences in the laparoscopy arm and 42% in the RA-MIS group occurred greater than 24 months after surgery, while 18% and 14% occurred after five years. Conclusions: RA-MIS was associated with poorer outcomes, even after adjusting for known risk factors. Our data in this lower-risk population suggest that relevant clinical endpoints may be occurring during intermediate and long-term follow-up windows. These findings support a prospective evaluation of the long-term outcomes of RA-MIS in this setting. Objectives: The LAP2 trial demonstrated that short-term outcomes for patients undergoing minimally invasive surgery (MIS) for endometrial cancer are similar to those undergoing laparotomy. However, recent reports in both cervical and uterine cancer suggest that route of surgery had an unanticipated impact on the long-term clinical outcomes of patients, including recurrence and death. Given an increasing use of robotic surgery since LAP2, we undertook to determine if outcomes following robotic surgery are similar to those of laparoscopy during intermediate and long-term follow-up. Methods: We performed a retrospective review of patients from a single, large, academic, urban practice who underwent either laparoscopic or robot-assisted MIS (RA-MIS) for the treatment of stage I endometrial carcinoma and had at least five years of potential followup. Comparisons of recurrence-free (RFS) and overall survival (OS) by route of surgery were conducted using Cox regression models adjusting for stage, grade, use of adjuvant therapy, and age at surgery. Results: We identified 1,138 patients treated in the study window; 482 in the laparoscopy group and 656 in the RA-MIS group. The groups were similar in age, stage, grade, completeness of staging, and adjuvant therapy. There was a steady increase in the use of RA-MIS surgeries during the study window. Traditional risk factors, such as increasing age, stage, and grade, were associated with poorer outcomes. After controlling for these, RA-MIS was associated with poorer RFS (HR: 1.55, 95% CI: 1.12-2.16) and OS (HR: 1.57, 95% CI: 1.06-2.33). Disease-specific death risk was also higher in the RA-MIS group (competing risks analysis; HR: 3.48, 95% CI: 1.79-6.77). Among those who recurred, the median time to the first recurrence was shorter in the RA-MIS group than in the laparoscopy group (16.3 vs 29.3 months, p=0.046). Fifty-three percent of recurrences in the laparoscopy arm and 42% in the RA-MIS group occurred greater than 24 months after surgery, while 18% and 14% occurred after five years. Conclusions: RA-MIS was associated with poorer outcomes, even after adjusting for known risk factors. Our data in this lower-risk population suggest that relevant clinical endpoints may be occurring during intermediate and long-term follow-up windows. These findings support a prospective evaluation of the long-term outcomes of RA-MIS in this setting.