Laparoscopy Compared With Laparotomy for Comprehensive Surgical Staging of Uterine Cancer: Gynecologic Oncology Group Study LAP2

Abstract

The conventional method for comprehensive surgical staging in endometrial cancer is open laparotomy. Since the 1990s, minimally invasive laparoscopy has been investigated for comprehensive surgical staging in endometrial cancer in small efficacy and safety studies. This prospective randomized trial was designed to compare use of laparotomy and laparoscopy for complete comprehensive surgical staging of uterine cancer. Between 1996 and 2005, a total of 2616 patients with clinical stage I to IIA uterine cancer were randomly assigned —920 to open laparotomy and 1696 to laparoscopy. The procedures undertaken with both methods included hysterectomy, salpingo-oophorectomy, pelvic and paraaortic lymphadenectomy, and peritoneal cytology. The primary study end points were short-term (6 weeks) surgical outcomes, including recurrence-free survival, intraoperative complications, laparoscopy conversion to laparotomy, length of hospital stay, operative time, patient-reported quality of life, and sites of recurrence. The data was adjusted for patient age, race/ethnicity, body mass index, and performance status. Laparoscopy was completed without conversion to open laparotomy in 1248 patients (74.2%). Conversion to laparotomy was required in 434 participants (25.8%). Reasons for conversion included poor exposure in 246 patients (14.6%), metastatic cancer in 69 patients (4.1%), excessive bleeding in 49 patients (2.9%), and other causes in 70 patients (4.2%). Fewer moderate-to-severe postoperative adverse events occurred with laparoscopy compared to laparotomy (14% versus 21%; P < 0.001). Although the median operative time was shorter for open laparotomy than laparoscopy (130 versus 204 minutes; P < 0.001), there was no statistical difference between the 2 treatment groups in rates of intraoperative complications (laparotomy: 8% versus laparoscopy: 10%; P = 0.106). The percentage of patients requiring more than 2 days of hospitalization after surgery was significantly lower in patients receiving laparoscopy compared with laparotomy (52% versus 94%; P < 0.001). Both pelvic and paraaortic nodes were not removed in 4% of laparotomy patients and 8% of laparoscopy patients (P < 0.0001). The proportion of laparotomy and laparoscopy patients found to have advanced surgical stage (FIGO stage IIIA, IIIC, or IV) was not significantly different (17% for each method; P = 0.851). The investigators conclude from these findings that laparoscopic comprehensive surgical staging for uterine cancer is feasible. Compared to laparotomy, short-term outcomes of laparoscopy show fewer postoperative complications, and shorter hospital stay without increased intraoperative injuries.