Next Article in Journal
Real-World Treatment Patterns and Timeliness of Clinical Care Pathway for Non-Small Cell Lung Cancer Patients in Austria: The PRATER Retrospective Study
Next Article in Special Issue
Sentinel Lymph Node Assessment in Endometrial Cancer: A Review
Previous Article in Journal
Brain Metastasis in the Emergency Department: Epidemiology, Presentation, Investigations, and Management
Previous Article in Special Issue
Blood Vessel Invasion Is an Independent Prognostic Factor in Endometrial Endometrioid Carcinoma Compared to Lymph Vessel Invasion and Myometrial Invasion Pattern
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Cancers
Volume 16
Issue 14
10.3390/cancers16142584
cancers-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Impact of Robotic Assistance on Minimally Invasive Surgery for Type II Endometrial Cancer: A National Cancer Database Analysis

by
Kelly Lamiman
1,
Michael Silver
1,
Nicole Goncalves
1,
Michael Kim
2 and
Ioannis Alagkiozidis
1,*
1
Department of Gynecologic Oncology, Maimonides Medical Center, Brooklyn, NY 11220, USA
2
Department of Obstetrics and Gynecology, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY 11215, USA
*
Author to whom correspondence should be addressed.
Cancers 2024, 16(14), 2584; https://doi.org/10.3390/cancers16142584
Submission received: 28 May 2024 / Revised: 13 July 2024 / Accepted: 15 July 2024 / Published: 19 July 2024
(This article belongs to the Special Issue Clinical Research Advances in Endometrial Carcinoma)
Browse Figure
Review Reports Versions Notes

Abstract

:

Simple Summary

This study compares the survival and surgical outcomes of patients who underwent conventional versus robot-assisted laparoscopy for aggressive histologic types of uterine cancer. While there is no association between the use of robotic assistance and overall survival, robot-assisted laparoscopy is associated with a decreased risk for conversion to laparotomy and a higher rate of surgical lymph node evaluation.

Abstract

The objective of this study is to compare the overall survival (OS) and surgical outcomes between conventional laparoscopy and robot-assisted laparoscopy (RAL) in women with type II endometrial cancer. We identified a large cohort of women who underwent hysterectomy for type II endometrial cancer between January 2010 and December 2014 using the National Cancer Database (NCDB). The primary outcome was to compare the OS of conventional laparoscopy versus RAL. Secondary outcomes included the length of hospital stay, 30-day readmission rate, 90-day mortality, rates of lymph node retrieval, rates of node positivity, and rates of conversion to laparotomy. Cohorts were compared and multivariable logistic regression was used to determine characteristics with statistically significant predictors of outcome. We identified 7168 patients with stage I–III type II endometrial cancer who had minimally invasive surgery as primary treatment between 2010 and 2014. A total of 5074 patients underwent RAL. Women who underwent RAL were less likely to have stage III disease (26.4% vs. 29.9%, p = 0.008) and had smaller primary tumors (4.6 vs. 4.1 cm, p < 0.001). In a multivariable model, there was no difference in OS between conventional laparoscopy and RAL. With regard to postoperative outcomes, RAL was associated with a decreased risk for conversion to laparotomy (2.7% vs. 12%, p < 0.001), a shorter hospital stay (1 vs. 2 days, p < 0.001), a decreased 90-day mortality (1.3% vs. 2.2%, p = 0.004), and an increased number of lymph nodes sampled (14 vs. 12, p < 0.001). In multivariable analysis, the use of RAL was independently associated with a reduced rate of conversion to laparotomy. In conclusion, there was no difference in OS between conventional laparoscopy and RAL in type II endometrial cancer in a large retrospective cohort of patients from the NCDB. RAL was associated with a decreased risk of conversion to laparotomy.

1. Introduction

The incidence of endometrial cancer in the United States is rising, with approximately 67,880 new cases anticipated in 2024 by the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) data [1]. Historically, endometrial cancer has been classified into two types based on histology findings [2]. Type I tumors comprise grade I or II endometrioid histology and represent >80% of all sporadic endometrial cancer diagnoses. Type II tumors represent <20% of all endometrial cancer diagnoses and include the more aggressive histologies of grade III endometrioid, clear-cell, serous, and carcinosarcoma. Despite being rarer, type II tumors represent about half of the deaths due to endometrial cancer. Type II endometrial cancers are typically diagnosed at later stages, with more aggressive courses and higher metastatic potential than type I tumors. In addition, African American women in the United States are disproportionally diagnosed with type II endometrial cancers and have worse survival outcomes [3,4]. Over the past few decades, the incidence of all endometrial cancers rose, with type II tumors at a steeper rate than type I tumors [5].
The primary surgical treatment for type II endometrial cancers comprises staging with hysterectomy, bilateral salpingo-oophorectomy, and omental and lymph node sampling. Adjuvant treatment with chemotherapy or radiation is common in type II cancers and dependent on staging. Minimally invasive staging surgery was found to have similar oncologic outcomes and reduced perioperative morbidity compared to open surgery in early endometrial cancer in two large randomized control trials known as LACE (Laparoscopic Approach to Cancer of the Endometrium) and LAP2 [6,7]. However, type II cancers were excluded from LACE and represented <20% of cases in LAP2. In addition, LACE only included stage I disease and LAP2 included stage I-IIA disease [8]. One single-center retrospective cohort study of exclusively type II endometrial cancers found that stage I and II treated with MIS experienced fewer complications and similar survival outcomes compared with open surgery, but found greater overall survival (OS) in open surgery for stage III disease [9]. A recent systematic review of the literature available on type II tumors treated with minimally invasive surgery (MIS) concluded better perioperative outcomes and comparable oncological outcomes with no differences by stage [10]. A recent assessment by Ontario Health identified that the robotic approach was associated with fewer conversions to laparotomy and similar rates of complication compared to conventional laparoscopy among obese women with BMI > 40 [11].
The lower incidence of type II tumors makes it challenging to study these aggressive histologies prospectively in a randomized clinical trial. A recent retrospective study using the National Cancer Database (NCDB) compared open surgery to MIS in type II endometrial cancers [12]. MIS was associated with improved OS compared to open surgery; however, the study did not differentiate between conventional laparoscopy and RAL. RAL offers distinct advantages over conventional laparoscopy, including three-dimensional visualization and enhanced instrument articulation. Nevertheless, the use of robotic assistance significantly increases the cost of the procedure, and it remains unclear whether the technical benefits of robotic surgery translate into improved postoperative outcomes or survival rates for patients with type II endometrial cancer [13]. To address this gap, we designed a large retrospective epidemiological study using the NCDB to evaluate the survival and surgical outcomes of patients with type II endometrial cancer who underwent minimally invasive surgery. The primary outcome was to compare OS between conventional laparoscopy and RAL. Secondary outcomes included the length of hospital stay, 30-day readmission rate, 90-day mortality, the number of lymph nodes removed, rates of any lymph node retrieval, rates of node positivity, and rates of conversion to laparotomy.

2. Materials and Methods

The NCDB includes patients who received care at a program accredited by the Commission on Cancer-Accredited Centers. The database covers more than 70% of newly diagnosed cancers in the United States collected from about 1500 facilities. We identified patients with stage I-III type II endometrial cancer (serous, clear-cell, and carcinosarcoma) between January 2010 and December 2014 who underwent hysterectomy as their primary treatment. The NCDB was originally accessed for this dataset on 14 September 2021. We excluded stage IV disease, patients without a hysterectomy or whose primary treatment was unknown, and those without pathologically confirmed disease. International Federation of Gynecology and Obstetrics (FIGO) 2009 staging was used to stratify the patients in accordance with the staging paradigm at the time of data collection. The surgical approach documented included MIS (either conventional laparoscopy or RAL) and intended MIS converted to laparotomy. Conventional laparoscopy and RAL groups were compared in terms of age, race, co-morbidities, stage, histology type, primary tumor size, and the use of adjuvant therapy. Histology in the NCDB participant user file (PUF) dictionary was reported as ICD-O-3 codes by SEER registries. Outcomes were compared using t-tests. The length of stay and the number of lymph nodes sampled were summarized with a median and IQR and compared between groups using the Wilcoxon Rank Sum Test. Categorical variables were summarized with frequency and percentage, and compared across groups using a chi-square test. OS was determined using Kaplan–Meier curves. Multivariable Cox proportional hazards models estimated the impact of robotic assistance on overall survival and the rate of conversion to laparotomy, while controlling for relevant covariates. A two-tailed p-value <0.05 was considered statistically significant. Analyses were performed using SPSS Version 28 (IBM Corp, Armonk, NY, USA).

3. Results

3.1. Patient and Disease Characteristics

We identified 7168 patients with stage I–III type II endometrial cancer who underwent MIS for primary treatment during the five-year period between 2010 and 2014. A total of 5074 patients underwent RAL and 2094 underwent conventional laparoscopy. There was no difference in median age or histology with respect to the type of MIS. Women undergoing RAL were more likely to be white and insured (Table 1). With regard to disease characteristics, RAL patients were less likely to have stage III disease (26.4% vs. 29.9%, p = 0.008) or positive lymph nodes (19.8% vs. 23.8%, p < 0.001), and had smaller tumors (4.14 cm vs. 4.59 cm, p < 0.001). Adjuvant chemotherapy or radiation treatment was more likely to be given in the RAL group (55.5% vs. 52.5%, p = 0.025).

3.2. Survival Analysis

Robotic assistance had no impact on overall survival. In a multivariable analysis, there was no difference in overall survival between conventional laparoscopy and RAL (HR 0.971, 95% CI (0.895–1.053); Figure 1 and Table 2). Factors associated with worse OS were older age (HR 1.049, 95% CI (1.041–1.049)), black race (HR 1.486, 95% CI (1.2–1.5)), carcinosarcoma histology (HR 1.8, 95% CI (1.6–2)), and advanced stage (HR 2.9, 95% CI (2.7–3.2) for stage III). Hispanic ethnicity was associated with improved OS (HR 0.8, 95% CI (0.6–0.9)). Adjuvant therapy with chemotherapy or radiation was associated with improved OS (HR 0.839, 95% CI (0.72–0.839) (Table 2).

3.3. Perioperative Outcomes

Conversion to laparotomy was less likely when robotic assistance was used. Of 7168 minimally invasive surgeries, there were 383 cases that were converted from MIS approach to laparotomy. The rate of conversion to laparotomy in RAL was lower compared to conventional laparoscopy (2.7% vs. 12%, p < 0.001) (Table 1). The effect of robotic assistance on the rate of conversion to laparotomy was independent of other variables. On multivariable analysis, conventional laparoscopy, black race, stage III disease, carcinosarcoma histology, and larger tumor size were associated with higher rates of conversion. Conventional laparoscopy only represented 26.8% of all minimally invasive cases, but represented the initial approach in 64% of all converted cases (p < 0.001). The rate of conversion for stage III disease was 8% compared to 4.4% for stage I disease (p < 0.001). Tumor size was bigger in the conversion group compared to the MIS group (5.32 cm vs. 4.19 cm, p < 0.001). Conversion to open surgery was not associated with the receipt of adjuvant chemotherapy or radiation (Table 3).
RAL was associated with lower 90-day postoperative mortality (1.3% vs. 2.2%, p = 0.004). The mean length of stay was shorter in the robotic group (1 vs. 2 days, p < 0.001). The 30-day readmission rate was similar between the groups (2.4% vs. 2.5%, p = 0.8) (Table 1).
Finally, patients undergoing RAL were more likely to have any lymph nodes retrieved compared to conventional laparoscopy (91.4% vs. 85%, p < 0.001) (Table 1). When nodal assessment was possible, RAL resulted in a higher median number of nodes removed compared to conventional laparoscopy (14 vs. 12, p < 0.001).

4. Discussion

Our findings suggest that RAL is associated with similar OS and superior perioperative outcomes among patients with type II endometrial cancer compared to conventional laparoscopy. Specifically, the robotic approach in type II endometrial cancers was associated with a shortened length of hospital stay, reduced 90-day postoperative mortality, and fewer conversions to open surgery, with equivalent survival outcomes compared to conventional laparoscopy. Additionally, the robotic approach was associated with higher rates of any lymph node sampling and a higher number of nodes retrieved, suggesting improved rates of complete surgical staging.
Prior studies have established that MIS has improved perioperative outcomes, reduced morbidity, and equivalent oncologic outcomes compared to laparotomy for endometrial cancer [6,14,15]. However, the impact of robotic assistance on survival and surgical outcomes is less clear. Previous retrospective studies comparing RAL to conventional laparoscopy in low-risk patients reported worse recurrence-free and overall survival for the robotic approach [16,17]. A recent meta-analysis of RAL and conventional laparoscopy in endometrial cancer showed similar rates of perioperative complications but a reduced rate of conversion to laparotomy in the robotic group, partly due to the positional intolerance of laparoscopy in patients with morbid obesity. The majority of the cases included in this study were early-stage and low-risk histology [18].
In our study, we included patients with type II histology at a very high risk of metastatic disease. This is reflected in the rate of positive lymph nodes in our cohort (19.8–23.8%). Several factors may have contributed to the superior surgical outcomes observed with robotic surgery in our study. The enhanced dexterity and precision of robotic wrist motion facilitate dissection. The ergonomic benefits of the robotic system could decrease surgeon fatigue. Furthermore, the superior three-dimensional visualization of the operative field facilitates the recognition of critical anatomic elements and decreases the risk of injuries. These advantages likely contributed to the higher rates of surgical lymph node assessment, the higher number of nodes examined in the era before the sentinel lymph node technique development (2010–2014), and the lower risk of complications that could potentially lead to conversion to laparotomy. In the high-risk population studied, these benefits increased the likelihood of completing the staging procedure minimally invasively.
There is a documented pattern in the literature associating the use of robotic surgery with higher socioeconomic factors [19,20]. In our study, Black patients underwent conventional laparoscopy at a higher rate compared to robotics (22.6% vs. 17.8%), experienced a higher rate of conversion from MIS to laparotomy compared to white patients (8.4% vs. 4.6%), and had worse overall survival. This study adds to the literature demonstrating racial and social disparities in the surgical management of endometrial cancer [21,22,23,24]. Disparities in endometrial cancer are well documented and multifactorial, stemming from biological dissimilarities, socioeconomics, implicit biases, and unequal access to care [25,26,27,28,29]. Ensuring the availability of all surgical modalities and specialized surgeons within marginalized communities could significantly enhance surgical and oncologic outcomes.
To our knowledge, our study offers the largest analysis to date on the use of RAL versus conventional laparoscopy in type II uterine cancer. We assessed several potential confounding factors that could affect survival or the possibility of conversion to laparotomy, such as histology type, stage, tumor size, and adjuvant therapy. In our cohort, robotic assistance is an independent prognostic factor associated with a decreased possibility of conversion to laparotomy without impacting overall survival.
Our study has several limitations. Although the National Cancer Database (NCDB) represents a large U.S. patient population, these data may not be representative of the entire population. Our data are retrospective in nature and may include unmeasured cofounding variables such as patient co-morbidities or the length of surgeon experience that influence our results. Another significant limitation is the absence of information about recurrence, treatment at recurrence, and cause of death recorded in the NCDB. Additionally, there was no information on factors affecting the choice between laparoscopy or the robotic approach, which could have led to potential selection bias. Conventional laparoscopy was associated with more advanced stages, likely related to socioeconomic disparities between the two approaches. To eliminate the effect of confounding factors, multivariable Cox regression analyses were performed, demonstrating that RAL was not associated with any difference in OS. However, RAL was associated with a decrease in the rate of conversion to laparotomy compared to conventional laparoscopy. Finally, our data lack information on peri-operative morbidity, a significant factor affecting the complex decision making behind the choice of surgical approach.
Another limitation pertains to the absence of tumor molecular classification data within the NCDB. Endometrial cancer is now categorized into four molecular subgroups (POLE ultramutated, MSI-H, copy number high, and copy number low), each with a distinct prognosis and typical response to treatment [30,31]. Investigating a connection between tumor molecular classification and the surgical approach is a potential topic for future studies.

5. Conclusions

In conclusion, this large national database study shows that robotic-assisted laparoscopy provides equivalent oncologic outcomes to conventional laparoscopy with lower rates of conversion to open surgery and higher rates of completion of surgical staging with nodal sampling. The effect of robotic assistance on the conversion rate is independent of other factors. Based on these data, robotic surgery should be the recommended surgical approach for patients with type II endometrial cancer when logistically and financially feasible.

Author Contributions

Conceptualization, I.A.; methodology, I.A., M.S.; formal analysis, M.S.; investigation, K.L., N.G. and M.K.; data curation, M.S.; writing—original draft preparation, K.L., N.G. and I.A.; writing—review and editing, I.A.; supervision, I.A.; project administration, I.A. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki, and was determined to be exempt by the Institutional Review Board of Maimonides Medical Center.

Informed Consent Statement

Patient consent was waived due to the retrospective study design.

Data Availability Statement

The data presented in this study are available from the National Cancer Database.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. SEER. Cancer of the Endometrium—Cancer Stat Facts. Available online: https://seer.cancer.gov/statfacts/html/corp.html (accessed on 5 May 2024).
  2. Bokhman, J.V. Two pathogenetic types of endometrial carcinoma. Gynecol. Oncol. 1983, 15, 10–17. [Google Scholar] [CrossRef] [PubMed]
  3. Horne, Z.D.; Teterichko, S.R.; Glaser, S.M.; Wegner, R.E.; Hasan, S.; Crafton, S.M.; Miller, E.M.; Krivak, T.C.; Viswanathan, A.; Olawaiye, A.B.; et al. Race-driven survival differential in women diagnosed with endometrial cancers in the USA. Int. J. Gynecol. Cancer 2020, 30, 1893–1901. [Google Scholar] [CrossRef] [PubMed]
  4. Karia, P.S.; Huang, Y.; Tehranifar, P.; Wright, J.D.; Genkinger, J.M. Racial and ethnic differences in type II endometrial cancer mortality outcomes: The contribution of sociodemographic, clinicopathologic, and treatment factors. Gynecol. Oncol. 2023, 168, 119–126. [Google Scholar] [CrossRef] [PubMed]
  5. Rodríguez-Palacios, D.Á.; Colorado-Yohar, S.M.; Velten, M.; Vaamonde-Martín, R.J.; Ballesta, M.; Chirlaque, M.-D. Incidence and Trend of Type I and II Endometrial Cancer in Women from Two Population-Based European Cancer Registries (1998–2012). Int. J. Environ. Res. Public Health 2022, 19, 3789. [Google Scholar] [CrossRef] [PubMed]
  6. Walker, J.L.; Piedmonte, M.R.; Spirtos, N.M.; Eisenkop, S.M.; Schlaerth, J.B.; Mannel, R.S.; Spiegel, G.; Barakat, R.; Pearl, M.L.; Sharma, S.K. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J. Clin. Oncol. 2009, 27, 5331–5336. [Google Scholar] [CrossRef] [PubMed]
  7. Janda, M.; McGrath, S.; Obermair, A. Challenges and controversies in the conservative management of uterine and ovarian cancer. Best Pract. Res. Clin. Obstet. Gynaecol. 2019, 55, 93–108. [Google Scholar] [CrossRef] [PubMed]
  8. Puppo, A.; Migliaretti, G.; Landoni, F.; Uccella, S.; Camanni, M.; Ceccaroni, M.; Delpiano, E.M.; Mantovani, G.; Roviglione, G.; Bianchi, T.; et al. Surgical Access and Pattern of Recurrence of Endometrial Cancer: The SUPeR Study, a Multicenter Retrospective Observational Study. J. Minim. Invasive Gynecol. 2024, 31, 321–329. [Google Scholar] [CrossRef] [PubMed]
  9. Monterossi, G.; Ghezzi, F.; Vizza, E.; Zannoni, G.F.; Uccella, S.; Corrado, G.; Restaino, S.; Quagliozzi, L.; Casarin, J.; Dinoi, G.; et al. Minimally Invasive Approach in Type II Endometrial Cancer: Is It Wise and Safe? J. Minim. Invasive Gynecol. 2017, 24, 438–445. [Google Scholar] [CrossRef]
  10. Scaletta, G.; Dinoi, G.; Capozzi, V.; Cianci, S.; Pelligra, S.; Ergasti, R.; Fagotti, A.; Scambia, G.; Fanfani, F. Comparison of minimally invasive surgery with laparotomic approach in the treatment of high risk endometrial cancer: A systematic review. Eur. J. Surg. Oncol. 2020, 46, 782–788. [Google Scholar] [CrossRef]
  11. Ontario Health (Quality). Robotic-Assisted Hysterectomy for Endometrial Cancer in People With Obesity: A Health Technology Assessment. Ont. Health Technol. Assess. Ser. 2023, 23, 1–70. [Google Scholar]
  12. Zhang, Q.; Silver, M.; Chen, Y.-J.; Wolf, J.; Hayek, J.; Alagkiozidis, I. Comparison of Minimally Invasive Surgery with Open Surgery for Type II Endometrial Cancer: An Analysis of the National Cancer Database. Healthcare 2023, 11, 3122. [Google Scholar] [CrossRef] [PubMed]
  13. Wright, J.D.; Burke, W.M.; Wilde, E.T.; Lewin, S.N.; Charles, A.S.; Kim, J.H.; Goldman, N.; Neugut, A.I.; Herzog, T.J.; Hershman, D.L. Comparative Effectiveness of Robotic Versus Laparoscopic Hysterectomy for Endometrial Cancer. J. Clin. Oncol. 2012, 30, 783–791. [Google Scholar] [CrossRef] [PubMed]
  14. Sia, T.Y.; Basaran, D.; Dagher, C.; Sassine, D.; Brandt, B.; Rosalik, K.; Mueller, J.J.; Broach, V.; Makker, V.; Soslow, R.A.; et al. Laparoscopy with or without robotic assistance does not negatively impact long-term oncologic outcomes in patients with uterine serous carcinoma. Gynecol. Oncol. 2023, 175, 8–14. [Google Scholar] [CrossRef] [PubMed]
  15. Eoh, K.-J.; Nam, E.-J.; Kim, S.-W.; Shin, M.; Kim, S.J.; Kim, J.A.; Kim, Y.T. Nationwide Comparison of Surgical and Oncologic Outcomes in Endometrial Cancer Patients Undergoing Robotic, Laparoscopic, and Open Surgery: A Population-Based Cohort Study. Cancer Res. Treat. 2021, 53, 549–557. [Google Scholar] [CrossRef] [PubMed]
  16. Argenta, P.A.; Mattson, J.; Rivard, C.L.; Luther, E.; Schefter, A.; Vogel, R.I. Robot-assisted versus laparoscopic minimally invasive surgery for the treatment of stage I endometrial cancer. Gynecol. Oncol. 2022, 165, 347–352. [Google Scholar] [CrossRef] [PubMed]
  17. Song, J.; Le, T.; Hopkins, L.; Fung-Kee-Fung, M.; Lupe, K.; Gaudet, M.; Choan, E.; Samant, R. A comparison of disease recurrence between robotic versus laparotomy approach in patients with intermediate-risk endometrial cancer. Int. J. Gynecol. Cancer 2020, 30, 160–166. [Google Scholar] [CrossRef] [PubMed]
  18. Cusimano, M.C.; Simpson, A.N.; Dossa, F.; Liani, V.; Kaur, Y.; Acuna, S.A.; Robertson, D.; Satkunaratnam, A.; Bernardini, M.Q.; Ferguson, S.E.; et al. Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: A systematic review and meta-analysis of conversions and complications. Am. J. Obstet. Gynecol. 2019, 221, 410–428. [Google Scholar] [CrossRef] [PubMed]
  19. Moss, E.L.; Morgan, G.; Martin, A.P.; Sarhanis, P.; Ind, T. Surgical trends, outcomes and disparities in minimal invasive surgery for patients with endometrial cancer in England: A retrospective cohort study. BMJ Open 2020, 10, e036222. [Google Scholar] [CrossRef] [PubMed]
  20. Blake, E.A.; Sheeder, J.; Behbakht, K.; Guntupalli, S.R. Factors Impacting Use of Robotic Surgery for Treatment of Endometrial Cancer in the United States. Ann. Surg. Oncol. 2016, 23, 3744–3748. [Google Scholar] [CrossRef]
  21. Whetstone, S.; Burke, W.; Sangini, S. Health disparities in endometrial cancer. Obstet. Gynecol. 2022, 139, 645–659. [Google Scholar] [CrossRef]
  22. Sherman, M.E.; Devesa, S.S. Analysis of racial differences in incidence, survival, and mortality for malignant tumors of the uterine corpus. Cancer 2003, 98, 176–186. [Google Scholar] [CrossRef]
  23. Doll, K.M.; Winn, A.N. Assessing endometrial cancer risk among US women:Long-term trends using hysterectomy-adjusted analysis. Am. J. Obstet. Gynecol. 2019, 221, 318.e1–318.e9. [Google Scholar] [CrossRef]
  24. Bach, P.B.; Schrag, D.; Brawley, O.W.; Galaznik, A.; Yakren, S.; Begg, C.B. Survival of Blacks and Whites after a cancer diagnosis. JAMA 2002, 287, 2106–2113. [Google Scholar] [CrossRef]
  25. Cote, M.L.; Ruterbusch, J.J.; Olson, S.H.; Lu, K.; Ali-Fehmi, R. The growing burden of endometrial cancer: A major racial disparity affecting Black women. Cancer Epidemiol. Biomark. Prev. 2015, 24, 1407–1415. [Google Scholar] [CrossRef]
  26. Wright, J.D.; Fiorelli, J.; Schiff, P.B.; Burke, W.M.; Kansler, A.L.; Cohen, C.J.; Herzog, T.J. Racial disparities for uterine corpus tumors: Changes in clinical characteristics and treatment over time. Cancer 2009, 115, 1276–1285. [Google Scholar] [CrossRef]
  27. Fader, A.N.; Habermann, E.B.; Hanson, K.T.; Lin, J.F.; Grendys, E.C.; Dowdy, S.C. Disparities in treatment and survival for women with endometrial cancer: A contemporary National Cancer Database registry analysis. Gynecol. Oncol. 2016, 143, 98–104. [Google Scholar] [CrossRef] [PubMed]
  28. Madison, T.; Schottenfeld, D.; James, S.A.; Schwartz, A.G.; Gruber, S.B. Endometrial cancer: Socioeconomic status and racial/ethnic differences in stage at diagnosis, treatment, and survival. Am. J. Public Health 2004, 94, 2104–2111. [Google Scholar] [CrossRef]
  29. Rojas, C.; Tian, C.; Powell, M.A.; Chan, J.K.; Bateman, N.W.; Conrads, T.P.; Rocconi, R.P.; Jones, N.L.; Shriver, C.D.; Hamilton, C.A.; et al. Racial disparities in uterine and ovarian carcinosarcoma: A population-based analysis of treatment and survival. Gynecol. Oncol. 2020, 157, 67–77. [Google Scholar] [CrossRef] [PubMed]
  30. Han, G.; Sidhu, D.; Duggan, M.A.; Arseneau, J.; Cesari, M.; Clement, P.B.; Ewanowich, C.A.; Kalloger, S.E.; Köbel, M. Reproducibility of Histological Cell Type in High-Grade Endometrial Carcinoma. Mod. Pathol. 2013, 26, 1594–1604. [Google Scholar] [CrossRef]
  31. Levine, D.A.; The Cancer Genome Atlas Research Network. Integrated genomic characterization of endometrial carcinoma. Nature 2013, 497, 67–73. [Google Scholar] [CrossRef]
Cancers 16 02584 g001
Figure 1. Overall survival of patients with type II endometrial cancer undergoing robot-assisted versus conventional laparoscopy.
Figure 1. Overall survival of patients with type II endometrial cancer undergoing robot-assisted versus conventional laparoscopy.
Cancers 16 02584 g001
Table 1. Patient demographics and disease characteristics.
Table 1. Patient demographics and disease characteristics.
Variable Laparoscopy (n = 2094)Robotic (n = 5074)p-Value
Age69 (68–69)68 (68–69)0.081
RaceWhite1478 (72.1%)3914 (77.1%)<0.001
Black463 (22.6%)905 (17.8%)
Asian/Pacific Islander65 (3.2%)149 (2.9%)
Other25 (1.2%)51 (1%)
Unknown18 (0.9%)55 (1.1%)
EthnicityNon-Hispanic1865 (91%)4639 (91.4%)0.049
Hispanic143 (7%)297 (5.9%)
Unknown41 (2%)138 (2.7%)
Insurance StatusNo Insurance55 (2.7%)86 (1.7%)0.048
Private Insurance702 (34.3%)1802 (35.5%)
Medicaid/Medicare/Other Public Insurance1275 (62.2%)3146 (62%)
Unknown17 (0.8%)40 (0.8%)
Year of Diagnosis2010268 (13.1%)547 (10.8%)0.005
2011359 (17.5%)793 (15.6%)
2012381 (18.6%)994 (19.6%)
2013475 (23.2%)1307 (25.8%)
2014566 (27.6%)1433 (28.2%)
HistologyClear-Cell261 (12.7%)640 (12.6%)0.929
Carcinosarcoma478 (23.3%)1205 (23.7%)
Serous1310 (63.9%)3229 (63.6%)
Stage I1282 (62.6%)3364 (66.3%)0.008
II155 (7.6%)370 (7.3%)
III612 (29.9%)1340 (26.4%)
Tumor Size (cm)4.59 (4.41–4.77)4.13 (4.04–4.21)<0.001
Any Lymph Nodes Retrieved 1739 (85%)4636 (91.4%)<0.001
Median Number of Lymph Nodes Retrieved per Patient 12 (4–20)14 (7–22)<0.001
Positive Lymph Nodes 413 (23.8%)918 (19.8%)<0.001
Conversion to Open Surgery 245 (12%)138 (2.7%)<0.001
Adjuvant Radiation or Chemotherapy 1066 (52.5%)2801 (55.5%)0.025
Hospital Length of Stay (days) 2 (1–3)1 (1–2)<0.001
30-day Readmission 49 (2.4%)127 (2.5%)0.819
90-day Mortality 45 (2.2%)64 (1.3%)0.004
Table 2. Multivariable overall survival analysis.
Table 2. Multivariable overall survival analysis.
VariablesLevelaHR95% Confidence Intervalp-Value
Robotic vs. Laparoscopic 0.971(0.895–1.053)0.477
Age 1.045(1.041–1.049)<0.001
RaceWhite ref.
Black/African American1.356(1.237–1.486)<0.001
Asian0.969(0.758–1.239)0.803
Other1.023(0.694–1.508)0.907
Unknown1.085(0.727–1.619)0.689
EthnicityNon-Hispanic ref.0.028
Hispanic0.782(0.649–0.941)0.009
Unknown0.914(0.724–1.155)0.452
HistologyClear-Cell ref.
Carcinosarcoma1.817(1.587–2.08)<0.001
Serous1.138(1.004–1.29)0.043
Stage1 ref.
21.87(1.63–2.145)<0.001
32.989(2.762–3.235)<0.001
Adjuvant Radiation or Chemotherapy 0.777(0.72–0.839)<0.001
Table 3. Multivariable analysis of conversion to laparotomy.
Table 3. Multivariable analysis of conversion to laparotomy.
Variable MIS (n = 6740)Converted to Open Surgery (n = 383)p-Value
Age68 (68–69)68 (67–69)0.935
RaceWhite5143 (76.3)249 (65)<0.001
Black1253 (18.6)115 (30)
Asian/Pacific Islander206 (3.1)8 (2.1)
Other73 (1.1)3 (0.8)
Unknown65 (1)8 (2.1)
EthnicityNon-Hispanic6152 (91.3)352 (91.9)0.26
Hispanic422 (6.3)18 (4.7)
Unknown166 (2.5)13 (3.4)
Insurance StatusNo Insurance130 (1.9)11 (2.9)0.101
Private Insurance2388 (35.4)116 (30.3)
Medicaid/Medicare/Other Public4169 (61.9)252 (65.8)
Unknown53 (0.8)4 (1)
Year of Diagnosis2010767 (11.4)48 (12.5)0.354
20111078 (16)74 (19.3)
20121302 (19.3)73 (19.1)
20131697 (25.2)85 (22.2)
20141896 (28.1)103 (26.9)
Tumor Size (cm) 4.19 (4.11–4.27)5.32 (4.94–5.71)<0.001
HistologyClear-Cell 859 (12.7)42 (11)0.036
Carcinosarcoma1572 (23.3%)111 (29%)
Serous4309 (63.9%)230 (60.0%)
StageI4442 (65.9)204 (53.3)<0.001
II504 (7.5)21 (5.5)
II1794 (26.6)158 (41.3)
Adjuvant therapy 3666 (54.7)201 (52.8)0.451
Surgery TypeLaparoscopy1804 (26.8)245 (64)<0.001
Robotic4936 (73.2)138 (36)
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Lamiman, K.; Silver, M.; Goncalves, N.; Kim, M.; Alagkiozidis, I. Impact of Robotic Assistance on Minimally Invasive Surgery for Type II Endometrial Cancer: A National Cancer Database Analysis. Cancers 2024, 16, 2584. https://doi.org/10.3390/cancers16142584

AMA Style

Lamiman K, Silver M, Goncalves N, Kim M, Alagkiozidis I. Impact of Robotic Assistance on Minimally Invasive Surgery for Type II Endometrial Cancer: A National Cancer Database Analysis. Cancers. 2024; 16(14):2584. https://doi.org/10.3390/cancers16142584

Chicago/Turabian Style

Lamiman, Kelly, Michael Silver, Nicole Goncalves, Michael Kim, and Ioannis Alagkiozidis. 2024. "Impact of Robotic Assistance on Minimally Invasive Surgery for Type II Endometrial Cancer: A National Cancer Database Analysis" Cancers 16, no. 14: 2584. https://doi.org/10.3390/cancers16142584

APA Style

Lamiman, K., Silver, M., Goncalves, N., Kim, M., & Alagkiozidis, I. (2024). Impact of Robotic Assistance on Minimally Invasive Surgery for Type II Endometrial Cancer: A National Cancer Database Analysis. Cancers, 16(14), 2584. https://doi.org/10.3390/cancers16142584

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop