Introduction

Endometrial cancer is the sixth most common female cancer and the second most common gynecologic cancer worldwide [1, 2]. It is the most common gynecologic cancer in developed western countries [3, 4], and the number of patients in these countries is increasing [5]. In eastern countries, the incidence also is increasing rapidly [5], and it will likely become the most common gynecologic cancer in the near future [69].

Approximately 75 % of endometrial cancers are diagnosed at an early stage in which the disease is confined to the uterus [10]. The cure and survival rate is very high in these patients after surgical management, with or without adjuvant therapy. Surgical management is the mainstay of treatment for patients with endometrial cancer. Contemporary standard surgical management for endometrial cancer includes total hysterectomy, bilateral salpingo-oophorectomy, and pelvic and/or para-aortic lymphadenectomy through laparotomy. However, a recent trend in the surgical management of endometrial cancer is the use of laparoscopic surgery. Laparoscopic surgery has been shown to have several benefits over a conventional abdominal approach in the surgical management of benign disease, including less postoperative pain, improved cosmesis, less blood loss, shorter recovery time, and shorter length of hospital stay without increasing perioperative complications [11]. Indeed, whilst endometrial cancer is the first gynecologic cancer to be treated laparoscopically, a laparoscopic approach also is being used for the surgical management of malignant disease. Following the first report on the use of laparoscopic surgery for endometrial cancer by Childers et al. [12], the feasibility, safety, and efficacy of laparoscopic surgery in the surgical management of endometrial cancer has been reported in numerous retrospective studies [1325], prospective nonrandomized studies [2629], or randomized, controlled trials (RCTs) [3042, 43••, 44••, 45••]. With advances in surgical technique and instrumentation, laparoscopic surgery recently has become widely used for the surgical management of endometrial cancer, with an increasing role being noted for treatment of the disease.

This review provides an update on the role of laparoscopic surgery for the surgical management of endometrial cancer with particular emphasis on feasibility, safety, and efficacy based on the results of randomized, controlled trials comparing laparoscopy and laparotomy for surgical staging of endometrial cancer.

Feasibility of Laparoscopic Surgery

With recent advances in surgical instrumentation and technique, all surgical procedures for the management of endometrial cancer can now be performed using laparoscopy. However, in the largest randomized, controlled trial (Gynecologic Oncology Group (GOG), LAP 2 trial) comparing laparoscopy with laparotomy for surgical staging of endometrial cancer, the rate of conversion to laparotomy after initially being assigned to laparoscopic surgery was 25.8 % [44••]. The main reason for conversion to laparotomy was obesity (approximately 60 % of cases), and the conversion rate for morbidly obese women was 57 % [44••]. Lack of surgical experience in using a laparoscopic technique for cancer treatment may be one key reason for such a high conversion rate; only 8 % of surgical staging procedures for endometrial cancer were performed using laparoscopic surgery during the GOG LAP2 trial in the United States (1996–2005) [46•]. The results of eight RCTs comparing laparoscopy and laparotomy for surgical staging of endometrial cancer are shown in Table 1 [3042, 43••, 44••, 45••]. The main reasons for conversion to laparotomy after initial assignment to laparoscopic surgery in these RCTs are shown in Table 2 [3042, 43••, 44••, 45••]. Excluding the GOG LAP2 trial, the conversion rate in RCTs ranged from 0 % to 10.8 %. In experienced surgeons’ retrospective or prospective series, the conversion rate is approximately 5 % [14, 17, 23, 26, 47]. In series where experienced surgeons performed consecutive laparoscopic surgery for all patients with early-stage endometrial cancer, regardless of age, body mass index, uterine size, or history of prior surgery, the conversion rate was only 3–5 % [46•, 48], and only 7 % for morbidly obese patients [46•]. This indicates that laparoscopic surgery is feasible for the vast majority of patients with early-stage endometrial cancer; however, surgeon’s experience in using the laparoscopic technique is critical to achieve good outcomes.

Table 1 Results of randomized, controlled trials comparing laparoscopy and laparotomy for surgical staging of endometrial cancer
Table 2 Cases that were convereted to laparotomy after assinged to laparoscopic surgery in randomized, controlled trials

Perioperative Outcomes and Complications of Laparoscopic Surgery

Many retrospective studies [1325], prospective nonrandomized studies [2629], and meta-analyses [49•, 5052, 53•] published during the last decade have suggested that laparoscopic surgery has an improved outcomes profile in terms of estimated blood loss and transfusion requirements, recovery of bowel movement, postoperative hospital stay, and perioperative complications compared with laparotomy in the surgical management of endometrial cancer. These findings have been confirmed in recent RCTs comparing laparoscopy and laparotomy for surgical staging of endometrial cancer (Table 1) [3042, 43••, 44••, 45••].

The following discussion of outcomes and complications of laparoscopic surgery compared with laparotomy is based on the results of the eight RCTs presented in Table 1. It can be seen that the operating time for laparoscopic surgery was similar to or slightly longer than that of laparotomy for surgical staging of endometrial cancer. However, operating time depended on the surgeon’s experience with laparoscopic surgery. Estimated blood loss was significantly less for laparoscopic surgery in all RCTs, and transfusion requirement also was less frequent for laparoscopic surgery in most studies. The time interval to the recovery of bowel movement was reported in only one RCT, and it was significantly shorter in the laparoscopic surgery group. Postoperative hospital stay was significantly shorter for the laparoscopic surgery group in all RCTs. These results demonstrate the overall faster recovery of patients who undergo laparoscopic surgery compared with laparotomy. Other studies have reported less need for pain medication and quicker resumption of daily activities in patients who undergo laparoscopic surgery [42]. Intraoperative complication rates were similar between laparoscopic surgery and laparotomy in all RCTs, but postoperative complication rates were lower for the laparoscopic surgery group in most studies. The number of lymph nodes retrieved was similar between laparoscopic surgery and laparotomy in most studies. Therefore, laparoscopic surgery for surgical staging of endometrial cancer is associated with less blood loss and transfusion, faster recovery of bowel movement, less use of pain medication and quicker resumption of daily activities, shorter postoperative hospital stay, and less frequent postoperative complications compared with laparotomy. Operating time of laparoscopic surgery is similar to or slightly longer than that of laparotomy.

Quality of Life after Laparoscopic Surgery

Only four RCTs have reported quality of life (QOL) data for patients undergoing either laparoscopic or laparotomy [36, 37, 39, 42, 43••]. Zullo et al. performed QOL assessments at baseline, at 1, 2, and 6 months, and then annually for 7 years after surgery [36, 37]. Laparoscopic surgery was associated with a significantly better QOL for the first 3 years after surgery, after which time no difference was noted.

Kornblith et al. reported quality of life (QOL) data for the first 802 patients of the GOG LAP2 study [43••]. Assessments were performed at baseline, at 1, 3, and 6 weeks, and 6 months after surgery. Laparoscopic surgery was associated with significantly higher Functional Assessment of Cancer Therapy-General (FACT-G) scores, better physical functioning, better body image, less pain (including its effect on QOL), and an earlier resumption of normal activities and return to work at 6 weeks after surgery compared with laparotomic surgery. However, the difference in body image and return to work between laparoscopic and laparotomic surgery groups was modest at 6 weeks after surgery, and differences in QOL parameters were not significant at 6 months after surgery except for body image where laparoscopic surgery showed a significant benefit.

Janda et al. compared the QOL results of 361 patients undergoing either laparoscopy or laparotomy for stage I endometrial cancer [39]. QOL assessments were performed at baseline, at 1 and 4 weeks (early), and 3 and 6 months (late) after surgery. Laparoscopic surgery was associated with a significantly greater improvement in QOL from baseline compared with that of laparotomic surgery in all subscales of FACT-G except emotional and social well being in the early phase of recovery. Improvement in QOL up to 6 months after surgery continued to favor laparoscopic surgery, except for the emotional and social well being subscale of FACT-G and the visual analogue scale of the EuroQOL five dimensions (EuroQOL-VAS).

Mourits et al. also compared QOL results between laparoscopy and laparotomy as a secondary outcome of their study [42]. Assessments were performed at baseline, and at 6 weeks, 3 months, and 6 months after surgery. The response rate from the 283 study participants to the QOL questionnaire was 90.1 %. Laparoscopic surgery was associated with a significantly higher physical functioning subscale of the SF-36 at 6 weeks and a significantly higher role-physical subscale at 3 months after surgery. However, laparoscopic surgery was associated with a significantly lower vitality subscale of the mental dimension at 3 months after surgery. There was no difference in other subscales between the two surgery groups.

These RCTs demonstrate that laparoscopic surgery is associated with an improved QOL compared with laparotomy after surgical staging for endometrial cancer, especially in the early phase of recovery. This benefit is, however, subdued in the late phase of recovery.

Survival Outcomes After Laparoscopic Surgery

There is no evidence that laparoscopic surgery compromises the survival of patients with endometrial cancer. Retrospective [1325] or prospective, nonrandomized studies [2629] have shown comparable survival outcomes for laparoscopic surgery and laparotomy. Four RCTs reported the long-term survival outcomes after laparoscopic surgery compared with laparotomy in patients with endometrial cancer (Table 1) [33, 35, 36, 45••]. Laparoscopic surgery had similar survival outcomes compared with laparotomy in these RCTs. The GOG LAP2 trial was designed to confirm the noninferiority of recurrence-free interval, defined as a hazard ratio of 1.4, for laparoscopy relative to laparotomy with sufficient statistical power [45••]. This trial confirmed the equivalence of survival outcomes between laparoscopy and laparotomy for surgical management of endometrial cancer. The estimated 5-year recurrence rate was 13.68 % for the laparoscopy group and 11.61 % for the laparotomy group. The estimated 5-year overall survival was 89.8 % for both surgery groups. The pattern of recurrence was not different between the two groups. Trocar site recurrence occurred in only 4 of 1,696 patients (0.24 %) in the laparoscopy group. Because three of the four patients with trocar site recurrence had stage III-IV disease, the risk of trocar site recurrence after laparoscopic surgery in patients with stage I-II disease appears negligible. It can be concluded that laparoscopic surgery has equivalent survival outcomes compared with laparotomy after stating operation of endometrial cancer.

Conclusions

Surgical management is the main stay for the treatment of endometrial cancer. Surgical staging through laparotomy has been the “gold standard” surgical management for endometrial cancer. However, with recent advances in laparoscopic surgical techniques and instruments, all surgical procedures for the treatment of endometrial cancer can be performed using laparoscopy, and the use of laparoscopic surgery for the surgical management of endometrial cancer is continuously increasing. Current literature shows that laparoscopic surgery is the preferred alternative to laparotomic surgery for the surgical management of endometrial cancer. Laparoscopic surgery is feasible in the vast majority of patients with endometrial cancer if the surgery is performed by an experienced surgeon. Laparoscopic surgery is associated with favorable operative outcomes, including less blood loss and need for transfusion, less use of pain medication, faster recovery of bowel movement, shorter postoperative hospital stay, less frequent perioperative complications, earlier return to work, and faster resumption of daily activities. The lymph node yield is similar between laparoscopic surgery and laparotomic surgery. The QOL of patients in the early phase of recovery after surgery is significantly improved in patients who undergo laparoscopic surgery. The disease-free and overall survival rates after either laparoscopic or laparotomic surgery are comparable. Surgeon’s training and experience are important factors in achieving optimal outcomes when using a laparoscopic approach.