Advances in endoscopic technologies and power sources allowed application of a laparoscopic approach to the management of endometrial cancer. Since 1992, there were multiple reports documenting the feasibility of laparoscopicallyassisted vaginal hysterectomy with bilateral salpingo-oophorectomy and laparoscopic lymphadenectomy for staging and treatment of patients with endometrial cancer (248–256). These early studies demonstrated no differences in lymph node counts, estimated blood loss, and recurrence or survival rates with laparoscopy versus laparotomy, whereas decreased perioperative morbidity, longer operating times, shorter hospital stays, and earlier return to work were associated with laparoscopy.
Although the literature has isolated case reports of port site metastases, there are few data documenting the incidence. Martinez et al. analyzed 1,216 patients with endometrial and cervical cancer and showed that the port site metastasis rate was less than 0.5%; no port site metastases occurred after excluding patients with peritoneal disease (257).
A large prospective study by GOG randomized patients to laparoscopy versus laparotomy for the primary treatment of patients with endometrial cancer (258). Over 2,500 patients were enrolled, 1,696 to laparoscopy and 920 to laparotomy. Consistent with early reports, patients randomized to laparoscopy had shorter hospital stay (52% more than 2 days vs. 94% in the laparotomy group), less blood loss, and fewer postoperative complications (14% vs. 21%). The rate of intra-operative complications was similar, and the operative time was longer in the laparoscopy cohort. There was no difference in lymph node counts, and stage distribution was identical between groups. A follow-up quality-of-life investigation of the same cohorts revealed improved Functional Assessment of Cancer Therapy–General (FACT-G) scores, better physical functioning, better body image, less pain and its interference with quality of life, and an earlier resumption of normal activities and return to work over the 6-week recovery period in the laparoscopic group (259). Although the differences were modest and negligible by 6 months, the analysis was performed as per intention to treat. Of concern is the 24% rate of conversions in the laparoscopic cohort; only 4% were converted because of advanced disease. Furthermore, the conversion rate increased dramatically with body mass index (BMI). This is problematic recognizing that the vast majority of patients with endometrial cancer are obese. The conversion rate for patients with a BMI of 40 was 57%. This implies a limitation of the surgical technique in obese patients.
The use of extraperitoneal laparoscopic staging for para-aortic lymphadenectomy was reported in a prospective investigation of 293 patients with endometrial cancer (260). The extraperitoneal approach greatly improved exposure by circumventing handling of the small bowel and was successful in over 90% of unselected patients up to a BMI of 51. There was no difference in lymph node counts, all dissections were performed to the level of the renal veins, and significant improvements in blood loss, postoperative complications, and length of stay were noted compared to the laparotomy group. The ability to gain access to the renal veins is important, given that 60% of patients with nodal involvement above the inferior mesenteric artery have negative ipsilateral inframesenteric para-aortic nodes (140). Thus, 38% to 46% of patients with para-aortic metastases will be missed if the dissection is limited to the region below the inframesenteric artery. Althoughinfrarenal lymphadenectomy has yet to be proven necessary, the extraperitoneal approach offers the most reliable method to consistently perform a thorough dissection.