Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2018 Oct 31;10(10):CD006655.
doi: 10.1002/14651858.CD006655.pub3.

Laparoscopy versus laparotomy for the management of early stage endometrial cancer

Khadra Galaal  1 , Hannah Donkers, Andrew Bryant, Alberto D Lopes
Affiliations
Meta-Analysis

Laparoscopy versus laparotomy for the management of early stage endometrial cancer

Khadra Galaal et al. Cochrane Database Syst Rev. .

Abstract

Background: This is an update of a previous Cochrane Review published in 2012, Issue 9.Surgery for endometrial cancer (hysterectomy with removal of both fallopian tubes and ovaries) is performed through laparotomy. It has been suggested that the laparoscopic approach is associated with a reduction in operative morbidity. Over the last two decades there has been a steady increase of the use of laparoscopy for endometrial cancer. This review investigated the evidence of benefits and harms of laparoscopic surgery compared with laparotomy for presumed early stage endometrial cancer.

Objectives: To compare overall survival (OS) and disease free survival (DFS) for laparoscopic surgery versus laparotomy in women with presumed early stage endometrial cancer.

Search methods: For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 5) in the Cochrane Library, MEDLINE via Ovid (April 2012 to June 2018) and Embase via Ovid (April 2012 to June 2018). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies. The trial registers included NHMRC Clinical Trials Register, UKCCCR Register of Cancer Trials, Meta-Register and Physician Data Query Protocol.

Selection criteria: Randomised controlled trials (RCTs) comparing laparoscopy and laparotomy for early stage endometrial cancer.

Data collection and analysis: We independently abstracted data and assessed risk of bias. We used hazard ratios (HRs) for OS and recurrence free survival (RFS), risk ratios (RR) for severe adverse events and mean differences (MD) for continuous outcomes in women who received laparoscopy or laparotomy with 9% confidence intervals (CI). These were pooled in random-effects meta-analyses.

Main results: We identified one new study in this update of the review. The review contains nine RCTs comparing laparoscopy with laparotomy for the surgical management of early stage endometrial cancer.All nine studies met the inclusion criteria and assessed 4389 women at the end of the studies. Six studies assessing 3993 participants with early stage endometrial cancer found no significant difference in the risk of death between women who underwent laparoscopy and women who underwent laparotomy (HR 1.04, 95% 0.86 to 1.25; moderate-certainty evidence) and five studies assessing 3710 participants found no significant difference in the risk of recurrence between the laparoscopy and laparotomy groups (HR 1.14, 95% CI 0.90 to 1.43; moderate-certainty evidence). There was no significant difference in the rate of perioperative death; women requiring a blood transfusion; and bladder, ureteric, bowel and vascular injury. However, one meta-analysis of three studies found that women in the laparoscopy group lost significantly less blood than women in the laparotomy group (MD -106.82 mL, 95% CI -141.59 to -72.06; low-certainty evidence). A further meta-analysis of two studies, which assessed 3344 women and included one very large trial of over 2500 participants, found that there was no clinical difference in the risk of severe postoperative complications in women in the laparoscopy and laparotomy groups (RR 0.78, 95% CI 0.44 to 1.38). Most studies were at moderate risk of bias. All nine studies reported hospital stay and results showed that on average, laparoscopy was associated with a significantly shorter hospital stay.

Authors' conclusions: This review found low to moderate-certainty evidence to support the role of laparoscopy for the management of early endometrial cancer. For presumed early stage primary endometrioid adenocarcinoma of the endometrium, laparoscopy is associated with similar OS and DFS. Furthermore, laparoscopy is associated with reduced operative morbidity and hospital stay. There is no significant difference in severe postoperative morbidity between the two modalities.The certainty of evidence for OS and RFS was moderate and was downgraded for unclear risk of bias profiles and imprecision in effect estimates. However, most studies used adequate methods of sequence generation and concealment of allocation so studies were not prone to selection bias. Adverse event outcomes were downgraded for the same reasons and additionally for low event rates and low power thus these outcomes provided low-certainty evidence.

PubMed Disclaimer

Conflict of interest statement

KG: none known. HD: none known. AB: none known. AL: none known.

Figures

1
1
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
2
2
Forest plot of comparison: 1 Primary outcomes, outcome: 1.1 Overall survival.
3
3
Forest plot of comparison: 1 Primary outcomes, outcome: 1.2 Recurrence free survival.
4
4
Forest plot of comparison: 2 Secondary outcomes, outcome: 2.1 Perioperative death.
1.1
1.1. Analysis
Comparison 1 Primary outcomes, Outcome 1 Overall survival.
1.2
1.2. Analysis
Comparison 1 Primary outcomes, Outcome 2 Recurrence free survival.
2.1
2.1. Analysis
Comparison 2 Secondary outcomes, Outcome 1 Perioperative death.
2.2
2.2. Analysis
Comparison 2 Secondary outcomes, Outcome 2 Bladder injury.
2.3
2.3. Analysis
Comparison 2 Secondary outcomes, Outcome 3 Urethral injury.
2.4
2.4. Analysis
Comparison 2 Secondary outcomes, Outcome 4 Vascular injury.
2.5
2.5. Analysis
Comparison 2 Secondary outcomes, Outcome 5 Bowel injury.
2.6
2.6. Analysis
Comparison 2 Secondary outcomes, Outcome 6 Severe postoperative adverse events.
2.7
2.7. Analysis
Comparison 2 Secondary outcomes, Outcome 7 Estimated blood loss (mL).
2.8
2.8. Analysis
Comparison 2 Secondary outcomes, Outcome 8 Blood transfusion required.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Fram 2002 {published data only}
    1. Fram KM. Laparoscopically assisted vaginal hysterectomy versus abdominal hysterectomy in stage I endometrial cancer. International Journal of Gynecological Cancer 2002;12(1):57‐61. [MEDLINE: ; 1048‐891X] - PubMed
Janda 2017 {published data only}
    1. Janda M, Gebski V, Brand A, Hogg R, Jobling TW, Land R, et al. Quality of life after total laparoscopic hysterectomy versus total abdominal hysterectomy for stage I endometrial cancer (LACE): a randomised trial. Lancet Oncology 2010;11(8):772‐80. [DOI: 10.1016/S1470-2045(10)70145-5] - DOI - PubMed
    1. Janda M, Gebski V, Davies LC, Forder P, Brand A, Hogg R, et al. Effect of total laparoscopic hysterectomy vs total abdominal hysterectomy on disease‐free survival among women with stage I endometrial cancer: a randomized clinical trial. JAMA 2017;317(12):1224‐33. - PubMed
    1. Janda M, Gebski V, Forder P, Jackson D, Williams G, Obermair A, LACE Trial Committee. Total laparoscopic versus open surgery for stage 1 endometrial cancer: the LACE randomized controlled trial. Contemporary Clinical Trials 2006;27(4):353‐63. [Clinical Trials identifier: NCT00096408; DOI: 10.1016/j.cct.2006.03.004; PUBMED: 16678497] - DOI - PubMed
    1. Kondalsamy‐Chennakesavan S, Janda M, Gebski V, Baker J, Brand A, Hogg R, et al. Risk factors to predict the incidence of surgical adverse events following open or laparoscopic surgery for apparent early stage endometrial cancer: results from a randomised controlled trial. European Journal of Cancer 2012;48(14):2155‐62. - PubMed
    1. Obermair A, Janda M, Baker J, Kondalsamy‐Chennakesavan S, Brand A, Hogg R, et al. Improved surgical safety after laparoscopic compared to open surgery for apparent early stage endometrial cancer: results from a randomised controlled trial. European Journal of Cancer 2012;48(8):1147‐53. - PubMed
Lu 2013 {published data only}
    1. Lu Q, Liu H, Liu C, Wang S, Li S, Guo S, et al. Comparison of laparoscopy and laparotomy for management of endometrial carcinoma: a prospective randomized study with 11‐year experience. Journal of Cancer Research and Clinical Oncology 2013;139:1853‐9. - PMC - PubMed
Malzoni 2009 {published data only}
    1. Malzoni M, Tinelli R, Consentino F, Perone C, Rasile M, Iuzzolino D, et al. Total laparoscopic hysterectomy vs. abdominal hysterectomy with lymphadenectomy for early stage endometrial cancer: a prospective randomized study. Gynecologic Oncology 2009;112:126‐33. - PubMed
Mourits 2010 {published data only}
    1. Bijen CB, Briët JM, Bock GH, Arts HJ, Bergsma‐Kadijk JA, Mourits MJ. Total laparoscopic hysterectomy versus abdominal hysterectomy in the treatment of patients with early stage endometrial cancer: a randomized multi center study. BMC Cancer 2009;9(1):23. [Dutch Trial Registry: NTR821] - PMC - PubMed
    1. Mourits MJ, Bijen CB, Arts HJ, Ter Brugge HG, Sidje R, Paulsen L, et al. Safety of laparoscopy versus laparotomy in early‐stage endometrial cancer: a randomised trial. Lancet Oncology 2010;11(8):763‐71. [DOI: 10.1016/S1470-2045(10)70143-1; Dutch Trial Registry: NTR821] - DOI - PubMed
Tozzi 2005 {published data only}
    1. Malur S, Possover M, Michels W, Schneider A. Laparoscopic‐assisted vaginal versus abdominal surgery in patients with endometrial cancer‐a prospective randomized trial. Gynecologic Oncology 2001;80(2):239‐44. - PubMed
    1. Tozzi R, Malur S, Koehler C, Schneider A. Analysis of morbidity in patients with endometrial cancer: is there a commitment to offer laparoscopy?. Gynecologic Oncology 2005;97(1):4‐9. - PubMed
    1. Tozzi R, Malur S, Koehler C, Schneider A. Laparoscopy versus laparotomy in endometrial cancer: first analysis of survival of a randomized prospective study. Journal of Minimally Invasive Gynecology 2005;12(2):130‐6. - PubMed
Walker 2012 {published data only}
    1. Kornblith AB, Huang HQ, Walker JL, Spirtos NM, Rotmensch J, Cella D. Quality of life of patients with endometrial cancer undergoing laparoscopic International Federation of Gynecology and Obstetrics staging compared with laparotomy: a Gynecologic Oncology Group Study. Journal of Clinical Oncology 2009;27(32):5337‐42. [DOI: 10.1200/JCO.2009.22.3529] - DOI - PMC - PubMed
    1. Walker JL, Piedmonte M, Spirtos N, Eisenkop S, Schlaerth J, Mannel RS, et al. Surgical staging of uterine cancer: randomized phase III trial of laparoscopy vs laparotomy – a Gyneclogic Oncology Group Study (GOG): preliminary results. Journal of Clinical Oncology 2006;24(18S):5010.
    1. Walker JL, Piedmonte M, Spirtos N, Eisenkop S, Schlaerth JB, Mannel RS, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. Journal of Clinical Oncology 2009;27:5331‐6. - PMC - PubMed
    1. Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, Barakat R, Pearl ML, Sharma SK. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. Journal of Clinical Oncology Mar 1, 2012;30(7):695‐700. [DOI: 10.1200/JCO.2011.38.8645.] - DOI - PMC - PubMed
    1. Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, et al. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. Journal of Clinical Oncology 2012;30(7):695‐700. - PMC - PubMed
Zorlu 2005 {published data only}
    1. Zorlu CG, Simsek T, Seker Ari E. Laparoscopy or laparotomy for the management of endometrial cancer. Journal of the Society of Laparoendoscopic Surgeons 2005;9:442‐6. - PMC - PubMed
Zullo 2009 {published data only}
    1. Zullo F, Palomba S, Falbo A, Russo T, Mocciaro R, Tartaglia E, et al. Laparoscopic surgery vs laparotomy for early stage endometrial cancer: long‐term data of a randomized controlled trial. American Journal of Obstetrics and Gynecology 2009; Vol. 200, issue 3:e1‐9. [0002‐9378; PUBMED: 19167698 ] - PubMed
    1. Zullo F, Palomba S, Russo T, Falbo A, Costantino M, Tolino A, et al. A prospective randomized comparison between laparoscopic and laparotomic approaches in women with early stage endometrial cancer: a focus on the quality of life. American Journal of Obstetrics and Gynecology 2005;1934:1344‐52. - PubMed

References to studies excluded from this review

de la Orden 2008 {published data only}
    1. Orden SG, Reza MM, Blasco JA, Andradas E, Callejo D, Pérez T. Laparoscopic hysterectomy in the treatment of endometrial cancer: a systematic review. Journal of Minimally Invasive Gynecology 2008;15(4):395‐401. - PubMed
Ghezzi 2006 {published data only}
    1. Ghezzi F, Cromi A, Bergamini V, Uccella S, Beretta P, Franchi M, et al. Laparoscopic‐assisted vaginal hysterectomy versus total laparoscopic hysterectomy for the management of endometrial cancer: a randomized clinical trial. Journal of Minimally Invasive Gynecology 2006;13(2):114‐20. [MEDLINE: ; 1553‐4650] - PubMed
Ghezzi 2010 {published data only}
    1. Ghezzi F, Cromi A, Uccella S, Siesto G, Giudici S, Serati M, et al. Laparoscopic versus open surgery for endometrial cancer: a minimum 3‐year follow‐up study. Annals of Surgical Oncology 2010;17:271‐8. [DOI: 10.1245/s10434-009-0720-1] - DOI - PubMed
Imesch 2009 {published data only}
    1. Imesch P, Dedes K, Fink D. Laparoscopic approach in endometrial cancer: current data and evidence [Laparoskopische Therapie des Korpuskarzinoms: Datenlage und Evidenz]. Gynakologisch‐geburtshilfliche Rundschau 2009;49(3):111‐6. - PubMed
Ju 2009 {published data only}
    1. Ju W, Myung SK, Kim Y, Choi HJ, Kim SC. Comparison of laparoscopy and laparotomy for management of endometrial carcinoma: a meta‐analysis. International Journal of Gynecological Cancer 2009;19(3):400‐6. [DOI: 10.1111/IGC.0b013e3181a1caf8] - DOI - PubMed
Lin 2007 {published data only}
    1. Lin F, Zhang QJ, Zheng FY, Zhao HQ, Zeng QQ, Zeng MH, et al. Laparoscopically assisted versus open surgery for endometrial cancer? A meta‐analysis of randomized controlled trials. International Journal of Gynecological Cancer 2007;18(6):1315‐25. [DOI: 10.1111/j.1525-1438.2007.01180.x] - DOI - PubMed
Liu 2009 {published data only}
    1. Liu J, Zhou X, Liang Y. Laparoscopic and abdominal hysterectomy: systematic evaluation and meta‐analysis of randomized controlled trials. Journal of Practical Obstetrics and Gynecology 2009. [DOI: ]
Palomba 2009 {published data only}
    1. Palomba S, Falbo A, Mocciaro R, Russo T, Zullo F. Laparoscopic treatment for endometrial cancer: a meta‐analysis of randomized controlled trials (RCTs). Gynecologic Oncology 2009;112(2):415‐21. [DOI: 10.1016/j.ygyno.2008.09.014] - DOI - PubMed
    1. Palomba S, Falbo A, Russo T, Zullo F. Updating of a recent meta‐analysis of randomized controlled trials to assess the safety and the efficacy of the laparoscopic surgery for treating early stage endometrial cancer. Gynecologic Oncology 2009;114(1):135‐6. [PUBMED: 19375153] - PubMed

Additional references

Berek 2010
    1. Berek JS, Hacker NF. Berek and Hacker's Gynecologic Oncology. 5th Edition. Philadelphia (PA): Lippincott Williams & Wilkins, 2010.
Creasman 2006
    1. Creasman WT, Odicino F, Mausinneuve P, Quinn MA, Beller U, Benedet JL, et al. Carcinoma of the corpus uteri. International Journal of Gynaecology and Obstetrics 2006;95(Suppl 1):S105‐43. - PubMed
CTCAE 2006
    1. Common Terminology Criteria for Adverse Events v3.0 (CTCAE). ctep.cancer.gov/forms/CTCAEv3.pdf 9 August 2006.
Deeks 2001
    1. Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for examining heterogeneity and combining results from several studies in meta‐analysis. Egger M, Davey Smith G, Altman DG, editor(s). Systematic Reviews in Health Care: Meta‐Analysis in Context, 2nd edition. London: BMJ Publication Group, 2001.
DerSimonian 1986
    1. DerSimonian R, Laird N. Meta‐analysis in clinical trials. Controlled Clinical Trials 1986;7:177‐88. - PubMed
Eltabbakh 2000
    1. Eltabbakh GH, Shamonki MI, Moody JM, Garafano LL. Hysterectomy for obese women with endometrial cancer: laparoscopy or laparotomy?. Gynecologic Oncology 2000;78(3):329‐35. - PubMed
Eltabbakh 2002
    1. Eltabbakh GH. Analysis of survival after laparoscopy in women with endometrial carcinoma. Cancer 2002;95(9):1894‐901. - PubMed
Ferlay 2015
    1. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. International Journal of Cancer 2015;136(5):E359‐86. [DOI: 10.1002/ijc.29210] - DOI - PubMed
FIGO Staging 2009
    1. FIGO Committee on Gyneacologic Oncology. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. International Journal of Gynecology and Obstetrics 2009;105:103‐4. - PubMed
GLOBOCAN 2008
    1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008, cancer incidence and mortality worldwide, 2010. globocan.iarc.fr. Lyon, France, (accessed prior to 12 October 2018).
GRADE Working Group
    1. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004;328:1490‐4. - PMC - PubMed
Hauspy 2010
    1. Hauspy J, Jiménez W, Rosen B, Gotlieb WH, Fung‐Kee‐Fung M, Plante M. Laparoscopic surgery for endometrial cancer: a review. Journal of Obstetrics and Gynaecology Canada 2010;32(6):570‐9. - PubMed
He 2013
    1. He H, Zeng D, Ou H, Tang Y, Li J, Zhong H. Laparoscopic treatment of endometrial cancer: systematic review. Journal of Minimally Invasive Gynecology 2013;20(4):413‐23. [DOI: 10.1016/j.jmig.2013.01.005] - DOI - PubMed
Higgins 2003
    1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analyses. BMJ 2003;327:557‐60. - PMC - PubMed
Higgins 2011
    1. Higgins JP, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org. Chichester: John Wiley & Sons, 2011.
Holub 2000
    1. Holub Z, Bartös P, Jabor A, Eim J, Fischlová D, Kliment L. Laparoscopic surgery in obese women with endometrial cancer. Journal of the American Association of Gynecologic Laparoscopists 2000;7(1):83‐8. [MEDLINE: ; 1074‐3804] - PubMed
Marana 1999
    1. Marana R, Busacca M, Zupi E, Garcea N, Paparella P, Catalano GF. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. American Journal of Obstetrics & Gynecology 1999;180:270‐5. - PubMed
Muntz 1999
    1. Muntz HG, Goff BA, Madsen BL, Yon JL. Port‐site recurrence after laparoscopic surgery for endometrial carcinoma. Obstetrics and Gynecology 1999;93(5):807‐9. - PubMed
Obermair 2004
    1. Obermair A, Manolitsas TP, Leung Y, Hammond IG, McCartney AJ. Total laparoscopic hysterectomy for endometrial cancer: patterns of recurrence and survival. Gynecologic Oncology 2004;92(3):789‐93. - PubMed
Obermair 2005
    1. Obermair A, Manolitsas TP, Leung Y, Hammond IG, McCartney AJ. Total laparoscopic hysterectomy versus total abdominal hysterectomy for obese women with endometrial cancer. International Journal of Gynecological Cancer 2005;15:319‐24. [MEDLINE: ; 1048‐891X] - PubMed
Parmar 1998
    1. Parmar MK, Torri V, Stewart L. Extracting summary statistics to perform meta‐analyses of the published literature for survival endpoints. Statistics in Medicine 1998;17(24):2815‐34. - PubMed
Review Manager 2014 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Sanjuan 2005
    1. Sanjuan A, Hernandez S, Pahisa J, Ayuso JR, Torne A, Martinez Roman S, et al. Port‐site metastasis after laparoscopic surgery for endometrial carcinoma: two case reports. Gynecologic Oncology 2005;96(2):539‐54. - PubMed
Scribner 2001
    1. Scribner J, Dennis R, Walker JL, Johnson GA, McMeekin SD, Gold MA, et al. Surgical management of early‐stage endometrial cancer in the elderly: is laparoscopy feasible?. Gynecologic Oncology 2001;83(3):563‐8. - PubMed
Seracchioli 2005
    1. Seracchioli R, Venturoli S, Ceccarin M, Cantarelli M, Ceccaroni M, Pignotti E, et al. Is total laparoscopic surgery for endometrial carcinoma at risk of local recurrence? A long‐term survival. Anticancer Research 2005;25:2423‐8. - PubMed
Shepherd 1989
    1. Shepherd JH. Revised FIGO staging for gynaecological cancer. British Journal of Obstetrics and Gynaecology 1989;96(8):889‐92. - PubMed
Smits 2013
    1. Smits A, Lopes A, Das N, Bekkers R, Galaal K. The impact of BMI on quality of life in obese endometrial cancer survivors: does size matter?. Gynecologic Oncology 2013;132(1):137‐41. [DOI: 10.1016/j.ygyno.2013.11.018] - DOI - PubMed
Tjalma 2003
    1. Tjalma WA. Laparoscopic surgery and port‐site metastases: routine measurements to reduce the risk. European Journal of Gynaecological Oncology 2003;24:3‐4. - PubMed

Publication types

MeSH terms