Which is the best surgical approach for endometrial cancer treatment in elderly women? A systematic review and meta-analysis

Abstract

Objective: To compare the surgical outcomes between laparoscopy, laparotomy and robotic surgery in young (<65 years) and elderly (≥65 years) women for treatment of endometrial cancer (EC). In addition, the secondary outcomes included a comparison of these surgical methods for EC management in patients aged <70 years and ≥70 years. Operative time, blood loss, requirement for blood transfusion, intra-operative and postoperative complications, and length of hospital stay were evaluated in the two groups of patients.

Methods: The meta-analysis included 10 trials between 2000 and 2024. Quantitative variables were meta-analysed using the mean difference (MD), while qualitative variables were analysed using the risk ratio (RR). The Dersimonian-Laird random effects models included a point estimate with 95 % confidence intervals (CI). The Cochran Q test and I² were used to assess heterogeneity. The risk of bias was evaluated using the OSQE method. The protocol for this study was recorded in PROSPERO (CRD42025633382).

Results: Regarding women aged <65 years, for total operative time, overall heterogeneity was 38.96 % and overall MD was -7.48 (95 % CI -23.67 to 8.71; p = 0.16). For length of stay, overall heterogeneity was 72.21 % and overall MD was 0.65 (95 % CI 0.36-0.94; p < 0.001). For blood loss, overall heterogeneity was 0 % and overall RR was -6.75 (95 % CI -35.72 to 22.22; p = 0.30). Moreover, for the requirement for blood transfusion, overall heterogeneity was 59.36 % and overall RR was 1.39 (95 % CI 0.96-2.01; p = 0.04). For intra-operative complications, overall heterogeneity was 56.93 % and overall RR was 1.61 (95 % CI 1.31-1.98; p = 0.02). Finally, for postoperative complications, overall heterogeneity was 15.48 % and overall RR was 1.03 (95 % CI 0.84-1.27; p = 0.35). No significant differences in these surgical outcomes were found between the three surgical approaches (p = 0.16, 0.31, 0.36, 0.79, 0.28 and 0.18, respectively). In women aged < 70 years, for total operative time, overall heterogeneity was 13.07 % and overall MD was 1.19 (95 % CI -11.16 to 13.54; p = 0.43). For length of stay, overall heterogeneity was 53.73 % and overall MD was 0.98 (95 % CI 0.32-1.65; p = 0.09). For blood loss, overall heterogeneity was 0 % and overall MD was 1.22 (95 % CI 0.78-1.91; p = 0.0.98). For intra-operative complications, overall heterogeneity was 0 % and overall MD was 1.00 (95 % CI 0.77-1.30; p = 0.96). Finally, for postoperative complications, overall heterogeneity was 43.36 % and overall MD was 1.21 (95 % CI 0.89-1.64; p = 0.13). No significant differences in these surgical outcomes were found between the three surgical approaches (p = 0.12, 0.08, 0.28, 0.91 and 0.81, respectively).

Conclusion: This systematic review and meta-analysis on different surgical approaches to treat EC found no significant differences in operative outcomes between minimally invasive surgery and laparotomy. Efforts to reduce related morbidity are crucial, and a multidisciplinary strategy is the optimal treatment pathway in elderly women.

Keywords: Elderly; Endometrial cancer; Laparoscopy; Laparotomy; Robotic.