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Does Extensive Upper Abdomen Surgery During Primary Cytoreduction Impact on Long-term Quality of Life? Baseline Plus Longitudinal Quality-of-Life Assessment Would Have Provided a Better Answer

W interest, we read the article of Lee et al.1 In this randomized parallel trial, the influence of the use of the RUMI intrauterine uterus manipulator on surgical outcomes was evaluated in a woman who underwent laparoscopic hysterectomy for endometrial cancer. The authors found no significant difference in positive peritoneal cytology and lymphovascular invasion between the 2 groups. Laparoscopic hysterectomy for earlystage endometrial carcinoma is considered to be equally safe with respect to outcome compared to total abdominal hysterectomy.2 For uterinemanipulation, 2 different devices are used, manipulators with insertion into the cervix and uterine cavity as well as the extracervical positioned McCartney tube.3 Currently, there is no standard recommendation for the use of uterine manipulation in the surgical treatment of endometrial cancer. However, manipulators that are inserted into the uterine cavity tend to make manipulation easier than the McCartney tube. However, as yet, the influence on both surgical and oncological outcome of using such intrauterine devices is unclear. Therefore, the study by Lee et al gives important new data on this subject. Yet, there are some limitations that need to be addressed. First, the uterine manipulator was inserted after ligation of both the fallopian tubes. This ligation procedure is not performed routinely by all surgeons. However, if done, one would not expect to find endometrial cancer cell spillage after insertion of the uterine manipulator, as the tubes are already occluded. This is more likely the explanation for the fact that no differences were found than the use of the manipulator itself. In this trial, the authors compared the use of an intrauterine manipulator with an EEA sizer covered with an occlusion balloon to maintain pneumoperitoneum. The occlusion balloon used was not initially designed for the EEA sizer. Data showed one patient with positive peritoneal cytology after the use of the EEA sizer, which is either a sample error or may imply spillage of cancer cells, which would make the EEA sizer of little value compared to the intrauterine manipulator. Using the McCartney tube instead would have been a better alternative. This tube is a flexible transvaginal tube that is inserted in the vagina and maintains pneumoperitoneumwithout fixation, cuffs, or packing and is specifically designed for laparoscopic hysterectomy.3 Third, the risk of perforation when using a uterine manipulator in endometrial cancer patients was not mentioned. Data on this topic is scant, which may reflect publication bias of relatively rare complications. Yet, especially in patients with deep myometrial invasion, this may be important. Due to the fact that over 70% of the included patients have less than 50%myometrial invasion, this study may be underpowered to detect differences in recurrence. Larger series are necessary to confirm the current findings of outcome as well as the risks of perforation and the reflection on outcome.