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Might robotic-assisted surgery become commonplace in endometrial cancer treatment?

Over the last few decades, minimally invasive surgery (MIS), such as traditional and robotic-assisted laparoscopy, has been progressively implemented as the standard approach to treat women with endometrial cancer [1]. Robotic-assisted laparoscopy emerged as an advancement of traditional laparoscopy with main advantages including three-dimensional optics, no tremor, camera stability, and shorter learning curves. In the past, laparotomy with extrafascial hysterectomy, bilateral salpingo-oophorectomy, with or without pelvic and paraaortic lymphadenectomy was the standard of treatment for endometrial cancer; however, this approach is associated with significant morbidity such as bleeding, pain, and wound infection or dehiscence mainly in obese and diabetic patients [2]. A large prospective randomized trial (LAP2), examining the surgical outcomes of laparoscopy compared to laparotomy for the staging of endometrial cancer patients, showed significantly fewer grade 2 postoperative complications in the laparoscopic arm (14.3%) compared to the laparotomy one (21.1%), as well as shorter hospital stay (2 days versus 4 days) (p < 0.0001). Final results do not demonstrate a survival decrement from laparoscopy, comforting patients and surgeons in choosing the less morbid procedure; however, such data could be biased by the relatively high (26%) conversion rate to laparotomy in the laparoscopic cohort [3]. A review of four previously published meta-analyses [4] involving 2913 robotic, 2196 laparoscopic, and 1219 laparotomy-treated endometrial cancer patients showed similar incidence of complications between robotic surgery and laparoscopy, except for reduced blood loss and fewer conversions to laparotomy for the former [5,6]. However, in the most recent Cochrane review [7] evaluating the efficacy and safety of robotic-assisted surgery (RAS) compared with conventional laparoscopic surgery (CLS) for benign and malignant gynecological disease, the authors concluded that it is uncertain whether RAS has lower intraoperative and postoperative complication rates. Moderate-quality evidence suggests that robotic hysterectomies (RHs) take longer but may be associated with a shorter hospital stay. Moreover, they found limited evidence on the efficacy and safety of RAS compared with CLS for gynecological cancer. On the other hand, a recent systematic review and metaanalysis [8] show that RH in endometrial cancer may have advantages in reducing overall complications, length of stay (LOS), estimated blood loss (EBL), transfusion, and readmission compared to those for open hysterectomy (OH) and in reducing LOS, EBL, and intraoperative complications (especially urinary tract injuries) compared to those for laparoscopic hysterectomy (LH). Therefore, RH may be a generally safer and better option than OH and LH for patients with endometrial cancer [9,10]. Another more recent review and meta-analysis [11] compared RH and LH, including 36 papers, one RCT, with a total of 8075 patients (3830 robotic and 4245 laparoscopic). There was no statistically significant difference in the duration of surgery or operating room times; except for the one RCT, that reported shorter operating times for robotic surgery. The EBL, the LOS, and the total complication rate were also less in the robotic arm. Furthermore, there were significantly less conversions to laparotomy for robotic surgery. However, very limited data are available regarding oncologic outcomes. A survival analysis was retrospectively performed on 415 endometrial cancer patients: 183 women had roboticand 232 laparoscopic-assisted surgery. With a median follow-up of 38 months, there was no significant difference in survival (3-year survival: 93.3% and 93.6%, respectively), disease-free survival (DFS) (3-year DFS: 83.3% and 88.4%, respectively), or disease recurrence (14.8% and 12.1%, respectively) [12]. Moreover, outcomes of robotic surgery were comparable to those reported in the Surveillance Epidemiology and End Results database from the National Cancer Institute, with 88.7% overall survival at 5 years for early stage endometrial [13]. A report from the American College of Surgeons National Surgical Quality Improvement Program database compared surgical outcomes in more than 2000 surgeries for patients affected by endometrial cancer performed by laparotomy or MIS in the United States between 2006 and 2010. Although a progressive implementation of MIS in the treatment of endometrial cancer patients was observed, this was still limited from 18% in 2006 to 48% of patients in 2010. The authors suggested that if 90% of patients would undergo MIS, 8059 fewer complications, 127,257 fewer days of hospitalization, and 534 million dollars would be saved yearly [14]. Therefore, employing MIS to treat women with endometrial cancer seems to be crucial to