Impact of uterine manipulator on oncological outcome in endometrial cancer surgery

Abstract

BACKGROUND: There are limited data available to indicate whether oncological outcomes might be influenced by the uterine manipulator, which is used at the time of hysterectomy for minimally invasive surgery in patients with endometrial cancer. The current evidence derives from retrospective studies with limited sample sizes. Without substantial evidence to support its use, surgeons are required to make decisions about its use based only on their personal choice and surgical experience. OBJECTIVE: To evaluate the use of the uterine manipulator on oncological outcomes after minimally invasive surgery, for apparent early-stage endometrial cancer. STUDY DESIGN: We performed a retrospective multicentric study to assess the oncological safety of uterine manipulator use in patients with apparent early-stage endometrial cancer, treated with minimally invasive surgery. The type of manipulator, surgical staging, histology, lymphovascular space invasion, International Federation of Gynecology and Obstetrics stage, adjuvant treatment, recurrence, and pattern of recurrence were evaluated. The primary objective was to determine the relapse rate. The secondary objective was to determine recurrence-free survival, overall survival, and the pattern of recurrence. RESULTS: A total of 2661 women from 15 centers were included; 1756 patients underwent hysterectomy with a uterine manipulator and 905 without it. Both groups were balanced with respect to histology, tumor grade, myometrial invasion, International Federation of Gynecology and Obstetrics stage, and adjuvant therapy. The rate of recurrence was 11.69% in the uterine manipulator group and 7.4% in the nomanipulator group (P<.001). The use of the uterine manipulator was associated with a higher risk of recurrence (hazard ratio, 2.31; 95% confidence interval, 1.27e4.20; P¼.006). The use of uterine manipulator in uterus-confined endometrial cancer (International Federation of Gynecology and Obstetrics [FIGO] IeII) was associated with lower disease-free survival (hazard ratio, 1.74; 95% confidence interval, 0.57e0.97; P¼.027) and higher risk of death (hazard ratio, 1.74; 95% confidence interval, 1.07e2.83; P¼.026). No differences were found regarding the pattern of recurrence between both groups (chi-square statistic, 1.74; P¼.63). CONCLUSION: In this study, the use of a uterine manipulator was associated with a worse oncological outcome in patients with uterusconfined endometrial cancer (International Federation of Gynecology and Obstetrics IeII) who underwent minimally invasive surgery. Prospective trials are essential to confirm these results.

A Multicentric Randomized Trial to Evaluate the ROle of Uterine MANipulator on Laparoscopic/Robotic HYsterectomy for the Treatment of Early-Stage Endometrial Cancer: The ROMANHY Trial

“…Those data have been confirmed in our analysis (Table 5). Again, in a recent retrospective study, Padilla-Iserte et al reported, in a large uterine-confined EC series, that the use of IUM was associated with a worse oncological outcome in patients with uterus-confined endometrial cancer (Figo Stages I-II) who underwent minimally invasive surgery (44).…”

Use of the uterine manipulator in minimally invasive surgery for endometrial cancer. Oncological outcomes

“…In a prospective study with 46 patients, in which peritoneal washing and cytology were performed before inserting the uterine manipulator, after its insertion and after removal of the uterus through the vagina, it was found that the use of the uterine manipulator was associated with a higher rate of positive peritoneal cytologies [12]. A retrospective, multicentre study carried out in Spain in which data were collected from 2,661 patients, of which 1,756 underwent hysterectomy with a uterine manipulator and 905 without it, found worse oncological results among the first patients: recurrence rate of 11.69% versus 7.4%, lower disease-free survival and higher risk of death [13].…”

How to avoid peritoneal tumor spillage during total abdominal hysterectomy in uterine cancers with cervical invasion

“…Worse oncological outcomes have been reported in patients presenting with gynecological malignancies in the event of inadequate tumor manipulation. 1 Since the publication of the Laparoscopic Approach to Cervical Cancer trial, 2 the importance of surgical protective maneuvers has been pointed out in the management of early-stage cervical and endometrial cancers. 1 3 These maneuvers aim to prevent tumor exposure and fragmentation, and peritoneal and vaginal spillage by avoiding the use of a uterine manipulator and performing a meticulous vaginal closure over the tumor.…”