Laparoscopy versus laparotomy for the surgical management of apparent early stage ovarian cancer

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Abstract

Objective.

To compare the results of laparoscopic staging of apparent early ovarian cancer (EOC) with those obtained with comprehensive surgical staging via laparotomy.

Methods.

Consecutive patients undergoing comprehensive laparoscopic staging for presumed EOC (LPS group; N = 15) were compared with historical controls selected from consecutive women who have had conventional staging with open surgery (LPT group; N = 19).

Results.

No difference was found in demographics and preoperative variables between the two groups. There were no significant differences between the two groups with regard to median number of lymph nodes and likelihood of identifying metastatic disease. No conversion to laparotomy and no intraoperative complication occurred in the LPS group. Operative time was significantly longer in the LPS group when compared with the LPT group (377 ± 47 vs. 272 ± 81 min, P = 0.002). One patient in the LPS group had a retroperitoneal haematoma recognized in the postoperative period, and this required laparotomy and ligature of the hypogastric arteries to achieve haemostasis. Minor postoperative complications occurred in 1 (6.7%) patient in the LPS group and in 8 (42.1%) patients in the LPT group (P = 0.047). Hospital stay was significantly shorter in the LPS group [3 (2–12) vs. 7 (4–14) days, P = 0.001]. Median (range) follow-up time was 16 (4–33) and 60 (32–108) months in the LPS and LPT group, respectively. Eleven (73.3%) patients in the LPS group and 13 (68.4%) in the LPT group received adjuvant treatment. There were no recurrences in the LPS group whereas 4 (7.1%) recurrences occurred in the LPT group. Overall survival was 100% in both groups.

Conclusion.

Our results suggest that laparoscopic comprehensive surgical staging of EOC is as safe and adequate as the standard surgical staging performed via laparotomy.

Introduction

Ovarian cancer accounts for approximately a quarter of all genital tract malignancies but is responsible for half the deaths from gynecological cancer, primarily due to its late presentation. Only 19% of the patients are diagnosed with stage I disease [1] and early diagnosis is frequently incidental during procedure for supposed benign adnexal masses. When the disease is limited to the ovaries, 5-year survival rates are excellent approaching 90%, but it has been demonstrated that nearly 30% of patients with an apparent early ovarian cancer (EOC) actually harbour microscopic metastatic disease [2], [3]. Disease upstaging has not only implications in providing the most accurate prognostic information, but it affects indications for adjuvant therapy and may ultimately result in an improved disease-free and overall survival [4], [5]. Therefore, an optimal surgical staging of women without gross evidence of extra-ovarian disease is of utmost importance, particularly when considering only clinical observation without adjuvant treatment for patients with stage I ovarian cancer.

Traditional approach to ovarian cancer is surgical comprehensive staging including peritoneal washing, total abdominal hysterectomy, bilateral salpingo-oophorectomy, multiple random biopsies of the peritoneal surface, omentectomy, and pelvic and paraaortic lymphadenectomy, performed through a generous longitudinal midline laparotomy. Laparoscopic approach for the surgical staging or restaging of EOC was first reported in the mid 1990s [6]. However, since stage I ovarian cancer is a rare condition, only limited case series addressing the technical feasibility and safety of laparoscopic staging of presumed EOC have been published so far [7], [8], [9], [10], [11], [12], [13], [14]. In the absence of large-scale randomized controlled trials to validate the benefits of laparoscopy over open surgery for the management of EOC, we must rely only on a small non-randomized case-control study [15] and a retrospective multicenter comparative survey [16] in the recent literature.

This study was designed to compare the results of laparoscopic staging of apparent EOC with those obtained with comprehensive surgical staging via laparotomy in terms of feasibility, adequacy and mid-term outcome.

Section snippets

Materials and methods

Laparoscopic approach for the management of early stage ovarian cancer was introduced at the Department of Obstetric and Gynecology of University of Insubria in January 2003. Consecutive women diagnosed with an apparent stage I ovarian cancer on frozen-section analysis at the time of primary surgery at our institution as well as patients who had previous adnexal surgery elsewhere and referred to our Oncologic Unit for restaging, underwent comprehensive surgical staging by laparoscopy (LPS

Results

The study group consisted of 15 women undergoing comprehensive laparoscopic surgical staging or restaging for EOC. The control group included 19 women who underwent surgical staging by traditional abdominal surgery. There was no difference in demographics and preoperative variables between the two groups (Table 1). In the subgroup of patients referred for restaging the mean interval between the initial surgery and the comprehensive staging was 8 days (range: 5–14). Histological types, tumor

Discussion

The findings of our study suggest that laparoscopy is feasible, safe, and adequate for the staging of EOC when compared with the gold standard laparotomic approach. In 1994 Querleu and Leblanc [6] first demonstrated in a series of 8 patients referred for restaging that laparoscopic surgery could be used to adequately stage ovarian malignancy. Since then several investigators from pioneering centers reported small case series of comprehensive laparoscopic surgical staging of EOC, showing

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  • Minimally invasive surgery for early-stage ovarian cancer: Association between hospital surgical volume and short-term perioperative outcomes

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    The rationale of this approach is that laparotomy is believed to be superior at identifying occult metastatic lesions through increased exposure and palpation that could otherwise be missed via the MIS approach. To examine the feasibility of and outcomes related to MIS for early-stage ovarian cancer, multiple researchers have compared the MIS approach to the historical standard, a laparotomy approach [4–19]. A 2012 systematic literature review concluded that the MIS is comparable to laparotomy with regards to accuracy and adequacy of surgical staging as well as oncologic outcome [20].

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