Push to replace open hysterectomy with keyhole

AUSTRALIAN research highlighting the benefits of total laparoscopic hysterectomy (TLH) for women with stage I endometrial cancer is already changing practice and improving outcomes for patients, and experts say that promoting the wide use of this approach must be a priority.

Lead researcher on the Laparoscopic Approach to Cancer of the Endometrium (LACE) trial and Director at the University of Queensland’s Centre for Gynaecological Cancer Research, Andreas Obermair, told MJA InSight that “our research shows that TLH is going to be the standard treatment for endometrial cancer – and for very good reasons”.

He said that the LACE trial had shown that when compared with total abdominal hysterectomy (TAH), TLH surgery for women with endometrial cancer prevented 120 Australian patients from developing a severe surgical complication every year, saved 2000 patients from staying in hospital for 5 days compared with only 2 days this year, and saved funders of health care $8 million per annum in health care expenditure.

The latest study from the LACE trial, recently published in JAMA, compared the survival outcomes from the two surgical approaches for women with stage I endometrial cancer.

The LACE trial was a multinational trial conducted from 2005 to 2010, in which 27 surgeons from 20 sites in Australia, New Zealand and Hong Kong randomised 760 women with stage I endometrial cancer to either TLH or TAH.

At 4.5 years of follow-up, disease-free survival was 81.3% in the TAH group and 81.6% in the TLH group, and this met the criteria for equivalence. There was no statistically significant difference between the groups in recurrence of endometrial cancer or in overall survival.

“These findings support the use of laparoscopic hysterectomy for women with stage I endometrial cancer,” the authors wrote.

In an accompanying editorial, Dr Jason Wright, from the College of Physicians and Surgeons at Columbia University, said that the research confirmed that laparoscopic hysterectomy was a safe and effective treatment approach for women with early-stage endometrial cancer and should be the preferred modality in this setting.

“Even though the road to defining the benefits of laparoscopic hysterectomy has been long, efforts to promote the procedure for women with endometrial cancer should now be a priority.”

Lead author of the LACE study and research fellow at Queensland University of Technology, Professor Monika Janda, told MJA InSight that what had been missing was evidence that TLH was an appropriate approach.

“Earlier we showed that if women had TLH they had a better quality of life, they left hospital earlier, and they recovered more quickly in regards to their wellbeing, but we hadn’t shown the survival outcomes and that’s what this article now adds.”

She said that since the trial had begun in 2005, practice had already changed.

“When we started the trial, there were only six gynaecological oncology units [in Australia] that were offering the laparoscopic approach to endometrial cancer surgery. Over the course of the trial until 2010, an additional 14 units came on board.”

Dr Stephen Lyons, chair of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and the Australasian Gynaecological Endoscopy and Surgery Society’s joint Endoscopic Surgery Advisory Committee, told MJA InSight that “before this study, there were lots of gynaecologists already doing keyhole surgery for stage I endometrial cancer”.

“That was all well and good. But now we’ve got very good, local evidence with which you can reassure your patients that the keyhole surgery route is the better route.

“Some people think that if it’s an open surgery, then it must be better because you’ve got a big cut and you can see into the tummy, but that is an antiquated view. When you’re looking through the laparoscope into the tummy, you’re magnified three times and are a centimetre or so away from where you’re operating,” Dr Lyons said.

Professor Obermair said that while the LACE trial focused on outcomes from endometrial cancer, there were implications for women who need hysterectomy for benign conditions.

“I hope that some of the general gynaecologists who look after women who need a hysterectomy for benign reasons come around and adopt the approach of laparoscopic hysterectomy.

“We’ve started a program to eradicate total abdominal hysterectomy. Hopefully, this will have a flow-on effect into the general gynaecology world as well.”

Dr Lyons said that he performed a lot of laparoscopy surgeries for benign conditions, such as endometriosis. “It is much easier to do through the keyhole when you know how to do it – it’s all a question of training.”

Professor Obermair said that a large, national TLH education program needed to be rolled out.

“We have done a study, which we’re in the process of submitting for publication, where we surveyed why women receive a total abdominal hysterectomy and not TLH. Basically, the upshot of this is that women follow the surgeon’s advice and with the surgeons who offer a total abdominal hysterectomy, it’s not because it’s better than TLH, it’s because they just can’t do a TLH.”

Dr Lyons said this type of research did put pressure on clinicians to upskill.

“Certainly, all gynaecology oncologists coming out through their training now will be trained to do laparoscopic hysterectomy. For some older doctors who are in a stage of their career where they can’t upskill or it’s too late to upskill, it is difficult, but that’s no excuse for not offering the optimum treatment, which is the laparoscopic route,” Dr Lyons said.

Dr Lyons said that there was a move towards performing many other cancer procedures through keyhole surgery, including ovarian cancer and sometimes early stage cervical cancer.

“With each step along the way, it’s important that good quality studies such as this one can be performed to give the evidence in terms of outcome.”

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