Nationwide Introduction of Minimally Invasive Robotic Surgery for Early-Stage Endometrial Cancer and Its Association With Severe Complications | Endometrial Cancer | JAMA Surgery | JAMA Network
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    Original Investigation
    February 27, 2019

    Nationwide Introduction of Minimally Invasive Robotic Surgery for Early-Stage Endometrial Cancer and Its Association With Severe Complications

    Author Affiliations
    • 1Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark
    • 2Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
    • 3Faculty of Health Sciences, Clinical Institute, University of Southern Denmark, Odense, Denmark
    • 4Department of Pelvic Cancer, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
    • 5Centre for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
    • 6Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
    • 7Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Odense, Denmark
    JAMA Surg. 2019;154(6):530-538. doi:10.1001/jamasurg.2018.5840
    Key Points

    Question  Is the nationwide introduction of minimally invasive robotic surgery associated with a decreased risk of severe complications in patients with early-stage endometrial cancer?

    Findings  A Danish nationwide cohort of 5654 women with early-stage endometrial cancer was divided into 2 groups based on the time of the introduction of minimally invasive robotic surgery in their region. The risk of severe complications was significantly reduced in the group undergoing surgery after the introduction of minimally invasive robotic surgery.

    Meaning  The national implementation of minimally invasive robotic surgery was associated with an increased proportion of minimally invasive surgical procedures, which translated into a reduced risk of severe complications in women with early-stage endometrial cancer.


    Importance  Minimally invasive laparoscopic surgery (MILS) for endometrial cancer reduces surgical morbidity compared with a total abdominal hysterectomy. However, only a minority of women with early-stage endometrial cancer undergo MILS.

    Objective  To evaluate the association between the Danish nationwide introduction of minimally invasive robotic surgery (MIRS) and severe complications in patients with early-stage endometrial cancer.

    Design, Setting, and Participants  In this nationwide prospective cohort study of 5654 women with early-stage endometrial cancer who had undergone surgery during the period from January 1, 2005, to June 30, 2015, data from the Danish Gynecological Cancer Database were linked with national registers on socioeconomic status, deaths, hospital diagnoses, and hospital treatments. The women were divided into 2 groups; group 1 underwent surgery before the introduction of MIRS in their region, and group 2 underwent surgery after the introduction of MIRS. Women with an unknown disease stage, an unknown association with MIRS implementation, unknown histologic findings, sarcoma, or synchronous cancer were excluded, as were women who underwent vaginal or an unknown surgical type of hysterectomy. Statistical analysis was conducted from February 2, 2017, to May 4, 2018.

    Exposure  Minimally invasive robotic surgery, MILS, or total abdominal hysterectomy.

    Main Outcomes and Measures  Severe complications were dichotomized and encompassed death within 30 days after surgery and intraoperative and postoperative complications diagnosed within 90 days after surgery.

    Results  A total of 3091 women (mean [SD] age, 67 [10] years) were allocated to group 1, and a total of 2563 women (mean [SD] age, 68 [10] years) were allocated to group 2. In multivariate logistic regression analyses, the odds of severe complications were significantly higher in group 1 than in group 2 (odds ratio [OR], 1.39; 95% CI, 1.11-1.74). The proportion of women undergoing MILS was 14.1% (n = 436) in group 1 and 22.2% in group 2 (n = 569). The proportion of women undergoing MIRS in group 2 was 50.0% (n = 1282). In group 2, multivariate logistic regression analyses demonstrated that a total abdominal hysterectomy was associated with increased odds of severe complications compared with MILS (OR, 2.58; 95% CI, 1.80-3.70) and MIRS (OR, 3.87; 95% CI, 2.52-5.93). No difference was found for MILS compared with MIRS (OR, 1.50; 95% CI, 0.99-2.27).

    Conclusions and Relevance  The national introduction of MIRS changed the surgical approach for early-stage endometrial cancer from open surgery to minimally invasive surgery. This change in surgical approach was associated with a significantly reduced risk of severe complications.