Laparoscopy Versus Laparotomy For Endometrial Cancer:a Meta-analysis Of Clinical Efficacy And Retrospective Study Of Safety

Background:At present,the disadvantage in the survival rate of laparoscopic surgery for cervical cancer has led to controversy among different scholars.A prospective multicenter randomized controlled clinical trial^[1]showed that in patients with cervical cancer the4.5-year disease-free survival rate in minimally invasive surgery group was 10.6%（86%vs 96.5%）lower than that in open surgery group,and the 3-year overall survival rate was significantly lower than that in open surgery group（93.8%vs 99.0%）.Another retrospective epidemiological study^[2],which combines Harvard University,Columbia University,Northwestern University and two large databases,the National Cancer Database（NCDB）and the National Cancer Center（NCI）,showed that:The mortality risk of cervical cancer patients in minimally invasive surgery group was 65%（HR=1.65）higher than that in open surgery group;Before minimally invasive surgery was used（2000year-2006year）,the survival rate of cervical cancer patients increased with years（although there was no statistical difference,but it increased by 0.3%annually）;Minimally invasive surgery was adopted from 2006 to 2010,the 4-years overall survival rate of cervical cancer decreased by 0.8%annually.The 2019 NCCN guidelines clearly pointed out:Compared with open surgery,the disease-free survival rate and total survival rate of laparoscopic surgery for cervical cancer are both lower,so it is only recommended for cervical cancer patients with stage IA1.The patients should be informed the short-term benefits and potential cancer risk of different surgical methods before the operation and choose the operative methods independently.FIGO Guidelines for Endometrial Cancer 2018^[3]is recommended laparoscopy for the treatment of early endometrial cancer.However,whether the safety,effectiveness and recurrence rate of laparoscopic surgery for endometrial cancer are as risky as that for cervical cancer,there is still lacked of evidence-based medical evidence to prove that laparoscopic surgery for endometrial cancer has a disadvantage in survival rate.We evaluate the safety and efficacy of laparoscopic and open surgery for endometrial cancer through meta-analysis and retrospective study in order to provide a strong basis for clinical treatment.Objective:To make a Meta-analysis to compare the efficacy and safety after laparoscopy or laparotomy for endometrial carcinoma.Retrospective analysis of clinical data of the endometrioid adenocarcinoma patients who were treated by laparoscopy or laparotomy in the First Affiliated Hospital of Jinan University hospital,and to compare the safety of the two kinds of operation methods.Methods:Using the computer search tool to search the Cochrane Library,PubMed,WanFang databases,CBM and CNKI databases with the terms and synonyms:"endometrial cancer","laparoscopy","laparotomy","randomized trials"between January 2011and August 2018 to find related studies.According to the literature collected inclusion and exclusion criteria to strictly screen to exclude non-compliant and low quality studies;Operative time,hospital stay,blood loss,intraoperative and postoperative complications,pelvic lymphadenectomy,the recurrence,overall survival rates and recurrence-free survival about laparoscopy or laparotomy were extracted from each study.Data were evaluated using RevMan 5.3 for meta-analysis.The datebase of the First Affiliated Hospital of Jinan University hospital was searched for the endometrioid adenocarcinoma patients who were treated by laparoscopy or laparotomy between January 1^st,2011 and January 1^st,2019.Operative time,blood loss,hospital stay,pelvic lymphadenectomy,intraoperative and postoperative complications,postoperative anal exhaust time and pelvic peritoneal drainage were collected and analysed.Results:A total of 11 RCTs involving 6574 patients were included.Meta-analysis showed that compared with laparotomy,laparoscopy had longer operation time（MD=37.56,95%CI:13.56⁶1.56,P=0.00200）,shorter time of hospital stay（MD=-2.41,95%CI:-3.08^-1.74,P<0.00001）,lesser amount of intraoperative bleeding（MD=-97.09,95%CI:-104.91^-89.28,P<0.00001）,the greater number of pelvic nodes removed during operation（MD=1.02,95%CI:0.83¹.21,P<0.00001）,a higher incidence of intraoperative complications（OR=1.27,95%CI:1.01¹.60,P=0.04000）,lower incidence of postoperative complications（OR=0.63,95%CI:0.54⁰.73,P<0.00001）.there were no differences between the 2 groups in the rate of recurrence（OR=1.02,95%CI:0.85¹.24,P=0.81000）、overall survival（OR=1.06,95%CI:0.87¹.29,P=0.54000）and recurrence-free survival（OR=0.97,95%CI:0.81¹.16,P=0.74000）.The related coefficient between the number of lymph node resection and recurrence rate in laparoscopic group was-0.826,and that in laparoscopic group was-0.621.There was no correlation between the number of lymph node resection and the recurrence of endometrial cancer.In the datebase of the First Affiliated Hospital of Jinan University hospital between January 1^st,2011 and January 1^st,2019,a total of 123 endometrioid adenocarcinoma patients who were treated by laparoscopy or laparotomy.The average operation time of laparoscopic group is 268.44±65.00 min and open abdomen group is 234.75±46.99 min,the difference was significant（P=0.00200）;The intraoperative blood loss of laparoscopic group is 211.67±347.92 ml and open abdomen group is 494.53±493.94 ml,the difference was significant（P=0.00000）;The hospitalization days of laparoscopic group is 16.22±6.30 days and open abdomen group is 22.31±7.27days,the difference was statistically significant（P=0.00000）;The pelvic peritoneal drainage of laparoscopic group is 496.08±701.97 ml and open abdomen group is423.36±772.55 ml,there is not significant differences（P=0.58500）;The average time of postoperative evacuation of laparoscopic group is 42.72±14.89 h and open abdomen group is 53.22±19.03 h,the difference was statistically significant（P=0.00100）;The average number of lymph nodes removed of laparoscopic group is14.04±6.32 pieces and open abdomen group is 21.18±6.38 pieces,the difference was statistically significant（P=0.00000）;The postoperative complications of laparoscopic group is 6（10.00%）cases and open abdomen group is 14（22.22%）cases,there is not significant differences（P=0.06600）.Conclusion:1.Laparoscopy and laparotomy are similar in the treatment of endometrial cancer.Although the risk of laparoscopic surgery is slightly higher,there is no difference in long-term efficacy.Therefore,laparoscopic surgery for early endometrial cancer is recommended.2.The number of lymph nodes resected for early endometrial cancer has no significant relationship with the survival rate after operation.The main purpose of lymph node resection is surgical pathological staging.