{"paper_id":"f879bd03-0232-4e6c-8c66-de9c45cfbd21","body_text":"RESEARCH\nJournal of Robotic Surgery          (2026) 20:468 \nhttps://doi.org/10.1007/s11701-026-03316-6\nIntroduction\nEndometrial cancer (EC) represents a major global health \nburden, ranking seventh among the most frequently diag -\nnosed cancers in women worldwide and fourth among \nEuropean women [1]. Approximately 420,300 new cases of \nEC were reported globally in 2022, of which nearly 125,000 \noccurred within Europe [2, 3]. Both the incidence and mor-\ntality rates of EC have continued to increase, largely attrib -\nutable to the growing prevalence of established risk factors \n[4–6].\nThe World Health Organization (WHO) classifies EC \ninto several main histologic tumour subtypes, including \nendometrioid, serous, and clear cell carcinoma (CCC), \nundifferentiated (UC) and dedifferentiated carcinomas, \ncarcinosarcoma (CS), and mixed carcinoma [ 1, 5, 6]. The \n \r Cornelis G. Gerestein\nc.g.gerestein-2@umcutrecht.nl\n1 Department of Gynecologic Oncology, University Medical \nCenter Utrecht, Utrecht University, PO Box 85500,  \n3508 GA Utrecht, The Netherlands\n2 Department of Radiotherapy, University Medical Center \nUtrecht, Utrecht University, Heidelberglaan 100,  \n3584 CX Utrecht, The Netherlands\n3 Department of Medical Oncology, University Medical Center \nUtrecht, Utrecht University, 85500, 3508 GA Utrecht, The \nNetherlands\n4 Department of Pathology, University Medical Center \nUtrecht, Utrecht University, 85500, 3508 GA Utrecht, The \nNetherlands\nAbstract\nThe prognostic relevance of surgical staging in patients with high-intermediate-risk and high-risk endometrial cancer \nremains uncertain. In this cohort study, we investigated the prognostic role of robot-assisted laparoscopic staging surgery \namong patients with clinically early-stage endometrial carcinoma at a high-intermediate-risk or high-risk for recurrence. \nClinical data of women with clinically International Federation of Gynaecology and Obstetrics (FIGO) 2009 stage I–II, \ngrade 3 endometrioid or non-endometrioid EC who were intended to undergo robot-assisted laparoscopic staging sur -\ngery were retrospectively collected from a single tertiary referral center. The procedure consisted of total hysterectomy \nwith bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and, when feasible, para-aortic lymphadenectomy, with \nadditional omentectomy and peritoneal biopsies performed in a subset of cases. Survival outcomes were assessed using \nKaplan–Meier analysis, with additional subgroup analyses by histological subtype. A total of 166 patients, of which 154 \npatients (92.8%) with FIGO 2009 stage I and 12 patients (7.2%) with FIGO 2009 stage II were included, comprising \nvarious histological subtypes, including 64 (38.6%) with endometrioid carcinoma, 52 (31.3%) with serous carcinoma, 11 \n(6.6%) with clear cell carcinoma, and 27 (16.3%) with carcinosarcoma. Thirty-two patients (19.3%) were reclassified as \nhaving FIGO stage disease III–IV based on final pathology. The 5-year disease-specific survival was 25.5% for upstaged \npatients compared with 73.1% for those who were not upstaged. Robot-assisted laparoscopic staging provides valuable \nprognostic information in clinically early-stage endometrial cancer with a high-intermediate-risk or high-risk of recurrence. \nThese findings underscore the value of surgical staging in informing prognosis and guiding adjuvant treatment decisions.\nKeywords Endometrial neoplasms · Robotic surgical procedures · Treatment outcome · Disease-free survival · \nRecurrence\nReceived: 13 January 2026 / Accepted: 3 March 2026\n© The Author(s) 2026\nLong-term prognostic value of staging surgery for high-intermediate-\nrisk and high-risk endometrial cancer\nAlise de Jong1  · Jasper Markus1  · Ronald P . Zweemer1  · Jacob P . Hoogendam1 · Judith M. Roesink2  ·  \nInge O. Baas3  · Geertruida N. Jonges4 · Cornelis G. Gerestein1\n1 3\n\n\nJournal of Robotic Surgery          (2026) 20:468 \nInternational Federation of Gynaecology and Obstetrics \n(FIGO) staging system further classifies EC by anatomical \ncharacteristics. In 2023, the FIGO classification system was \nupdated to integrate molecular classification with tumour \ncharacteristics and histological subtype [7].\nTo further determine stage, staging surgery is recom -\nmended for patients with grade 3 endometrioid endome -\ntrial carcinoma (EEC) or non-endometrioid EC [ 1, 7–9]. \nIn staging surgery, pelvic lymph node dissection (PLND) \nwith or without paraaortic lymph node dissection (PALND) \nis performed in addition to hysterectomy and bilateral \nsalpingo-oophorectomy. In serous carcinoma (SC) and CS \nomentectomy and peritoneal biopsies should be considered \n[10]. Surgical staging plays an important role in determin -\ning which patients require intensive adjuvant treatment. It \nprovides insight into predictors of prognosis, such as lymph \nnode status, lymphovascular space invasion (LVSI) and dept \nof myometrial invasion [ 11, 12]. This can guide adjuvant \ntreatment strategies and identify patients in whom adju -\nvant treatment may be safely omitted. However, it remains \nunclear whether the prognostic information obtained \nthrough (robot-assisted laparoscopic) staging surgery has an \nimpact on overall survival (OS), disease-specific survival \n(DSS) or disease-free survival (DFS) [ 13]. In this cohort \nstudy, we evaluated the prognostic role of robot-assisted \nlaparoscopic staging (RALS) surgery among patients with \nclinically early-stage EC at a high-intermediate-risk or \nhigh-risk for recurrence.\nMethods\nAll women diagnosed with clinically FIGO 2009 stage I or \nII, grade 3 EEC or non-endometrioid EC who were intended \nto treat with RALS surgery between the 1st of January, 2012, \nuntil the 31st of December, 2023, at the University Medical \nCenter Utrecht, were retrospectively included. Patients were \ntreated in accordance with contemporaneous national and \ninternational guidelines. Follow-up information was docu -\nmented in the medical files. Given the retrospective design \nand use of pseudonominysed data, formal informed consent \nwas not required, as approved by the institutional review \nboard.\nThe primary aim is to evaluate the prognostic role of \nRALS among patients with clinically early-stage EC, with \npresumed high-intermediate-risk or high-risk for recur -\nrence. Main objectives are to determine in how many \npatients RALS resulted in upstaging to advanced FIGO \nstages (FIGO 2009 stage III or IV) and to determine OS, \nDSS, and DFS for patients in whom RALS resulted in \nupstaging to advanced FIGO stages III or IV and compare \nresults to patients without upstaging.\nSecondary objectives are to determine which were the \nlocalisations of metastases leading to upstaging. Other \nobjectives include assessing differences in OS, DSS and \nDFS between patients who were upstaged and those who \nwere not for each histological subtype.\nPatients eligible for inclusion were 18 years old or older, \nwith a diagnosis of primary endometrial carcinoma (grade 3 \nEEC, SC, CCC, CS, UC and dedifferentiated carcinomas or \nmixed carcinoma) confirmed by histopathological examina-\ntion, pre-operative early FIGO 2009 stage (defined as stage \nI or II) who were treated primarily with RALS surgery. \nPatients receiving neoadjuvant treatment prior to surgery \nwere excluded. Relevant clinical variables, including demo-\ngraphics, tumour characteristics, surgical treatment, and \nfollow-up data, were obtained from electronic patient files.\nRisk group classification was performed in accordance \nwith the European Society of Gynaecological Oncology/\nEuropean Society for Radiotherapy and Oncology/Euro -\npean Society of Pathology (ESGO/ESTRO/ESP) guidelines \nof 2020 [ 14]. During the study period, complete molecu -\nlar classification was not routinely available. Patients with \npreoperative stage I grade 3 EEC and stage II EEC were \nclassified as high-intermediate risk EC, whereas preopera -\ntive stage I or II EC with non-endometrioid histologies (SC, \nCCC, UC and dedifferentiated carcinomas, CS, or mixed \ncarcinoma) with myometrial invasion were classified as \nhigh-risk EC. Standard preoperative imaging consisted of \ntransvaginal ultrasonography and abdominal and thoracic \ncomputed tomography (CT). Preoperative magnetic reso -\nnance imaging was not routinely performed to assess for \nmyometrial invasion.\nThe surgical procedure regarding patients with clini -\ncally early-stage EC at high-intermediate- or high-risk for \nrecurrence, performed at the UMC Utrecht has been pre -\nviously described [ 15]. Surgery was performed by a team \nof three gynaecologic oncologists using a robotic surgi -\ncal system (da Vinci Surgical System Si until 2017, X or \nXi from 2018–2023; Intuitive Surgical, Sunnyvale, CA). \nRALS surgery comprised of total hysterectomy with bilat -\neral salpingo-oophorectomy, PLND, and, when feasible, \nPAOLND. PLND included systematic excision of lym -\nphatic tissue along the common, external and internal iliac \nvessels and in the obturator fossa. PAOLND comprised \nexcision of precaval and paracaval lymphatic tissue up to \nthe level of the left renal vein. During this study period, \nthe sentinel lymph node (SLN) procedure was not standard \nof care according to contemporaneous guidelines. In CSa, \nSCs or CCC histologies, omentectomy and peritoneal tis -\nsue sampling were performed in addition to standard stag -\ning. Surgical methods used, including use of the McCartney \nuterine manipulator manufactures by LiNA Medical (Den -\nmark), remained unchanged throughout the study period. \n1 3\n  468  Page 2 of 10\n\nJournal of Robotic Surgery          (2026) 20:468 \nOperation time was calculated from incision until the skin \nwas sutured. Adjuvant treatment strategies were determined \nin a multidisciplinary tumour board setting in accordance \nwith contemporary guidelines and were risk-adapted based \non postoperative FIGO 2009 stage, histological subtype, \ntumour grade, depth of myometrial invasion, LVSI, nodal \ninvolvement, and patient-related factors. Oncological fol -\nlow-up was conducted according to national guidelines, \nwith visits scheduled at three-monthly intervals during the \nfirst two years after surgery, followed by six-monthly inter-\nvals thereafter, up to five years post-treatment. Follow-up \nvisits alternated between the gynaecologist and the radiation \noncologist or medical oncologist, and no routine CT scans \nor tumour marker assessments were performed.\nContinuous variables were described using means with \nstandard deviation (SD) or medians with interquartile range \n(IQR) depending on data distribution. Categorial variables \nwere reported as counts and percentages. Images were cre -\nated with Biorender.com.\nOS was defined as the interval, in days, from the date of \nthe operation to the date of death from any cause or the date \nof last-follow-up. DSS was defined as the interval from the \ndate of the operation to the date of death of disease or the \ndate of last follow-up. Non–disease deaths are censored at \ndeath for DSS. DFS was defined as the interval from the \noperation date until formal confirmation of recurrence at a \nmultidisciplinary tumour board meeting, or until the most \nrecent follow-up. Time-to-event outcomes were evaluated \nusing Kaplan–Meier survival analysis. Statistical signifi -\ncance was assessed using log-rank tests with administra -\ntive censoring at 12, 36, and 60 months. A p-value < 0.05 \nwas defined as statistically significant. Standard error was \ndetermined using Greenwood’s formula. Cox proportional \nhazards regression was performed to assess whether upstag-\ning remained independently associated with survival after \nadjustment for confounders. Multivariable models included \nage, LVSI, and myometrial invasion, selected based on clin-\nical relevance and univariable significance, with the number \nof covariates restricted to avoid overfitting. Hazard ratios \n(HRs) with 95% confidence intervals (CIs) were reported. \nAll analysis, figures and plots were generated in the R statis-\ntical computing environment (R version 4.5.1R Core Team, \n2025).\nResults\nClinical characteristics of the 166 included patients with \nclinically early-stage EC at a high-intermediate- or high-\nrisk for recurrence are described in Table 1. Follow-up dura-\ntion was 25 months [IQR 13.0–44.8].\n160 patients (96.4%) underwent PLND. 136 patients \n(81.9%) underwent PALND. The median BMI was 33.96 \n(30.47–39.04) in the group without PALND, compared to \n25.83 (29.38–23.31) in the group that underwent PALND \n(Table 1).\nFollowing RALS, 32/166 included patients (19.3%) \nwere reclassified as having advanced stage FIGO III-IV \ndisease after surgical staging and were therefore considered \nupstaged (Fig. 1) In total, 21/32 patients (65.6%) had meta-\nstatic lymph nodes; only 5/21 patients (23.8%) had isolated \npara-aortic lymph node metastasis. 5/32 patients (15.6%) \nhad omental metastasis and 5/32 patients (15.6%) had peri-\ntoneum metastasis. Patients were upstaged due to the fol -\nlowing findings: 2/32 (6.3%) because of both omental and \nperitoneal metastases, 3/32 (9.4%) due to omental metas -\ntases only, and 3/32 (9.4%) due to peritoneal metastases \nonly. Among these eight patients, 4/8 (50%) had parametrial \nTable 1 Baseline characteristics of study population\nCharacteristic Study population, n = 166\nAge, years 68.50 (62.00, 73.00)\nBMI, kg/m2 27.48 (23.74, 31.89)\nPrevious abdominal infection 31 (18.7%)\nPrevious abdominal surgery 85 (51.2%)\nSmoking\nCurrent 18 (10.8%)\nStopped over ten years ago 8 (4.8%)\nStopped over five years ago 1 (0.6%)\nStopped less than five years ago 5 (3.0%)\nStopped 4 (2.4%)\nNever 130 (78.3%)\nPreoperative histology\nEndometrioid carcinoma 67 (40.4%)\nSerous carcinoma 58 (34.9%)\nClear cell carcinoma 14 (8.4%)\nCarcinosarcoma 18 (10.8%)\nUndifferentiated carcinoma 5 (3.0%)\nOther 4 (2.4%)\nPreoperative FIGO 2009\nIA 141 (84.9%)\nIB 13 (7.8%)\nII 12 (7.2%)\nPLND performed 160 (96.4%)\nPALND performed 136 (81.9%)\nLymph nodes dissected, n 20 (14, 23)\nOmentectomy performed 108 (65.1%)\nPeritoneum biopsy performed 91 (54.8%)\nOperation time, min 230 (195, 267)\nUnknown 1\nBlood loss, ml 100 (50, 150)\nUnknown 15\nStatistics presented: median (interquartile range); n (%)\nBMI = body mass index, PLND = pelvic lymph node dissection, \nPALND = para-aortic lymph node dissection, ml = milliliters, \nmin = minutes, FIGO = International Federation of Gynecology and \nObstetrics\n1 3\nPage 3 of 10   468 \n\nJournal of Robotic Surgery          (2026) 20:468 \nwere reclassified as having advanced FIGO stages III or IV \ndisease (Table 3).\nSurvival analysis using Kaplan–Meier method demon -\nstrated a statistically significant prognostic effect of upstag-\ning to advanced FIGO stages III-IV following RALS on \nlong-term survival outcomes in patients with clinically \nearly-stage EC at a high-intermediate-risk or high-risk for \nrecurrence. Patients reclassified as having advanced stage \nFIGO III or IV disease had a statistically significant worse \nOS (p < 0.01), DSS (p < 0.01) and DFS (p < 0.01) in contrast \nto patients who remained classified as early-stage disease \n(Fig. 2). In multivariable Cox regression adjusting for age, \nLVSI, and myometrial invasion, upstaging remained inde -\npendently associated with worse overall survival (HR 2.77, \n95% CI 1.40—5.48, p = 0.003), disease-specific survival \n(HR 3.21, 95% CI 1.57—6.54, p = 0.001) and disease-free \nsurvival (HR 2.06, 95% CI 1.09—3.92, p = 0.027) (Supple-\nmentary 2).\nIn total, 52 patients (31.3%) had a recurrence of dis -\nease. Of the 32 patients who were upstaged to advanced \nstage FIGO III-IV , 20 patients (62,5%) had a recurrence \nof disease. Of the 134 patients who remained classified \nas FIGO stage I-II, 32 patients (23.9%) had disease recur -\nrence. The median time until recurrence of these patients \nwas 14 months (IQR 7.50–28.00). 17/32 (53.1%) patients \nhad unifocal recurrence of disease. 3/32 patients (9.4%) had \nport site metastasis, all of whom had additional locations \nof disease recurrence. Further information on lymph node \nand organ recurrences in patients who remained classified as \nFIGO stage I-II are presented in Supplementary 3.\ninvolvement and 3 (37.5%) also had positive lymph nodes. \nAn additional 18/32 patients (56.3%) were upstaged due to \nlymph node metastases, of whom 3/18 (16.7%) also showed \nparametrial involvement. Finally, 4/32 patients (12.5%) \nwere upstaged due to parametrial involvement alone, 1/32 \n(3.1%) due to vaginal involvement, and 1/32 (3.1%) due to \nadnexal invasion (Table 2).\nThe majority of patients who remained classified as \nearly-stage FIGO stage I-II disease underwent vaginal \nbrachytherapy (VBT) ( n = 94/134, 70.1%) postoperatively. \nThe majority of patients who were reclassified as hav -\ning advanced stage FIGO III-IV disease received external \nbeam radiotherapy (EBRT) (n = 13/32, 40.6%). 9/32 patients \n(28.1%) underwent adjuvant chemotherapy. Adjuvant ther-\napy was not administered in 6/32 patients(18.8%) due to \nrapid disease progression in two patients, refusal of adju -\nvant therapy in two patients who subsequently received hor-\nmonal therapy or chemotherapy at disease relapse, another \npatient being judged unfit for adjuvant treatment, and fol -\nlow-up information missing for one patient (Supplementary \n1).\nOS rates for the 134 patients who remained classified as \nearly-stage FIGO stages I-II were 93.4%, 82.5% and 67.5%, \ncompared to 68%, 34.9% and 25.5% in the upstaged group \nat 1, 3 and 5-year follow-up, respectively ( p-value < 0.01). \nDSS rates in patients who remained classified as early-stage \nFIGO stages I-II were 93.4%, 83.4% and 73.1% at 1, 3 and \n5-year follow-up, respectively ( p-value < 0.01). DSS rates \ndid not differ from overall survival among patients who \nFig. 1 Pre- and postoperative FIGO 2009 \nstage\n \n1 3\n  468  Page 4 of 10\n\nJournal of Robotic Surgery          (2026) 20:468 \nrisk groups, OS rates for the 94 patients who remained \nFIGO stages I-II at 1, 3, and 5-year follow-up were 93.1%, \n79.8% and 58.6% and DSS rates were 93.1%, 81.1%, and \n66.2%. OS and DSS rates for the 32 patients who were \nreclassified as having advanced stage FIGO III-IV did not \ndiffer from those previously reported for the entire cohort, \nas these patients represent the same subgroup (Table 3). In \ntotal, 47 of 126 patients (37.3%) in the combined postop -\nerative high-(intermediate-)risk groups had a recurrence of \ndisease. Of the 94 patients who remained early-stage FIGO \nI-II, 20 patients (21.3%) had a recurrence of disease. Among \npatients with EEC ( n = 64), 7 patients (10.9%) were reclas -\nsified as having advanced stage FIGO III-IV disease follow-\ning RALS (Supplementary 4). Upstaging was not associated \nwith a significant difference for both OS (p = 0.59) and DSS \n(p = 0.61), in contrast with patients who remained early-\nstage FIGO I-II EEC. In contrast, DFS was significantly \nlower in the upstaged group ( p < 0.01), indicating a higher \nrisk of recurrence without an apparent effect on long-term \nsurvival (Supplementary 5).\nIn 90 patients with non-endometrioid carcinoma, 24 \npatients (26.7%) were reclassified as having FIGO stage \nIII-IV disease following RALS (Supplementary 4). 19.2% \nof patients with SC (10/52), was reclassified as hav -\ning advanced stage FIGO III-IV disease (Supplementary \n6). Among patients with SC, those reclassified as hav -\ning advanced stage FIGO III-IV disease had a statistically \nsignificantly worse OS ( p < 0.01), DSS (p < 0.01) and DFS \n(p < 0.01) than those who remained early stage FIGO I-II \n(Supplementary 7).\nFour patients diagnosed with CCC were reclassified \nas having advanced stage FIGO III-IV disease follow -\ning RALS and had a statistically significantly worse OS \n(p < 0.01) and DSS (p < 0.01) in contrast to those remaining \nearly stage FIGO I-II. In contrast, no significant difference \nin DFS was observed between the groups (p = 0.14), though \nthese findings should be interpreted with caution due to the \nsmall subgroup size (n = 11) (Supplementary 8 & 9).\n37% of patients with CS (10/27) were reclassified as hav-\ning advanced stage FIGO III-IV disease following RALS \n(Supplementary 10) Upstaging was not associated with a \nsignificant difference in OS (p = 0.09) or DSS ( p = 0.06). In \ncontrast, DFS was statistically significant worse in upstaged \npatients (p = 0.05) in contrast to those who remained clas -\nsified as early-stage disease, although this finding may be \ninfluenced by the limited subgroup size ( n = 27) (Supple -\nmentary 11).\nPostoperative histopathological assessment identified CS \nin four patients (2.4%). Other histological subtypes were \ndiagnosed in an additional six patients (3.6%) (Table 2) \nThis group consisted of two patients with rhabdomyosar -\ncoma, one patient with adenosarcoma, one patient with \nOf the 166 included patients, risk stratification identified \n34 patients (20.5%) as intermediate-risk, 32 patients (19.3%) \nas high-intermediate-risk and 94 patients (56.5%) as high-\nrisk for recurrence (Table 2). This is mainly explained by \nthe absence of preoperative MRI, resulting in 34 patients \nwho were found to have < 50% myometrial invasion only \nafter surgery. In three cases, the postoperative differentia -\ntion grade was lower than the preoperative assessment.\nAll 32 patients who were upstaged postoperatively were \nclassified as high-intermediate risk or high risk (32/126, \n25.4%). In this combined postoperative high-(intermediate-)\nTable 2 Postoperative pathology characteristics of study population\nCharacteristic Study population, n = 166\nUpstaged to FIGO stage III–IV 32 (19.3%)\nRisk classification1\nLow 3 (1.8%)\nIntermediate 34 (20.9%)\nHigh‑intermediate 32 (19.6%)\nHigh 94 (57.7%)\nUnknown 3\nPostoperative histology\nEndometrioid carcinoma 64 (38.6%)\nSerous carcinoma 52 (31.3%)\nClear cell carcinoma 11 (6.6%)\nCarcinosarcoma 27 (16.3%)\nUndifferentiated carcinoma 4 (2.4%)\nOther 6 (3.6%)\nTumor free 2 (1.2%)\nLymph node metastasis\nYes 21 (12.7%)\nMicrometastasis 18 (10.7%)\nMacrometastasis 3 (1.8%)\nNo 141 (84.9%)\nNot performed 4 (2.4%)\nOmental metastasis\nYes 5 (3.0%)\nNo 103 (62.0%)\nNot performed 58 (34.9%)\nPeritoneal metastasis\nYes 5 (3.0%)\nNo 86 (51.8%)\nNot performed 75 (45.2%)\nAdjuvant therapy\nNone 25 (15.1%)\nVaginal brachytherapy 95 (57.2%)\nExternal beam radiotherapy 30 (18.1%)\nChemotherapy 11 (6.6%)\nOther 5 (3.0%)\nStatistics presented: median (interquartile range); n (%)\nESGO = European Society of Gynaecological Oncology, \nESTRO = European Society for Radiotherapy and Oncology, \nESP = European Society of Pathology, FIGO = International Federa -\ntion of Gynecology and Obstetrics\n1ESGO/ESTRO/ESP guidelines 2020\n1 3\nPage 5 of 10   468 \n\nJournal of Robotic Surgery          (2026) 20:468 \nsurvival outcomes in multivariable Cox regression analy -\nses, underscoring its prognostic significance. The question \nremains how this prognostic information can be translated \nto improved adjuvant treatment for upstaged patients and \nwhether there are patients who should receive adjuvant \ntherapy regardless of the results of staging surgery. Hope -\nfully, the molecular classification will improve surgical and \nadjuvant treatment strategies and provide new therapeutic \ntargets.\nRALS is associated with fewer morbidities such as \nlymphedema and lymphoceles, compared to laparotomic \nstaging [ 15, 18, 19]. To further reduce the morbidity of \nstaging surgery, SLN procedure is increasingly being \nadopted by gynaecologic oncologists as a replacement for \nsystematic lymphadenectomy. Various systematic reviews \nfound that no statistically significant differences in sur -\nvival were observed between patients who underwent SLN \nand lymphadenectomy [ 20–25]. However, several of these \nreviews were assessed as low quality and did not explicitly \ndescribe survival outcomes of SLN in patients with EC at \na high-intermediate- or high-risk for recurrence [ 26]. The \nSENTIREC-ENDO trial demonstrated a safe diagnostic \nalgorithm for SLN mapping in high-risk EC [ 27]. A lim -\nitation however of the SLN procedure is the risk to miss \nisolated paraaortic metastases [28, 29]. In this study cohort \n5/166 patients (3%) had isolated paraaortic metastases. \nPALND was not performed mainly due to technical feasibil-\nity in a subset of patients (30/166, 18.1%), which could have \nled to missed isolated paraaortic lymph node metastasis. \nAlthough paraaortic metastasis could be missed, SLN pro -\ncedure uses ultrastaging which increases the likelihood of \ndetecting lymph node metastasis [ 30, 31]. Future research \nmay determine whether lymphadenectomy can be omitted \nor substituted by SLN procedure guided by preoperative \nmolecular risk classification. Arguably SLN procedure will \nbecome the standard of care in the near future [32–34].\nA strength of this study is the availability of detailed \nclinicopathological and surgical data, allowing for a \nmesonephric-like adenocarcinoma, one patient with muci -\nnous carcinoma, and one patient with neuroendocrine \ncarcinoma.\nDiscussion\nThis study evaluates RALS in 166 high-intermediate and \nhigh-risk EC patients resulting in 19.3% upstaging. 5-year \nDSS for patients who reclassified as having advanced \nFIGO stages III-IV following RALS was 25.5% compared \nto 73.1% for patients who were not upstaged. Notably, the \nmajority of not upstaged patients underwent VBT and the \nmajority upstaged patients underwent either EBRT or che -\nmotherapy. During the study period, combined chemoradio-\ntherapy was not routinely administered, as this was not our \ninstitutional standard.\nOS and DSS did not differ significantly between upstaged \nand non-upstaged patients with EEC and CS, despite a sig -\nnificant reduction in their DFS. This observation in patients \nwith CS should be interpreted with caution given the lim -\nited sample size ( n = 27). For patients with EEC this may \nbe explained by the fact that the risk groups in this study \ndiffered from the current updated risk classification. This \nsubgroup may include POLE-mutated tumours, whose \ngenerally favourable clinical course could contribute to the \nfavourable survival outcomes reported in this study [16]. In \nthis cohort, the recurrence rate was 31.3%, similar to the \n27.4%–44.8% range reported in the PORTEC-3 study [17]. \nThe most frequent locations of recurrence were the pelvis \n(11.2%, of which 3/15 patients had vaginal recurrence), \nperitoneum (11.2%) or lungs (7.5%).\nThis study demonstrates that the added value of surgi -\ncal staging without performing molecular classification lies \nin the prognostic information it provides regarding patient \noutcomes. Especially for patients who are not upstaged \nafter surgical staging 5-years survival rate is nearly 75%. \nUpstaging remained independently associated with worse \nTable 3 Survival rates\nSurvival type Timepoint Study population (n = 166) Postoperative high-(intermediate-) risk group (n = 106)\nNot upstaged (n at \nrisk)\nUpstaged (n at \nrisk)\np-value Not upstaged (n at risk) Upstaged (n at \nrisk)\np-value\nOverall \nsurvival\n12 months 93.4% (n = 107) 68.0% (n = 1 8 )  < 0.01 93.1% (n = 7 5 ) 68.0% (n = 1 8 )  < 0.01\n36 months 82.5% (n = 4 8 ) 34.9% (n = 10)  < 0.01 79.8% (n = 33) 34.9% (n = 10)  < 0.01\n60 months 67.5% (n = 1 8 ) 25.5% (n = 3)  < 0.01 58.6% (n = 12) 25.5% (n = 3)  < 0.01\nDisease-spe-\ncific survival\n12 months 93.4% (n = 107) 68.0% (n = 1 8 )  < 0.01 93.1% (n = 7 5 ) 68.0% (n = 1 8 )  < 0.01\n36 months 83.4% (n = 4 8 ) 34.9% (n = 10)  < 0.01 81.1% (n = 33) 34.9% (n = 10)  < 0.01\n60 months 73.1% (n = 1 8 ) 25.5% (n = 3)  < 0.01 66.2% (n = 12) 25.5% (n = 3)  < 0.01\nDisease-free \nsurvival\n12 months 88.7% (n = 102) 61.2% (n = 14)  < 0.01 86.3% (n = 7 0 ) 61.2% (n = 14)  < 0.01\n36 months 72.8% (n = 40) 24.6% (n = 5)  < 0.01 67.1% (n = 26) 24.6% (n = 5)  < 0.01\n60 months 65.7% (n = 13) 14.8% (n = 2)  < 0.01 56.8% (n = 8 ) 14.8% (n = 2)  < 0.01\nStatistics presented: p-values are calculated with log-rank tests with administrative censoring at predefined time points (12, 36, and 60  months)\n1 3\n  468  Page 6 of 10\n\nJournal of Robotic Surgery          (2026) 20:468 \nRALS and prevents definitive conclusions about therapeu -\ntic benefit. Furthermore, the impact of adjuvant treatments \ncould not be adequately evaluated because no control group \nwas available. We cannot conclude that omitting or add -\ning adjuvant EBRT and/or chemotherapy for patients who \nremained early stage FIGO I-II following RALS would lead \nto improved oncological outcomes. Adjuvant therapy strate-\ngies after RALS differ in national and international practice, \ncomprehensive evaluation of oncological outcomes in a \nreal-world tertiary care setting. Nonetheless, the retrospec -\ntive study design may limit the broader applicability of our \nresults. A limitation is the heterogenous study population, \nresulting in small subgroup sizes that limit the ability to draw \ndefinite conclusions from our findings. The lack of a control \ngroup without comprehensive staging limits the interpret -\nability of our findings to prognostic stratification following \nFig. 2 Survival analysis\n \n1 3\nPage 7 of 10   468 \n\nJournal of Robotic Surgery          (2026) 20:468 \nhttps://BioRender.com.\nAuthor contributions Alise de Jong, Cornelis G. Gerestein en Ronald \nP. Zweemer contributed to the study conception and design. Material \npreparation and data collection were performed by Jasper Markus and \nAlise de Jong. Analysis was performed by Alise de Jong. The first draft \nof the manuscript was written by Alise de Jong and all authors com -\nmented on previous versions of the manuscript. All authors read and \napproved the final manuscript.\nFunding No grants, sponsorships, or other sources of financial support \nwere provided for performing this study and writing the manuscript.\nData availability Metadata describing the participant data analyzed in \nthis study are available through the HDSU catalogue (  h t t p  s : /  / c a t  a l  o g u  \ne . h d  s u .  n l /  H D S  U / c  o l l e  c t  i o n s / R o b E c O). Participant data was extracted \nfrom electronic medical patient files. Due to the sensitive and pro -\ntected nature of the underlying data, the raw datasets are not publicly \navailable. Access to the data may be granted upon reasonable request, \nsubject to approval of a research proposal and completion of a data-\nsharing agreement.\nDeclarations\nCompeting interests Ronald P. Zweemer is a proctor for robot-assist-\ned surgery in gynaecological oncology on behalf of Intuitive Surgi -\ncal. The authors declare no further financial or non-financial conflicts \nof interest.\nEthics approval The protocol was reviewed in accordance with insti -\ntutional guidelines and classified as exempt from Institutional Review \nBoard approval.\nOpen Access   This article is licensed under a Creative Commons \nAttribution 4.0 International License, which permits use, sharing, \nadaptation, distribution and reproduction in any medium or format, \nas long as you give appropriate credit to the original author(s) and the \nsource, provide a link to the Creative Commons licence, and indicate \nif changes were made. The images or other third party material in this \narticle are included in the article’s Creative Commons licence, unless \nindicated otherwise in a credit line to the material. If material is not \nincluded in the article’s Creative Commons licence and your intended \nuse is not permitted by statutory regulation or exceeds the permitted \nuse, you will need to obtain permission directly from the copyright \nholder. To view a copy of this licence, visit  h t t p  : / /  c r e a  t i  v e c  o m m o  n s .  o \nr g  / l i c e n s e s / b y / 4 . 0 /.\nReferences\n1. Oaknin A, Bosse TJ, Creutzberg CL, Giornelli G, Harter P, Joly \nF et al (2022) Endometrial cancer: ESMO clinical practice guide-\nline for diagnosis, treatment and follow-up. Ann Oncol 33:860–\n877.  h t t p  s : /  / d o i  . o  r g /  1 0 . 1  0 1 6  / j .  a n n o n c . 2 0 2 2 . 0 5 . 0 0 9\n2. Cancer Today (2022) [Internet]. World Health Organization. \nAvailable from:  h t t p  s : /  / g c o  . i  a r c  . f r /  t o d  a y /  e n /  d a t  a v i z  / t  a b l  e s ? m  o d e  \n= c a  n c e  r & g  r o u p  _ p  o p u  l a t i  o n s  = 1 &  m u l t i p l e _ p o p u l a t i o n s = 1\n3. Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomata-\nram I et al (2024) Global cancer statistics 2022: GLOBOCAN \nestimates of incidence and mortality worldwide for 36 cancers in \n185 countries. CA Cancer J Clin 74:229–263.  h t t p  s : /  / d o i  . o  r g /  1 0 . 3  \n3 2 2  / c a  a c . 2 1 8 3 4\nwhich precludes definitive conclusions regarding the best \noptimal adjuvant treatment after RALS. In our cohort, the \nmajority of patients who were not upstaged underwent VBT \npostoperatively. For patients who were upstaged, combined \nchemotherapy and radiotherapy were not routinely admin -\nistered, which differs from practice in some centres world -\nwide. Changes in the adjuvant treatment standards during \nthe inclusion period may also have influenced oncological \noutcomes and may limit the generalisability of these find -\nings to current treatment strategies. Another limitation \nconcerns the variability in staging approaches, as the SLN \nprocedure has already been implemented in several centres \nworldwide. Nevertheless, these differences are unlikely to \nhave substantially influenced the observed upstaging rates.\nFuture research should focus on integrating the clinico -\npathological factors with molecular risk groups to inform \nthe extent of surgical staging and to optimize adjuvant ther-\napy strategies. The role of molecular risk stratification in \ninforming surgical staging decisions, through evaluation of \nmetastatic patterns across molecular subgroups, is currently \nbeing investigated in the prospective EUGENIE trial. A less \ninvasive approach using SLN mapping may be considered \nfor patients with EC at a high-intermediate- or high-risk for \nrecurrence. Evaluating the clinical integration of molecular \nclassification may allow for patient-specific adjuvant ther -\napy decisions, ultimately contributing to improved survival \noutcomes.\nConclusions\nThis cohort study contributes to a better understanding of \nprognosis in patients with clinically early-stage EC at high-\nintermediate or high-risk for recurrence, who underwent \nsurgically staging with RALS. We found that 5-year DSS \nfor upstaged patients was 25.5% compared to 73.1% for \npatients who were not upstaged. RALS provides impor -\ntant prognostic information, while its therapeutic benefit \nwarrants further investigation. Prospective research should \nassess the impact of adjuvant treatment strategies guided \nby surgical staging. 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Gynecol Oncol 170:273–281.  \nh t t p  s : /  / d o i  . o  r g /  1 0 . 1  0 1 6  / j .  y g y n o . 2 0 2 3 . 0 1 . 0 2 2\n1 3\nPage 9 of 10   468 \n\nJournal of Robotic Surgery          (2026) 20:468 \nPublisher’s Note Springer Nature remains neutral with regard to juris-\ndictional claims in published maps and institutional affiliations.\nintermediate- and high-risk endometrial cancer by sentinel lymph \nnode biopsy implementation. Front Oncol 11:654285.  h t t p s :   /  / d o  i . \no  r  g  /  1 0  . 3 3   8 9 /  f  o n c . 2  0 2 1 . 6 5 4 2 8 5\n1 3\n  468  Page 10 of 10","source_license":"CC0","license_restricted":false}