Could the Long-Term Oncological Safety of Laparoscopic Surgery in Low Risk Endometrial Cancer be also valid for the High Intermediate and High-Risk Patients? A Multi-center Turkish Gynecologic Oncology Group Study Conducted with 2745 Endometrial Cancer Cases. (TRSGO-End-001)

Could the Long-Term Oncological Safety of Laparoscopic Surgery in Low Risk Endometrial Cancer be also valid for the High Intermediate and High-Risk Patients? A Multi-center Turkish Gynecologic Oncology Group Study Conducted with 2745 Endometrial Cancer Cases. 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A Multi-center Turkish Gynecologic Oncology Group Study Conducted with 2745 Endometrial Cancer Cases. (TRSGO-End-001) Mehmet Ali Vardar, Ahmet Baris Guzel, Salih Taşkın, Mete Güngör, and 21 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-263938/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Oct, 2021 Read the published version in Current Oncology → Version 1 posted You are reading this latest preprint version Abstract Could the Long-Term Oncological Safety of Laparoscopic Surgery in Low Risk Endometrial Cancer be also valid for the High Intermediate and High-Risk Patients? A Multi-center Turkish Gynecologic Oncology Group Study Conducted with 2745 Endometrial Cancer Cases. (TRSGO-End-001) Aim : to compare the long-term oncological outcomes of laparotomy and laparoscopic surgeries in endometrial cancer under the light of 2016 ESMO-ESGO-ESTRO risk classification system with particular focus on the high intermediate and high-risk categories. Methods : Using multicentric database between January 2005 and January 2016, disease-free and overall survivals of 2745 endometrial cancer cases were compared according to the surgery route, laparotomy vs laparoscopy. The high intermediate and high-risk patients were defined with respect to the 2016 ESMO-ESGO-ESTRO risk classification system and they were analyzed with respect to difference in survival rates. Results : Of the 2745 patients 1743 (63.5%) were operated by laparotomy, and the remaining were operated with laparoscopy. The total numbers of high intermediate and high-risk endometrial cancer cases were 734 (45%) patients in the LT group and 307 (30.7%) patients in the LS group. Disease-free and overall survivals were not statistically different when compared between laparoscopy and laparotomy groups in terms of low, intermediate, high intermediate and high-risk endometrial cancer. Conclusions : Regardless of the endometrial cancer risk category, long-term oncological outcomes of laparoscopic approach were found to be comparable to those treated with laparotomy. Our results are encouraging to consider laparoscopic surgery for high intermediate and high-risk endometrial cancer cases. Sexual & Reproductive Medicine Oncology High-risk endometrial cancer laparoscopic surgery survival. Figures Figure 1 Introduction Endometrial cancer is the most common gynecological cancer among women in the developed world [1]. Surgery, including total hysterectomy (TH), bilateral salpingo-oophorectomy (BSO) with or without lymphadenectomy and omentectomy is the mainstay of endometrial cancer treatment [1-3]. Postoperative adjuvant treatments are decided according to the risk category of the patients. Recently, ESMO-ESGO-ESTRO classified endometrial cancer to low, intermediate, high intermediate and high-risk categories in order to tailor the adjuvant therapy after surgery [4]. Surgery of the endometrial cancer can be performed by either laparotomy (LT) or laparoscopic approach. In 1990s, the laparoscopic surgery of the gynecologic malignancies was pioneered by the studies of Dargent et al. [5] and Querleu et al. [6] from France and Childers et al. [7] and Spirtos et al. [8] from the United States [9]. Nevertheless, since the publication of the LACC study, in which laparoscopic approach was found to be associated with poor oncological outcomes in cervical cancer, concerns regarding laparoscopy in gynecological malignancies have been raised [10]. On the other side, the safety of laparoscopy (LS) in endometrial cancer has been demonstrated previously in the randomized GOG lap2 and LACE studies [11, 12]. Numerous studies including the abovementioned landmark studies have found comparable safety and oncological outcomes between laparotomy and laparoscopic modalities in low-risk endometrial cancer [3, 11-17]. However, such studies in the high-risk patients are scarce [18-22]. Therefore, it is necessary to increase the studies investigating the oncological safety of laparoscopic surgery in endometrial cancer, particularly those encompassing the high-risk category. Hence, as the Turkish Society of Gynecologic Oncology (TRSGO), we designed this multi-centric retrospective study to compare the oncologic outcomes of the laparotomy and laparoscopic surgeries in endometrial cancer focusing on the high intermediate and high-risk categories. Materials And Methods Data were collected from 12 TRSGO centers between January 2005 and January 2016, and it was entered by the investigators of each center and controlled by the biostatistician (GS). Approval for this study was obtained from the Research Ethics Committee at Çukurova University Faculty of Medicine. A written informed consent for the use of research and educational purpose was attained from all patients. All participating centers are known for their long-standing experience in laparoscopic surgery for endometrial cancer. Expert gynecologic pathologists in each of these centers evaluated the pathological materials. A data sheet of variables related to demographic, clinical, surgical, pathological, follow-up and survival characteristics was recorded from the databases of each center. Only cases with comprehensive data were included, and finally 2745 endometrial cancer patients were selected for analysis. Age, body mass index (BMI), parity, comorbidities, and surgical variables including; type of surgery, conversion rate of laparoscopy to laparotomy, duration of surgery, fall in hemoglobin level, postoperative stay in the hospital (day), intraoperative and postoperative complications, stage, grade, histopathological type, myometrial invasion (MI: as <50% and ≥50%), lymph node (LN) involvement, lymphovascular space invasion (LVSI), and number of harvested lymph nodes were recorded. Adjuvant therapy modalities, follow-up data and survival outcomes were also gathered. All patients’ diagnoses were made upon a preoperative endometrial biopsy. All patients were preoperatively assessed with transvaginal ultrasonography and chest x-ray. Based on the clinician’ decision, further preoperative screenings such as abdomen and thorax computed tomography or magnetic resonance imaging were administered particularly when there was a suspicion of extra-uterine disease or >50% MI, and in case of grade 3 or type 2 carcinomas. As this was a retrospective study, no standard preoperative selection criteria were taken into account for laparoscopic surgery. Unless in case of extrauterine disease existence on the imaging methods, LT was preferred. Similarly, no standardization was set among the institutions in this study regarding patients’ discharge decision. Staging was adapted according to the International Federation of Gynecology and Obstetrics 2009 surgical staging classification. Either in LT arm or in LS arm, all cases underwent TH and BSO. Uterine manipulator was used for all laparoscopically- operated cases. Intraoperative frozen section was applied for all included cases, and a decision to pursue or not to pursue on lymphadenectomy was taken based on its result. Lymphadenectomy was not performed in patients with, stage 1a, grade 1-2, 2cm, ≥50% MI, stage >1a or non-endometrioid histologies, pelvic ± para-aortic lymphadenectomy (± omentectomy) was considered compatible with the Mayo clinic protocol [23]. Adjuvant therapies (brachytherapy, external beam radiotherapy and/or chemotherapy) were kept in view for patients with ≥ intermediate risk factors. A sub-analysis of survival was made between laparoscopy and laparotomy groups according to the pathologic prognostic factors including stage, grade, MI, LVSI, LN status, histopathological type and the recent ESMO- ESGO- ESTRO risk classification system for endometrial cancer [4]. In the ESMO- ESGO- ESTRO classification, patients with Stage I endometrioid, grade 1–2, <50% myometrial invasion, LVSI negative were described as low risk and patients with stage 1 endometrioid, grade 1-2, ≥50% MI, and LVSI negative were defined as intermediate risk. High intermediate risk category was identified as patients with stage I endometrioid, grade 3, <50% MI, regardless of LVSI status or with stage I endometrioid, grade 1–2, LVSI unequivocally positive, regardless of MI. High-risk category was decided to include patients with; 1- Stage I endometrioid, grade 3, ≥50% MI, regardless of LVSI status, 2- Stage II endometrioid, 3- Stage III endometrioid, no residual disease, and 4- Non-endometrioid histologies (serous, clear-cell, undifferentiated carcinoma, carcinosarcoma). Data were analyzed using the SPSS software version 20.0 (IBM, Armonk, NY, USA). The variables were shown as mean ± standard deviation, median (minimum-maximum) or n (%). The variables were analyzed firstly to detect whether or not they were normally distributed by visual (histograms, probability plots) and analytical methods (Shapiro-Wilk’s test). Independent T test and Chi-square test were used for comparisons between the groups. The follow-up period was accepted as the time between patient's primary surgery and the last contact. Disease-free survival was designated as the duration (months) from surgery to recurrence. Overall survival was described as the period in months between the diagnosis and the death or last follow-up. The effect of clinico-pathological variables, ESMO- ESGO- ESTRO risk groups and type of surgery on disease-free and overall survival rates of the patients were analyzed using Kaplan-Meier method. Log- rank test was used to calculate the differences among the survival curves. The significance of multiple variables was assessed using the Cox proportional hazard model without violating the proportional hazards assumption. Results Overall, 2745 patients with endometrial cancer were enrolled in this study. Of them, 1743 (63.5%) cases were operated by LT, and 1002 (36.5%) were operated with conventional LS. Demographic and surgical charateristics of the groups are summarized in Table 1 . Mean age of the laparotomy and laparoscopy groups was 59.3 ± 10.7 and 57.5 ± 10.1, respectively. Patients < 50 years were 16.5% and 18.8% in the LT and LS groups, respectively. Mean of BMI was significantly higher in the LS arm (38.8 ± 4.79) than the LT (32.1 ± 5.9). Only TH + BSO was performed for 510 (29%) patients in the LT and for 329 (32.9%) patients in the LS groups. Staging procedures (retroperitoneal lymphadenectomy ± omentectomy) were added to TH-BSO in the remaining cases of both groups. Mean resected LN number in patients who underwent pelvic lymphadenectomy was 16.3 in the LT vs 20.9 in the LS groups (p < 0.001); and 35.5 in the LT vs 40.9 in the LS groups for patients who underwent pelvic plus para-aortic lymphadenectomy (p < 0.001). Perioperative and postoperative complications were significantly lower in the LS group compared to the LT group (3% vs 4.8%; p < 0.001 and 4.3% vs 7.6%; p < 0.001, respectively). However, peri- and postoperative complications related to the urinary and intestinal injuries were noticed more frequently in the LS group. Operation time was significantly lower in the LT group, while estimated blood loss, drop in hemoglobin and postoperative hospital stay were significantly lower in the LS group. Conversion from LS to LT was required in 27 (3%) cases. Table 1 Demographic and surgical characteristics of the patients. Variables LT LS P (Mean)/N SD/(%) (Mean)/N SD/(%) Age (years) (59,3) 10,7 (57,5) 10,1 < 0.05 Parity (3,1) 2,3 (2,7) 1,9 < 0.05 BMI (kg/m 2 ) (32,1) 5,9 (38,8) 4,7 < 0.05 BMI group 40 449 (33,2) 331 (36,8) < 0.001 560 (41,5) 258 (28,7) 184 (13,6) 171 (19,0) 158 (11,7) 139 (15,5) Comorbidities No Yes 565 (34,5) 480 (48,0) < 0.001 1072 (65,5) 521 (52,0) Menopausal status Premenopausal Postmenopausal 307 (35,2) 248 (32,8) < 0.001 566 (64,8) 507 (67,2) Operation type TH + BSO 510 (29) 329 (32,9) < 0.001 TH + BSO + BPLND ± OMENTECTOMY 386 (21,3) 440 (44,0) TH + BSO + BPPALND ± OMENTECTOMY 847 (49,7) 233 (14,2) Perioperative complications No 1255 (95,2) 736 (97,0) < 0.001 Bleeding 54 (4,1) 9 (1,2) Urinary system injury 4 (,3) 8 (1,1) Intestinal injury 2 (,2) 4 (,5) Others 3 (,2) 2 (,3) Postoperative complications No 1221 (92,4) 727 (95,7) < 0.001 Infection 88 (6,7) 15 (2,0) Urinary system injury 0 (,0) 1 (,1) Intestinal injury 1 (,1) 2 (,3) Others 12 (,9) 15 (2,0) Operation time (minute) (119,3) 42,8 (142,2) 66,4 < 0.05 Estimated blood loss (ml) (243,3) 167,2 (114,6) 81,7 < 0.05 Drop in hemoglobin (gr/dl) (1,6) 1,1 (1,4) 1,1 < 0.05 Conversion of laparoscopy to laparotomy 27 (3,0) Postoperative hospitalization (day) (5.4) 3.3 (3.3) 1.7 < 0.05 LT: laparotomy, LS: laparoscopy, N: count, SD: Standard deviation, BMI: body mass index, TH + BSO: total hysterectomy bilateral salpingo-oophorectomy, BPLND: bilateral pelvic lymph node dissection, BPPALND: bilateral pelvic para-aortic lymph node dissection. Histopathological results of the LT and LS groups are documented in Table 2 . Stage 3–4 cases were noted in 23.9% of the LT arm vs 11.3% of the LS arm. The grade 3 cases were determined as 12.7% of the LT group and 7.8% of the LS group. Ratios of grade 3 and advanced stage were significantly higher in the LT group than the LS group. Type 2 (non-endometrioid) histologies were reported in 20.9% and 12.1% of the LT and LS groups, respectively (p < 0.001). More than 50% MI was observed in 38.2% and 25.3% of LT and LS groups, respectively (p < 0.001). Cervix was invaded in 16.5% and 4.6% of the LT and LS arms, respectively (p < 0.001). LVSI was found in 36% of the LT and 22.7% of the LS arm (p 40 in 26.3%, 26.1%, 18.3% and 26.7%, 25.9%, 14.6% of the LT and LS groups, respectively. Metastatic LN ratio was 13.2% in the LT group vs 7.1% in the LS group (p < 0.001). Isolated para-aortic LN metastases were recorded in 2.3% and 0.7% of LT and LS cases, respectively. Table 2 Histopathological features of the groups. Variables LT LS P (Mean)/N SD/(%) (Mean)/N SD/(%) Stage 1a 825 (47,3) 664 (66,2) < 0.001 1b 372 (21,4) 195 (19,4) 2 130 (7,4) 31 (3,1) 3a + 3b + 3c + 4 414 (23,9) 114 (11,3) Histopathology Endometrioid 1280 (79,1) 875 (87,9) < 0.001 Serous 113 (7,0) 38 (3,8) Clear 33 (2,0) 2 (,2) Mixed 128 (7,9) 67 (6,7) Carcinosarcoma 65 (4,0) 14 (1,4) Histologic type Type1 1280 (79,1) 875 (87,9) < 0.001 Type2 339 (20,9) 121 (12,1) Grade 1 715 (43,9) 537 (54,7) < 0.001 2 524 (32,2) 342 (34,9) 3 389 (23,9) 102 (10,4) Myometrial invasion No 324 (20,1) 239 (24,0) < 0.001 <%50 670 (41,6) 506 (50,8) ≥%50 615 (38,2) 252 (25,3) Cervical invasion No 1065 (83,5) 711 (95,4) < 0.001 Yes 211 (16,5) 34 (4,6) LVSI No 988 (64,0) 749 (77,3) 40 320 (18,3) 147 (14,6) Metastatic LN No 1512 (86,8) 931 (93,0) < 0.001 Pelvic 103 (5,9) 46 (4,6) Paraaortic 41 (2,3) 8 (0,7) Pelvic + paraaortic 87 (5,0) 17 (1,7) LT: laparotomy, LS: laparoscopy, N: count, SD: Standard deviation, LVSI: lymphovascular space invasion; LN: lymph node. The patients were categorized according to the 2016 ESMO-ESGO-ESTRO risk classification system. There was 1226 (46.6%), 363 (13.8%), 389 (14.8%), and 652 (24.8%) patients in the low, intermediate, high intermediate and high-risk categories, respectively. There was no statistically significant difference between LS and LT groups according to the subcategories of 2016 ESMO-ESGO-ESTRO risk classification system, in terms of disease-free survival and overall survival (Table 3 , Fig. 1 ). Table 3 Comparison of DFS and OS rates between groups with respect to the ESMO-ESGO-ESTRO risk classification system. Risk group DFS OS LT LS LT LS Total n /censored% Mean Total n /censored% Mean P Total n/ censored% Mean Total n/ censored% Mean P Low 668/96,4 121,6 564/98,2 120,7 0,274 668/96,9 122,8 564/98,4 121,2 0,320 Intermediate 234/84,2 89,6 130/91,5 105,3 0,180 234/90,6 109,7 130/96,2 110,8 0,129 High-intermediate 271/75,6 80,0 121/75,2 77,7 0,366 271/87,8 101,9 121/94,2 98,2 0,153 High 464/53,2 32,4 186/54,3 23,9 0,106 464/72,8 60,5 186/78,0 58,8 0,231 P < 0.001 < 0.001 < 0.001 < 0.001 DFS: Disease-free survival; OS: Overall survival; LT: laparotomy, LS: laparoscopy, n: count. Univariate and multivariate analyses are shown in Table 4 and Table 5 , respectively. Only age, BMI, LN status, stage, histopathological type and risk group for disease-free survival and age, BMI, cervical invasion, LN status, and risk group for overall survival, were determined as independent prognostic factors on the multivariate analysis. No superiority between surgical groups were found in the multivariate analysis regarding both disease-free survival and overall survival. Table 4 Univariate analysis of DFS and OS. Variables Total / Dead n DFS Mean OS Mean Metastatic lymph node No Yes P Stage 2317/132 283/109 98.5 19.5 < 0.001 115.9 44.9 < 0.001 1a 1502/47 120.0 121.3 1b 567/40 74.0 112.5 2 162/31 52.8 82.5 3a + 3b + 3c + 4 394/130 23.4 54.9 p < 0.001 < 0.001 Grade 1 1208/49 122.1 129.3 2 798/63 92.3 114.1 3 231/51 24.0 74.6 p < 0.001 < 0.001 Myometrial invasion None 867/153 119.3 121.3 <%50 1176/64 110.4 115.2 ≥%50 271/80 51.5 93.3 p < 0.001 < 0.001 Lymphovascular space invasion No 1737/77 110.9 118.4 Yes 775/154 51.8 85.3 p < 0.001 < 0.001 Histopathological type Type1 2155/141 103.9 114.7 Type2 460/103 30.9 62.2 p < 0.001 < 0.001 DFS: Disease-free survival, OS: Overall survival, n: count. Table 5 Multivariate analysis of DFS and OS. Variables HR (95,0% CI) DFS P OS P Age Surgery type Comorbidities BMI 40 MI None %50 LVSI Cervical invasion Metastatic LN Stage 1a 1b 2 3a + 3b + 3c + 4 Grade 1 2 3 Histopathological type Risk group Low Intermediate High-intermediate High 1,025 (1,012 − 1,038) 1,055 (0,869-1,282) 0,980 (0,762-1,262) ref 1,281 (0,946-1,735) 1,386 (1,032 − 1,863) ref 0,689 (0,434-1,095) 1,008 (0,599-1,698) 0,887 (0,618-1,274) 1,374 (0,987-1,912) 1,713 (1,131-2,595) ref 1,051 (0,669-1,652) 1,847 (1,083 − 3,150) 2,012 (1,226-3,303) ref 0,428 (0,313-0,585) 0,827 (0,641-1,067) 1,973 (1,495-2,605) ref 1,204 (0,935-1,549) 2,833 (1,452-5,529) 6,349 (3,569 − 11,294) < 0.001 0.587 0.877 0.109 0.003 0.115 0.975 0.517 0.060 0.011 0.828 0.024 0.006 0.146 0.761 < 0.001 0.082 0.002 < 0.001 1,038 (1,020 − 1,055) 1,338 (0,895-1,999) 0,959 (0,669-1,374) 1,831 (1,150-2,914) 2,133 (1,353-3,361) 0,640 (0,381-1,076) 0,770 (0,427-1,387) 0,713 (0,398-1,275) 1,982 (1,288-3,050) 3,139 (1,662-5,926) 0,576 (0,268-1,241) 1,379 (0,623-3,052) 1,519 (0,685-3,368) 0,643 (0,392-1,054) 0,791 (0,518-1,210) 1,462 (0,974-2,196) 2,411 (1,076 − 5,405) 2,406 (1,084 − 5,337) 3,216 (1,482-6,978) < 0.001 0.156 0.820 0.011 0.001 0.092 0.383 0.253 0.002 < 0.001 0.159 0.427 0.304 0.280 0.458 0.067 0.036 0.019 < 0.001 HR: Hazard Ratio; CI: Confidence Interval; DFS: Disease-free survival; OS: Overall survival; BMI: Body mass index; MI: Myometrial invasion; LVSI: Lymphovascular space invasion; LN: Lymph node. Discussion This retrospective multicentric study was conducted to evaluate the oncologic safety and efficacy of the conventional laparoscopy in endometrial cancer by stratifying patients with respect to 2016 ESMO- ESGO- ESTRO risk classification system. Lower pain, lower postoperative complications, shorter hospital stay and recovery, and less cost were the well-known advantages of LS compared to LT in numerous studies [ 2 , 19 ]. These short-term advantages are valid for all patients regardless of their risk category. The similar long-term oncological outcomes of LS in low risk endometrial cancer patients have been demonstrated in the literature to be comparable to the open surgery [ 3 , 11 , 13 – 15 ]. The literature is scarce on the issue of high intermediate and high-risk endometrial cancer [ 18 – 20 ]. As a reflection of this reality, the European guidelines’ recommendation for the management of low and intermediate risk endometrial cancer with minimally invasive surgery (MIS) was -level of evidence: I, strength of recommendation: A-, whereas it was considered as -level of evidence: IV, strength of recommendation: C- for the management of high-risk endometrial cancer [ 4 ]. Consequently, this gap in the literature has inspired us to compare the long-term oncologic outcomes of LS and LT in different risk categories of endometrial cancer. Herein, 2745 endometrial cancer cases were investigated. Of them, 389 (269 LT vs 120 LS) cases were in the high intermediate and 652 (465 LT vs 187 LS) in the high-risk categories. To the best of our knowledge, with the exclusion of the National Cancer Database study on the non-endometrioid uterine cancers including sarcomas by Nieto and colleagues, [ 24 ] none of the previous papers had compared such a high number of cases. Compatible with the literature, short-term advantages of LS such as less blood loss, less perioperative and postoperative complications and shorter hospitalization were observed even with the addition of high intermediate and high-risk patients in our study. Moreover, BMI of the LS cohort was significantly higher from the LT group. Mean BMI (38.8 ± 4.7) of our LS group was higher than many published studies including the landmark study LAP2, which was 28.4 [ 13 , 14 , 18 ]. In addition, more than half of the LS group had at least one comorbidity. The participating centers in this study are well-known tertiary gynecologic oncology centers in Turkey, which are highly experienced in treating such obese and comorbid patients laparoscopically. Therefore, even with these patients’ characteristics, sufficient number of LNs were harvested and low conversion rates were obtained. In LS arm, the resected LN number in patients who underwent pelvic lymphadenectomy was 20.91 and it was 40.93 in pelvic plus para-aortic lymphadenectomy; which is in accordance with the literature [ 2 , 14 , 18 , 25 – 29 ]. Conversion from laparoscopy to laparotomy was required only in 3% of our series, despite the high volume of high-risk patients. Even though it is clearly less than those in the landmark LAP2 study (25.8%), and comparable to the following literature, which is mainly below 20% and varies between 0% and 25.8% [ 2 , 13 , 18 , 19 ]. The conversion rate in our study was in accordance with the Italian type 2 endometrial cancer series (2.1%) [ 21 ]. The low rate of conversion in our series can be attributed to the high expertise of the participating centers in gyne-oncological laparoscopy. According to a multi-centric study in high-volume experienced centers, even when high-risk cases were included, a proposed MIS rate of 80% was found to be an achievable benchmark for the management of women with newly diagnosed endometrial cancer [ 30 ]. Hence, patients with endometrial cancer including high-risk cases should referred to centers where this benchmark can be achieved [ 30 ]. In our recently published single institution study, there was no difference in disease-free survival and overall survival between LS and LT groups according to the risk categories [ 31 ]. This result is coherent with the previous publications on the comparison of LS and LT in high-risk endometrial cancer [ 18 – 20 , 32 ]. In their multi-centric retrospective study, Fader et al. [ 18 ] compared MIS (n = 191) and LT (n = 192) in type 2 and high grade endometrial cancer, and they stated that high-risk histopathologic types were not a contraindication for MIS when managed by expert laparoscopists. Fader et al. [ 32 ] addressed again in their 2016 publication that patients with grade 3 endometrioid and type 2 endometrial cancer had similar survival outcomes regardless of the surgical approach, MIS or LT. Koskas et al. [ 19 ] conducted a comparative study between MIS (n = 114) and LT (n = 114) in the high risk endometrial cancer. Authors reported identical oncologic outcomes between groups and concluded that their study provides evidence supporting the use of MIS for high-risk endometrial cancer. Therefore, fear for a poor long-term outcome should not be the reason to refrain from laparoscopic procedure in these patients. [ 19 ] Nieto et al. [ 24 ] evaluated the impact of MIS in 13392 patients with stage I-III non-endometrioid uterine cancer (including sarcomas) who underwent hysterectomy between 2010 and 2014 using the National Cancer Database. Authors reported that the route of surgery does not appear to impact survival adversely in these patients [ 24 ]. In a multicentric retrospective study by Monterossi et al. [ 21 ] 283 patients with type 2 endometrial cancer were evaluated among 2 groups (LS; 141, LT; 142) and comparable survival outcomes were reported for both of them in stage I-II cases. Favero et al. [ 20 ] assessed the oncologic safety of laparoscopic surgery in type 2 endometrial cancer, and found that both 5-year disease-free and overall survival were better among laparoscopically treated patients. However, this superiority was not statistically significant [ 20 ]. Consistent with these studies, both disease-free and overall survival of the high intermediate and high-risk patients were not statistically different between groups in the current study. Comparison between groups according to the 2016 ESMO-ESGO-ESTRO risk classification system was a distinguishable characteristic of our study from the former studies. A recently published review on the comparison between MIS and open surgery in the high-risk endometrial cancer addressed that MIS showed better perioperative and postoperative outcomes and comparable oncological outcomes than open surgery [ 22 ]. However, authors pointed out to the need of prospective randomized studies to approve these results. Because of the numerous advantages of LS, its importance in the endometrial cancer surgery is raising day by day and its increased frequent use more than LT has been shown in some studies [ 25 , 33 ]. According to the data from National Cancer Database provided in the study of Nieto and colleagues [ 24 ]. on the non-endometrioid uterine cancers, > 50% of the hysterectomies were performed with MIS for all of the histologic subtypes (except leiomyosarcoma), by 2014. Authors stated that their findings suggest that MIS has already been widely accepted among clinicians for non-endometrioid uterine cancers, despite the lack of data supporting the procedure’s efficacy and safety. They attributed this condition to the widespread acceptance of MIS for endometrioid endometrial cancers, which likely boosted the acceleration of MIS for other histologic subtypes [ 24 ]. However limited the studies are, availability of comparable oncologic outcomes with MIS versus to LT in high-risk endometrial cancer are promising and encouraging. The present study has strived to strengthen the assertion that laparoscopy was equal to laparotomy in the high intermediate and high-risk endometrial cancer patients, in terms of long-term oncologic outcomes. Nevertheless, this result should cautiously be interpreted considering the retrospective nature and possible selection biases, which is the main weakness of our study. Heterogeneous histologic subtypes, stages and adjuvant treatments were the other limitations. On the other hand, however, pioneering the concept of ESMO-ESGO-ESTRO risk- based comparative survival analysis and including the large number of patients from academic comprehensive cancer centers with expert gynecologic pathologists and gynecologic oncologists who are familiar with LS in gynecologic oncology are the main strengths of our study. Conclusion Regardless of the endometrial cancer risk category, long-term oncologic outcomes of LS is comparable to those treated with LT. Since short-term advantages (less complications, short hospitalization, and rapid recovery) of LS are also valid for the high intermediate and high-risk endometrial cancer, it is reasonable to assume that LS has the ability to accelerate treatment with adjuvant therapies in these patients. Therefore, considering the laparoscopic approach as the preferable choice for high intermediate and high-risk endometrial cancer as well as for the low and intermediate risk categories, will probably be the issue of debate for the foreseeable future. Hence, the need for prospective randomized studies on this subject is indisputable. Declarations Acknowledgement Authors thank Prof. Naki Tütüncü for editing. Ethical Standards: Approval for this study was obtained from the Research Ethics Committee at Çukurova University Faculty of Medicine. Conflicts of interest The authors declared that they have no conflicts of interest. Funding: The authors declare that they did not receive any financial support regarding this work. Disclosure: None declared References (1) Amant F, Moerman P, Neven P, Timmerman D, Van Limbergen E, Vergote I. Endometrial cancer. Lancet. 2005;366:491-505. (2) Zullo F, Falbo A, Palomba S. Safety of laparoscopy vs laparotomy in the surgical staging of endometrial cancer: a systematic review and metaanalysis of randomized controlled trials. Am J Obstet Gynecol. 2012;207:94-100. (3) Palomba S, Falbo A, Mocciaro R, Russo T, Zullo F. Laparoscopic treatment for endometrial cancer: a meta-analysis of randomized controlled trials (RCTs). Gynecol Oncol. 2009;112:415-21. (4) Colombo N, Creutzberg C, Amant F, Bosse T, Gonzalez-Martin A, Ledermann J, et al. ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: Diagnosis, Treatment and Follow-up. Int J Gynecol Cancer. 2016;26:2-30. (5) D. D. A new future for Schauta's operation through presurgical retroperitoneal pelviscopy. . Eur J Gynaecol Oncol 8. (6) Querleu D, Leblanc E, Castelain B. Laparoscopic pelvic lymphadenectomy in the staging of early carcinoma of the cervix. Am J Obstet Gynecol. 1991;164:579-81. (7) Childers JM, Hatch KD, Tran AN, Surwit EA. Laparoscopic para-aortic lymphadenectomy in gynecologic malignancies. Obstet Gynecol. 1993;82:741-7. (8) Spirtos NM, Schlaerth JB, Spirtos TW, Schlaerth AC, Indman PD, Kimball RE. Laparoscopic bilateral pelvic and paraaortic lymph node sampling: an evolving technique. Am J Obstet Gynecol. 1995;173:105-11. (9) Lee CL, Kusunoki S, Huang KG, Wu KY, Huang CY, Yen CF. Long-term survival outcomes of laparoscopic staging surgery in treating endometrial cancer: 20 years of follow-up. Taiwan J Obstet Gynecol. 2016;55:545-51. (10) Ramirez PT, Frumovitz M, Pareja R, Lopez A, Vieira M, Ribeiro R, et al. Minimally Invasive versus Abdominal Radical Hysterectomy for Cervical Cancer. N Engl J Med. 2018;379:1895-904. (11) Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol. 2009;27:5331-6. (12) Janda M, Gebski V, Forder P, Jackson D, Williams G, Obermair A, et al. Total laparoscopic versus open surgery for stage 1 endometrial cancer: the LACE randomized controlled trial. Contemp Clin Trials. 2006;27:353-63. (13) Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, et al. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. J Clin Oncol. 2012;30:695-700. (14) Malzoni M, Tinelli R, Cosentino F, Perone C, Rasile M, Iuzzolino D, et al. Total laparoscopic hysterectomy versus abdominal hysterectomy with lymphadenectomy for early-stage endometrial cancer: a prospective randomized study. Gynecol Oncol. 2009;112:126-33. (15) Galaal K, Donkers H, Bryant A, Lopes AD. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database Syst Rev. 2018;10:CD006655. (16) Janda M, Gebski V, Davies LC, Forder P, Brand A, Hogg R, et al. Effect of Total Laparoscopic Hysterectomy vs Total Abdominal Hysterectomy on Disease-Free Survival Among Women With Stage I Endometrial Cancer: A Randomized Clinical Trial. JAMA. 2017;317:1224-33. (17) Deura I, Shimada M, Azuma Y, Komatsu H, Nagira K, Sawada M, et al. Comparison of laparoscopic surgery and conventional laparotomy for surgical staging of patients with presumed low-risk endometrial cancer: The current state of Japan. Taiwan J Obstet Gynecol. 2019;58:99-104. (18) Fader AN, Seamon LG, Escobar PF, Frasure HE, Havrilesky LA, Zanotti KM, et al. Minimally invasive surgery versus laparotomy in women with high grade endometrial cancer: a multi-site study performed at high volume cancer centers. Gynecol Oncol. 2012;126:180-5. (19) Koskas M, Jozwiak M, Fournier M, Vergote I, Trum H, Lok C, et al. Long-term oncological safety of minimally invasive surgery in high-risk endometrial cancer. Eur J Cancer. 2016;65:185-91. (20) Favero G, Anton C, Le X, Silva ESA, Dogan NU, Pfiffer T, et al. Oncologic Safety of Laparoscopy in the Surgical Treatment of Type II Endometrial Cancer. Int J Gynecol Cancer. 2016;26:1673-8. (21) Monterossi G, Ghezzi F, Vizza E, Zannoni GF, Uccella S, Corrado G, et al. Minimally Invasive Approach in Type II Endometrial Cancer: Is It Wise and Safe? J Minim Invasive Gynecol. 2017;24:438-45. (22) Scaletta G, Dinoi G, Capozzi V, Cianci S, Pelligra S, Ergasti R, et al. Comparison of minimally invasive surgery with laparotomic approach in the treatment of high risk endometrial cancer: A systematic review. Eur J Surg Oncol. 2019. (23) Mariani A, Dowdy SC, Cliby WA, Gostout BS, Jones MB, Wilson TO, et al. Prospective assessment of lymphatic dissemination in endometrial cancer: a paradigm shift in surgical staging. Gynecol Oncol. 2008;109:11-8. (24) Nieto VL, Huang Y, Hou JY, Tergas AI, St Clair CM, Ananth CV, et al. Use and outcomes of minimally invasive hysterectomy for women with nonendometrioid endometrial cancers. Am J Obstet Gynecol. 2018;219:463 e1- e12. (25) Chu LH, Chang WC, Sheu BC. Comparison of the laparoscopic versus conventional open method for surgical staging of endometrial carcinoma. Taiwan J Obstet Gynecol. 2016;55:188-92. (26) Eisenkop SM. Total laparoscopic hysterectomy with pelvic/aortic lymph node dissection for endometrial cancer--a consecutive series without case selection and comparison to laparotomy. Gynecol Oncol. 2010;117:216-23. (27) Palomba S, Ghezzi F, Falbo A, Mandato VD, Annunziata G, Lucia E, et al. Laparoscopic versus abdominal approach to endometrial cancer: a 10-year retrospective multicenter analysis. Int J Gynecol Cancer. 2012;22:425-33. (28) He H, Zeng D, Ou H, Tang Y, Li J, Zhong H. Laparoscopic treatment of endometrial cancer: systematic review. J Minim Invasive Gynecol. 2013;20:413-23. (29) Eisenkop SM. Total Laparoscopic Hysterectomy with Pelvic/Aortic Lymph Node Dissection for Endometrial Cancer Using Passive Instrument Positioners: A Retrospective Case-Control Series. J Minim Invasive Gynecol. 2018;25:800-9. (30) Bergstrom J, Aloisi A, Armbruster S, Yen TT, Casarin J, Leitao MM, Jr., et al. Minimally invasive hysterectomy surgery rates for endometrial cancer performed at National Comprehensive Cancer Network (NCCN) Centers. Gynecol Oncol. 2018;148:480-4. (31) Vardar MA, Gulec UK, Guzel AB, Gumurdulu D, Khatib G, Seydaoglu G. Laparoscopic surgery for low, intermediate and high-risk endometrial cancer. J Gynecol Oncol. 2019;30:e24. (32) Fader AN, Java J, Tenney M, Ricci S, Gunderson CC, Temkin SM, et al. Impact of histology and surgical approach on survival among women with early-stage, high-grade uterine cancer: An NRG Oncology/Gynecologic Oncology Group ancillary analysis. Gynecol Oncol. 2016;143:460-5. (33) Ghezzi F, Cromi A, Uccella S, Siesto G, Giudici S, Serati M, et al. Laparoscopic versus open surgery for endometrial cancer: a minimum 3-year follow-up study. Ann Surg Oncol. 2010;17:271-8. Cite Share Download PDF Status: Published Journal Publication published 28 Oct, 2021 Read the published version in Current Oncology → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Faculty","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Derya","middleName":"","lastName":"Gumurdulu","suffix":""},{"id":18905188,"identity":"fd357728-bd1b-4683-a6bb-dd38b046c407","order_by":24,"name":"Ali Ayhan","email":"","orcid":"","institution":"Başkent University Medical Faculty","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Ayhan","suffix":""}],"badges":[],"createdAt":"2021-02-21 13:27:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-263938/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-263938/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.3390/curroncol28060368","type":"published","date":"2021-10-29T01:09:49+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":7488661,"identity":"b44367e1-c7a5-410f-91eb-ff55459e0a5a","added_by":"auto","created_at":"2021-03-30 16:00:16","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":58247,"visible":true,"origin":"","legend":"OS and DFS of the groups according to the risk categories.","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-263938/v1/5a936d78a555778ac1bb73fe.jpg"},{"id":60754319,"identity":"129b2e62-456d-4d16-b468-b75c140f46dc","added_by":"auto","created_at":"2024-07-21 01:09:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1116741,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-263938/v1/e648d895-c0d4-4364-a280-ee2e58356b57.pdf"}],"financialInterests":"","formattedTitle":"Could the Long-Term Oncological Safety of Laparoscopic Surgery in Low Risk Endometrial Cancer be also valid for the High Intermediate and High-Risk Patients? A Multi-center Turkish Gynecologic Oncology Group Study Conducted with 2745 Endometrial Cancer Cases. (TRSGO-End-001)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometrial cancer is the most common gynecological cancer among women in the developed world [1]. Surgery, including total hysterectomy (TH), bilateral salpingo-oophorectomy (BSO) with or without lymphadenectomy and omentectomy is the mainstay of endometrial cancer treatment [1-3]. Postoperative adjuvant treatments are decided according to the risk category of the patients. Recently, ESMO-ESGO-ESTRO classified endometrial cancer to low, intermediate, high intermediate and high-risk categories in order to tailor the adjuvant therapy after surgery [4]. Surgery of the endometrial cancer can be performed by either laparotomy (LT) or laparoscopic approach. In 1990s, the laparoscopic surgery of the gynecologic malignancies was pioneered by the studies of Dargent et al. [5] and Querleu et al. [6] from France and Childers et al. [7] and Spirtos et al. [8] from the United States [9]. Nevertheless, since the publication of the LACC study, in which laparoscopic approach was found to be associated with poor oncological outcomes in cervical cancer, concerns regarding laparoscopy in gynecological malignancies have been raised [10]. On the other side, the safety of laparoscopy (LS) in endometrial cancer has been demonstrated previously in the randomized GOG lap2 and LACE studies [11, 12]. Numerous studies including the abovementioned landmark studies have found comparable safety and oncological outcomes between laparotomy and laparoscopic modalities in low-risk endometrial cancer [3, 11-17]. However, such studies in the high-risk patients are scarce [18-22]. Therefore, it is necessary to increase the studies investigating the oncological safety of laparoscopic surgery in endometrial cancer, particularly those encompassing the high-risk category. Hence, as the Turkish Society of Gynecologic Oncology (TRSGO), we designed this multi-centric retrospective study to compare the oncologic outcomes of the laparotomy and laparoscopic surgeries in endometrial cancer focusing on the high intermediate and high-risk categories.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eData were collected from 12 TRSGO centers between January 2005 and January 2016, and it was entered by the investigators of each center and controlled by the biostatistician (GS).\u0026nbsp; Approval for this study was obtained from the Research Ethics Committee at \u0026Ccedil;ukurova University Faculty of Medicine. A written informed consent for the use of research and educational purpose was attained from all patients. All participating centers are known for their long-standing experience in laparoscopic surgery for endometrial cancer. Expert gynecologic pathologists in each of these centers evaluated the pathological materials.\u003c/p\u003e\n\u003cp\u003eA data sheet of variables related to demographic, clinical, surgical, pathological, follow-up and survival characteristics was recorded from the databases of each center. Only cases with comprehensive data were included, and finally 2745 endometrial cancer patients were selected for analysis. Age, body mass index (BMI), parity, comorbidities, and surgical variables including; type of surgery, conversion rate of laparoscopy to laparotomy, duration of surgery, fall in hemoglobin level, postoperative stay in the hospital (day), intraoperative and postoperative complications, stage, grade, histopathological type, myometrial invasion (MI: as \u0026lt;50% and \u0026ge;50%), lymph node (LN) involvement, lymphovascular space invasion (LVSI), and number of harvested lymph nodes were recorded. Adjuvant therapy modalities, follow-up data and survival outcomes were also gathered.\u003c/p\u003e\n\u003cp\u003eAll patients\u0026rsquo; diagnoses were made upon a preoperative endometrial biopsy. All patients were preoperatively assessed with transvaginal ultrasonography and chest x-ray. Based on the clinician\u0026rsquo; decision, further preoperative screenings such as abdomen and thorax computed tomography or magnetic resonance imaging were administered particularly when there was a suspicion of extra-uterine disease or \u0026gt;50% MI, and in case of grade 3 or type 2 carcinomas. As this was a retrospective study, no standard preoperative selection criteria were taken into account for laparoscopic surgery. Unless in case of extrauterine disease existence on the imaging methods, LT was preferred. Similarly, no standardization was set among the institutions in this study regarding patients\u0026rsquo; discharge decision. Staging was adapted according to the International Federation of Gynecology and Obstetrics 2009 surgical staging classification. Either in LT arm or in LS arm, all cases underwent TH and BSO. Uterine manipulator was used for all laparoscopically- operated cases. Intraoperative frozen section was applied for all included cases, and a decision to pursue or not to pursue on lymphadenectomy was taken based on its result. Lymphadenectomy was not performed in patients with, stage 1a, grade 1-2, \u0026lt;2 cm tumors (low-risk factors). In the presence of any of the following circumstances; endometrioid adenocarcinoma grade 3, tumor diameter \u0026gt;2cm, \u0026ge;50% MI, stage \u0026gt;1a or non-endometrioid histologies, pelvic \u0026plusmn; para-aortic lymphadenectomy (\u0026plusmn; omentectomy) was considered compatible with the Mayo clinic protocol [23]. Adjuvant therapies (brachytherapy, external beam radiotherapy and/or chemotherapy) were kept in view for patients with \u0026ge; intermediate risk factors.\u003c/p\u003e\n\u003cp\u003eA sub-analysis of survival was made between laparoscopy and laparotomy groups according to the pathologic prognostic factors including stage, grade, MI, LVSI, LN status, histopathological type and the recent ESMO- ESGO- ESTRO risk classification system for endometrial cancer [4]. In the ESMO- ESGO- ESTRO classification, patients with Stage I endometrioid, grade 1\u0026ndash;2, \u0026lt;50% myometrial invasion, LVSI negative were described as low risk and patients with stage 1 endometrioid, grade 1-2, \u0026ge;50% MI, and LVSI negative were defined as intermediate risk. High intermediate risk category was identified as patients with stage I endometrioid, grade 3, \u0026lt;50% MI, regardless of LVSI status or with stage I endometrioid, grade 1\u0026ndash;2, LVSI unequivocally positive, regardless of MI. High-risk category was decided to include patients with; 1- Stage I endometrioid, grade 3, \u0026ge;50% MI, regardless of LVSI status, 2- Stage II endometrioid, 3- Stage III endometrioid, no residual disease, and 4- Non-endometrioid histologies (serous, clear-cell, undifferentiated carcinoma, carcinosarcoma).\u003c/p\u003e\n\u003cp\u003eData were analyzed using the SPSS software version 20.0 (IBM, Armonk, NY, USA). The variables were shown as mean \u0026plusmn; standard deviation, median (minimum-maximum) or n (%). The variables were analyzed firstly to detect whether or not they were normally distributed by visual (histograms, probability plots) and analytical methods (Shapiro-Wilk\u0026rsquo;s test). Independent T test and Chi-square test were used for comparisons between the groups. The follow-up period was accepted as the time between patient's primary surgery and the last contact. Disease-free survival was designated as the duration (months) from surgery to recurrence. Overall survival was described as the period in months between the diagnosis and the death or last follow-up. The effect of clinico-pathological variables, ESMO- ESGO- ESTRO risk groups and type of surgery on disease-free and overall survival rates of the patients were analyzed using Kaplan-Meier method. Log- rank test was used to calculate the differences among the survival curves. The significance of multiple variables was assessed using the Cox proportional hazard model without violating the proportional hazards assumption.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOverall, 2745 patients with endometrial cancer were enrolled in this study. Of them, 1743 (63.5%) cases were operated by LT, and 1002 (36.5%) were operated with conventional LS. Demographic and surgical charateristics of the groups are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Mean age of the laparotomy and laparoscopy groups was 59.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7 and 57.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1, respectively. Patients\u0026thinsp;\u0026lt;\u0026thinsp;50 years were 16.5% and 18.8% in the LT and LS groups, respectively. Mean of BMI was significantly higher in the LS arm (38.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.79) than the LT (32.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9). Only TH\u0026thinsp;+\u0026thinsp;BSO was performed for 510 (29%) patients in the LT and for 329 (32.9%) patients in the LS groups. Staging procedures (retroperitoneal lymphadenectomy\u0026thinsp;\u0026plusmn;\u0026thinsp;omentectomy) were added to TH-BSO in the remaining cases of both groups. Mean resected LN number in patients who underwent pelvic lymphadenectomy was 16.3 in the LT vs 20.9 in the LS groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); and 35.5 in the LT vs 40.9 in the LS groups for patients who underwent pelvic plus para-aortic lymphadenectomy (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Perioperative and postoperative complications were significantly lower in the LS group compared to the LT group (3% vs 4.8%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and 4.3% vs 7.6%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively). However, peri- and postoperative complications related to the urinary and intestinal injuries were noticed more frequently in the LS group. Operation time was significantly lower in the LT group, while estimated blood loss, drop in hemoglobin and postoperative hospital stay were significantly lower in the LS group. Conversion from LS to LT was required in 27 (3%) cases.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDemographic and surgical characteristics of the patients.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eVariables\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eLT\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eLS\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eP\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e(Mean)/N\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSD/(%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e(Mean)/N\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSD/(%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(59,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10,7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(57,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10,1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eParity\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(3,1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2,3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(2,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(32,1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5,9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(38,8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4,7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eBMI group\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;30\u003c/p\u003e\n\u003cp\u003e30\u0026ndash;35\u003c/p\u003e\n\u003cp\u003e35\u0026ndash;40\u003c/p\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e449\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(33,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e331\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(36,8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e560\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(41,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e258\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(28,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e184\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(13,6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e171\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(19,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e158\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(11,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e139\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(15,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eComorbidities\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e565\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(34,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e480\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(48,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1072\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(65,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e521\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(52,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMenopausal status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePremenopausal\u003c/p\u003e\n\u003cp\u003ePostmenopausal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e307\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(35,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e248\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(32,8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e566\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(64,8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e507\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(67,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOperation type\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTH\u0026thinsp;+\u0026thinsp;BSO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e510\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e329\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(32,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTH\u0026thinsp;+\u0026thinsp;BSO\u0026thinsp;+\u0026thinsp;BPLND\u0026thinsp;\u0026plusmn;\u0026thinsp;OMENTECTOMY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e386\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(21,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e440\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(44,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTH\u0026thinsp;+\u0026thinsp;BSO\u0026thinsp;+\u0026thinsp;BPPALND\u0026thinsp;\u0026plusmn;\u0026thinsp;OMENTECTOMY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e847\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(49,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e233\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(14,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePerioperative complications\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1255\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(95,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e736\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(97,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(4,1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(1,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUrinary system injury\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(1,1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIntestinal injury\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative complications\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1221\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(92,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e727\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(95,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInfection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e88\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(6,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(2,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUrinary system injury\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(,1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIntestinal injury\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(,1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(2,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOperation time (minute)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(119,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42,8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(142,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e66,4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eEstimated blood loss (ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(243,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e167,2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(114,6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e81,7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDrop in hemoglobin (gr/dl)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(1,6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(1,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eConversion of laparoscopy to laparotomy\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(3,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative hospitalization (day)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(5.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(3.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003eLT: laparotomy, LS: laparoscopy, N: count, SD: Standard deviation, BMI: body mass index, TH\u0026thinsp;+\u0026thinsp;BSO: total hysterectomy bilateral salpingo-oophorectomy, BPLND: bilateral pelvic lymph node dissection, BPPALND: bilateral pelvic para-aortic lymph node dissection.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHistopathological results of the LT and LS groups are documented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Stage 3\u0026ndash;4 cases were noted in 23.9% of the LT arm vs 11.3% of the LS arm. The grade 3 cases were determined as 12.7% of the LT group and 7.8% of the LS group. Ratios of grade 3 and advanced stage were significantly higher in the LT group than the LS group. Type 2 (non-endometrioid) histologies were reported in 20.9% and 12.1% of the LT and LS groups, respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). More than 50% MI was observed in 38.2% and 25.3% of LT and LS groups, respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Cervix was invaded in 16.5% and 4.6% of the LT and LS arms, respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). LVSI was found in 36% of the LT and 22.7% of the LS arm (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Removed lymph nodes\u0026rsquo; count was 1\u0026ndash;20, 21\u0026ndash;40, \u0026gt;\u0026thinsp;40 in 26.3%, 26.1%, 18.3% and 26.7%, 25.9%, 14.6% of the LT and LS groups, respectively. Metastatic LN ratio was 13.2% in the LT group vs 7.1% in the LS group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Isolated para-aortic LN metastases were recorded in 2.3% and 0.7% of LT and LS cases, respectively.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eHistopathological features of the groups.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eVariables\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eLT\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eLS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eP\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e(Mean)/N\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSD/(%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e(Mean)/N\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSD/(%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eStage\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1a\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e825\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(47,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e664\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(66,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1b\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e372\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(21,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e195\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(19,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e130\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(7,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(3,1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3a\u0026thinsp;+\u0026thinsp;3b\u0026thinsp;+\u0026thinsp;3c\u0026thinsp;+\u0026thinsp;4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e414\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(23,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e114\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(11,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHistopathology\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEndometrioid\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1280\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(79,1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e875\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(87,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSerous\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e113\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(7,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(3,8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eClear\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(2,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMixed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e128\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(7,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(6,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCarcinosarcoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(4,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(1,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHistologic type\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eType1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1280\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(79,1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e875\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(87,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eType2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e339\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(20,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e121\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(12,1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGrade\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e715\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(43,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e537\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(54,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e524\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(32,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e342\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(34,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e389\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(23,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e102\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(10,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMyometrial invasion\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e324\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(20,1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e239\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(24,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;%50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e670\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(41,6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e506\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(50,8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ge;%50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e615\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(38,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e252\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(25,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCervical invasion\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1065\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(83,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e711\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(95,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e211\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(16,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(4,6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLVSI\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e988\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(64,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e749\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(77,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e555\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(36,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e220\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(22,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLN count\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo lymphadenectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e510\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(29,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e329\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(32,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e0.037\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u0026ndash;20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e460\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(26,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e267\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(26,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21\u0026ndash;40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e453\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(26,1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e259\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(25,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e320\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(18,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e147\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(14,6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMetastatic LN\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1512\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(86,8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e931\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(93,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePelvic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e103\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(5,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(4,6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eParaaortic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(2,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(0,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePelvic\u0026thinsp;+\u0026thinsp;paraaortic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(5,0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(1,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003eLT: laparotomy, LS: laparoscopy, N: count, SD: Standard deviation, LVSI: lymphovascular space invasion; LN: lymph node.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe patients were categorized according to the 2016 ESMO-ESGO-ESTRO risk classification system. There was 1226 (46.6%), 363 (13.8%), 389 (14.8%), and 652 (24.8%) patients in the low, intermediate, high intermediate and high-risk categories, respectively. There was no statistically significant difference between LS and LT groups according to the subcategories of 2016 ESMO-ESGO-ESTRO risk classification system, in terms of disease-free survival and overall survival (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eComparison of DFS and OS rates between groups with respect to the ESMO-ESGO-ESTRO risk classification system.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eRisk group\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eDFS\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eOS\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLT\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLS\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLT\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLS\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal n /censored%\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal n /censored%\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal n/ censored%\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal n/ censored%\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLow\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e668/96,4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e121,6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e564/98,2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e120,7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0,274\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e668/96,9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e122,8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e564/98,4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e121,2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0,320\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eIntermediate\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e234/84,2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e89,6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e130/91,5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e105,3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0,180\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e234/90,6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e109,7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e130/96,2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e110,8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0,129\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHigh-intermediate\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e271/75,6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e80,0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e121/75,2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77,7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0,366\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e271/87,8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e101,9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e121/94,2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e98,2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0,153\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHigh\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e464/53,2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32,4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e186/54,3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23,9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0,106\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e464/72,8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60,5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e186/78,0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58,8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0,231\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"11\"\u003eDFS: Disease-free survival; OS: Overall survival; LT: laparotomy, LS: laparoscopy, n: count.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUnivariate and multivariate analyses are shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e and Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e, respectively. Only age, BMI, LN status, stage, histopathological type and risk group for disease-free survival and age, BMI, cervical invasion, LN status, and risk group for overall survival, were determined as independent prognostic factors on the multivariate analysis. No superiority between surgical groups were found in the multivariate analysis regarding both disease-free survival and overall survival.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eUnivariate analysis of DFS and OS.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eVariables\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal / Dead n\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDFS Mean\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOS Mean\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMetastatic lymph node\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003eP\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStage\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2317/132\u003c/p\u003e\n\u003cp\u003e283/109\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e98.5\u003c/p\u003e\n\u003cp\u003e19.5\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e115.9\u003c/p\u003e\n\u003cp\u003e44.9\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1a\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1502/47\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e120.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e121.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1b\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e567/40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e74.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e112.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e162/31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e82.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3a\u0026thinsp;+\u0026thinsp;3b\u0026thinsp;+\u0026thinsp;3c\u0026thinsp;+\u0026thinsp;4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e394/130\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ep\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGrade\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1208/49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e122.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e129.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e798/63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e92.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e114.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e231/51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e74.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ep\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMyometrial invasion\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e867/153\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e119.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e121.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;%50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1176/64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e110.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e115.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ge;%50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e271/80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e93.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ep\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLymphovascular space invasion\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1737/77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e110.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e118.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e775/154\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ep\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHistopathological type\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eType1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2155/141\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e103.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e114.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eType2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e460/103\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ep\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003eDFS: Disease-free survival, OS: Overall survival, n: count.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eMultivariate analysis of DFS and OS.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eVariables\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eHR (95,0% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDFS\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOS\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003cp\u003eSurgery type\u003c/p\u003e\n\u003cp\u003eComorbidities\u003c/p\u003e\n\u003cp\u003eBMI \u0026lt;30\u003c/p\u003e\n\u003cp\u003e30\u0026ndash;40\u003c/p\u003e\n\u003cp\u003e\u0026gt;40\u003c/p\u003e\n\u003cp\u003eMI None\u003c/p\u003e\n\u003cp\u003e\u0026lt;%50\u003c/p\u003e\n\u003cp\u003e\u0026gt;%50\u003c/p\u003e\n\u003cp\u003eLVSI\u003c/p\u003e\n\u003cp\u003eCervical invasion\u003c/p\u003e\n\u003cp\u003eMetastatic LN\u003c/p\u003e\n\u003cp\u003eStage 1a\u003c/p\u003e\n\u003cp\u003e1b\u003c/p\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003cp\u003e3a\u0026thinsp;+\u0026thinsp;3b\u0026thinsp;+\u0026thinsp;3c\u0026thinsp;+\u0026thinsp;4\u003c/p\u003e\n\u003cp\u003eGrade 1\u003c/p\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003cp\u003eHistopathological type\u003c/p\u003e\n\u003cp\u003eRisk group Low\u003c/p\u003e\n\u003cp\u003eIntermediate\u003c/p\u003e\n\u003cp\u003eHigh-intermediate\u003c/p\u003e\n\u003cp\u003eHigh\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e1,025 (1,012\u0026thinsp;\u0026minus;\u0026thinsp;1,038)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1,055 (0,869-1,282)\u003c/p\u003e\n\u003cp\u003e0,980 (0,762-1,262)\u003c/p\u003e\n\u003cp\u003eref\u003c/p\u003e\n\u003cp\u003e1,281 (0,946-1,735)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1,386 (1,032\u0026thinsp;\u0026minus;\u0026thinsp;1,863)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eref\u003c/p\u003e\n\u003cp\u003e0,689 (0,434-1,095)\u003c/p\u003e\n\u003cp\u003e1,008 (0,599-1,698)\u003c/p\u003e\n\u003cp\u003e0,887 (0,618-1,274)\u003c/p\u003e\n\u003cp\u003e1,374 (0,987-1,912)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1,713 (1,131-2,595)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eref\u003c/p\u003e\n\u003cp\u003e1,051 (0,669-1,652)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1,847 (1,083\u0026thinsp;\u0026minus;\u0026thinsp;3,150)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2,012 (1,226-3,303)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eref\u003c/p\u003e\n\u003cp\u003e0,428 (0,313-0,585)\u003c/p\u003e\n\u003cp\u003e0,827 (0,641-1,067)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1,973 (1,495-2,605)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eref\u003c/p\u003e\n\u003cp\u003e1,204 (0,935-1,549)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2,833 (1,452-5,529)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6,349 (3,569\u0026thinsp;\u0026minus;\u0026thinsp;11,294)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd 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align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e0.156\u003c/p\u003e\n\u003cp\u003e0.820\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e0.011\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e0.092\u003c/p\u003e\n\u003cp\u003e0.383\u003c/p\u003e\n\u003cp\u003e0.253\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e0.159\u003c/p\u003e\n\u003cp\u003e0.427\u003c/p\u003e\n\u003cp\u003e0.304\u003c/p\u003e\n\u003cp\u003e0.280\u003c/p\u003e\n\u003cp\u003e0.458\u003c/p\u003e\n\u003cp\u003e0.067\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e0.036\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e0.019\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003eHR: Hazard Ratio; CI: Confidence Interval; DFS: Disease-free survival; OS: Overall survival; BMI: Body mass index; MI: Myometrial invasion; LVSI: Lymphovascular space invasion; LN: Lymph node.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis retrospective multicentric study was conducted to evaluate the oncologic safety and efficacy of the conventional laparoscopy in endometrial cancer by stratifying patients with respect to 2016 ESMO- ESGO- ESTRO risk classification system. Lower pain, lower postoperative complications, shorter hospital stay and recovery, and less cost were the well-known advantages of LS compared to LT in numerous studies [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. These short-term advantages are valid for all patients regardless of their risk category. The similar long-term oncological outcomes of LS in low risk endometrial cancer patients have been demonstrated in the literature to be comparable to the open surgery [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. The literature is scarce on the issue of high intermediate and high-risk endometrial cancer [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. As a reflection of this reality, the European guidelines\u0026rsquo; recommendation for the management of low and intermediate risk endometrial cancer with minimally invasive surgery (MIS) was -level of evidence: I, strength of recommendation: A-, whereas it was considered as -level of evidence: IV, strength of recommendation: C- for the management of high-risk endometrial cancer [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, this gap in the literature has inspired us to compare the long-term oncologic outcomes of LS and LT in different risk categories of endometrial cancer. Herein, 2745 endometrial cancer cases were investigated. Of them, 389 (269 LT vs 120 LS) cases were in the high intermediate and 652 (465 LT vs 187 LS) in the high-risk categories. To the best of our knowledge, with the exclusion of the National Cancer Database study on the non-endometrioid uterine cancers including sarcomas by Nieto and colleagues, [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e] none of the previous papers had compared such a high number of cases.\u003c/p\u003e\n\u003cp\u003eCompatible with the literature, short-term advantages of LS such as less blood loss, less perioperative and postoperative complications and shorter hospitalization were observed even with the addition of high intermediate and high-risk patients in our study. Moreover, BMI of the LS cohort was significantly higher from the LT group. Mean BMI (38.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7) of our LS group was higher than many published studies including the landmark study LAP2, which was 28.4 [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. In addition, more than half of the LS group had at least one comorbidity.\u003c/p\u003e\n\u003cdiv class=\"Ethics-ToolTip\"\u003eThe participating centers in this study are well-known tertiary gynecologic oncology centers in Turkey, which are highly experienced in treating such obese and comorbid patients laparoscopically.\u003c/div\u003e\n\u003cp\u003eTherefore, even with these patients\u0026rsquo; characteristics, sufficient number of LNs were harvested and low conversion rates were obtained. In LS arm, the resected LN number in patients who underwent pelvic lymphadenectomy was 20.91 and it was 40.93 in pelvic plus para-aortic lymphadenectomy; which is in accordance with the literature [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eConversion from laparoscopy to laparotomy was required only in 3% of our series, despite the high volume of high-risk patients. Even though it is clearly less than those in the landmark LAP2 study (25.8%), and comparable to the following literature, which is mainly below 20% and varies between 0% and 25.8% [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. The conversion rate in our study was in accordance with the Italian type 2 endometrial cancer series (2.1%) [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. The low rate of conversion in our series can be attributed to the high expertise of the participating centers in gyne-oncological laparoscopy. According to a multi-centric study in high-volume experienced centers, even when high-risk cases were included, a proposed MIS rate of 80% was found to be an achievable benchmark for the management of women with newly diagnosed endometrial cancer [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. Hence, patients with endometrial cancer including high-risk cases should referred to centers where this benchmark can be achieved [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eIn our recently published single institution study, there was no difference in disease-free survival and overall survival between LS and LT groups according to the risk categories [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. This result is coherent with the previous publications on the comparison of LS and LT in high-risk endometrial cancer [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. In their multi-centric retrospective study, Fader et al. [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e] compared MIS (n\u0026thinsp;=\u0026thinsp;191) and LT (n\u0026thinsp;=\u0026thinsp;192) in type 2 and high grade endometrial cancer, and they stated that high-risk histopathologic types were not a contraindication for MIS when managed by expert laparoscopists. Fader et al. [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e] addressed again in their 2016 publication that patients with grade 3 endometrioid and type 2 endometrial cancer had similar survival outcomes regardless of the surgical approach, MIS or LT. Koskas et al. [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e] conducted a comparative study between MIS (n\u0026thinsp;=\u0026thinsp;114) and LT (n\u0026thinsp;=\u0026thinsp;114) in the high risk endometrial cancer. Authors reported identical oncologic outcomes between groups and concluded that their study provides evidence supporting the use of MIS for high-risk endometrial cancer. Therefore, fear for a poor long-term outcome should not be the reason to refrain from laparoscopic procedure in these patients. [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e] Nieto et al. [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e] evaluated the impact of MIS in 13392 patients with stage I-III non-endometrioid uterine cancer (including sarcomas) who underwent hysterectomy between 2010 and 2014 using the National Cancer Database. Authors reported that the route of surgery does not appear to impact survival adversely in these patients [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. In a multicentric retrospective study by Monterossi et al. [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] 283 patients with type 2 endometrial cancer were evaluated among 2 groups (LS; 141, LT; 142) and comparable survival outcomes were reported for both of them in stage I-II cases. Favero et al. [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e] assessed the oncologic safety of laparoscopic surgery in type 2 endometrial cancer, and found that both 5-year disease-free and overall survival were better among laparoscopically treated patients. However, this superiority was not statistically significant [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Consistent with these studies, both disease-free and overall survival of the high intermediate and high-risk patients were not statistically different between groups in the current study. Comparison between groups according to the 2016 ESMO-ESGO-ESTRO risk classification system was a distinguishable characteristic of our study from the former studies. A recently published review on the comparison between MIS and open surgery in the high-risk endometrial cancer addressed that MIS showed better perioperative and postoperative outcomes and comparable oncological outcomes than open surgery [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, authors pointed out to the need of prospective randomized studies to approve these results.\u003c/p\u003e\n\u003cp\u003eBecause of the numerous advantages of LS, its importance in the endometrial cancer surgery is raising day by day and its increased frequent use more than LT has been shown in some studies [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. According to the data from National Cancer Database provided in the study of Nieto and colleagues [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. on the non-endometrioid uterine cancers, \u0026gt;\u0026thinsp;50% of the hysterectomies were performed with MIS for all of the histologic subtypes (except leiomyosarcoma), by 2014. Authors stated that their findings suggest that MIS has already been widely accepted among clinicians for non-endometrioid uterine cancers, despite the lack of data supporting the procedure\u0026rsquo;s efficacy and safety. They attributed this condition to the widespread acceptance of MIS for endometrioid endometrial cancers, which likely boosted the acceleration of MIS for other histologic subtypes [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. However limited the studies are, availability of comparable oncologic outcomes with MIS versus to LT in high-risk endometrial cancer are promising and encouraging. The present study has strived to strengthen the assertion that laparoscopy was equal to laparotomy in the high intermediate and high-risk endometrial cancer patients, in terms of long-term oncologic outcomes. Nevertheless, this result should cautiously be interpreted considering the retrospective nature and possible selection biases, which is the main weakness of our study. Heterogeneous histologic subtypes, stages and adjuvant treatments were the other limitations. On the other hand, however, pioneering the concept of ESMO-ESGO-ESTRO risk- based comparative survival analysis and including the large number of patients from academic comprehensive cancer centers with expert gynecologic pathologists and gynecologic oncologists who are familiar with LS in gynecologic oncology are the main strengths of our study.\u003c/p\u003e"},{"header":"Conclusion","content":" \u003cp\u003eRegardless of the endometrial cancer risk category, long-term oncologic outcomes of LS is comparable to those treated with LT. Since short-term advantages (less complications, short hospitalization, and rapid recovery) of LS are also valid for the high intermediate and high-risk endometrial cancer, it is reasonable to assume that LS has the ability to accelerate treatment with adjuvant therapies in these patients. Therefore, considering the laparoscopic approach as the preferable choice for high intermediate and high-risk endometrial cancer as well as for the low and intermediate risk categories, will probably be the issue of debate for the foreseeable future. Hence, the need for prospective randomized studies on this subject is indisputable.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement \u003c/strong\u003eAuthors thank Prof. Naki T\u0026uuml;t\u0026uuml;nc\u0026uuml; for editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Standards:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval for this study was obtained from the Research Ethics Committee at \u0026Ccedil;ukurova University Faculty of Medicine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eThe authors declare that they did not receive any financial support regarding this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure: \u003c/strong\u003eNone declared\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e(1) Amant F, Moerman P, Neven P, Timmerman D, Van Limbergen E, Vergote I. Endometrial cancer. Lancet. 2005;366:491-505.\u003c/p\u003e\n\u003cp\u003e(2) Zullo F, Falbo A, Palomba S. Safety of laparoscopy vs laparotomy in the surgical staging of endometrial cancer: a systematic review and metaanalysis of randomized controlled trials. Am J Obstet Gynecol. 2012;207:94-100.\u003c/p\u003e\n\u003cp\u003e(3) Palomba S, Falbo A, Mocciaro R, Russo T, Zullo F. Laparoscopic treatment for endometrial cancer: a meta-analysis of randomized controlled trials (RCTs). Gynecol Oncol. 2009;112:415-21.\u003c/p\u003e\n\u003cp\u003e(4) Colombo N, Creutzberg C, Amant F, Bosse T, Gonzalez-Martin A, Ledermann J, et al. ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: Diagnosis, Treatment and Follow-up. Int J Gynecol Cancer. 2016;26:2-30.\u003c/p\u003e\n\u003cp\u003e(5) D. D. A new future for Schauta's operation through presurgical retroperitoneal\u0026nbsp;pelviscopy. . Eur J Gynaecol Oncol 8.\u003c/p\u003e\n\u003cp\u003e(6) Querleu D, Leblanc E, Castelain B. 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Taiwan J Obstet Gynecol. 2019;58:99-104.\u003c/p\u003e\n\u003cp\u003e(18) Fader AN, Seamon LG, Escobar PF, Frasure HE, Havrilesky LA, Zanotti KM, et al. Minimally invasive surgery versus laparotomy in women with high grade endometrial cancer: a multi-site study performed at high volume cancer centers. Gynecol Oncol. 2012;126:180-5.\u003c/p\u003e\n\u003cp\u003e(19) Koskas M, Jozwiak M, Fournier M, Vergote I, Trum H, Lok C, et al. Long-term oncological safety of minimally invasive surgery in high-risk endometrial cancer. Eur J Cancer. 2016;65:185-91.\u003c/p\u003e\n\u003cp\u003e(20) Favero G, Anton C, Le X, Silva ESA, Dogan NU, Pfiffer T, et al. Oncologic Safety of Laparoscopy in the Surgical Treatment of Type II Endometrial Cancer. Int J Gynecol Cancer. 2016;26:1673-8.\u003c/p\u003e\n\u003cp\u003e(21) Monterossi G, Ghezzi F, Vizza E, Zannoni GF, Uccella S, Corrado G, et al. Minimally Invasive Approach in Type II Endometrial Cancer: Is It Wise and Safe? 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J Minim Invasive Gynecol. 2018;25:800-9.\u003c/p\u003e\n\u003cp\u003e(30) Bergstrom J, Aloisi A, Armbruster S, Yen TT, Casarin J, Leitao MM, Jr., et al. Minimally invasive hysterectomy surgery rates for endometrial cancer performed at National Comprehensive Cancer Network (NCCN) Centers. Gynecol Oncol. 2018;148:480-4.\u003c/p\u003e\n\u003cp\u003e(31) Vardar MA, Gulec UK, Guzel AB, Gumurdulu D, Khatib G, Seydaoglu G. Laparoscopic surgery for low, intermediate and high-risk endometrial cancer. J Gynecol Oncol. 2019;30:e24.\u003c/p\u003e\n\u003cp\u003e(32) Fader AN, Java J, Tenney M, Ricci S, Gunderson CC, Temkin SM, et al. Impact of histology and surgical approach on survival among women with early-stage, high-grade uterine cancer: An NRG Oncology/Gynecologic Oncology Group ancillary analysis. Gynecol Oncol. 2016;143:460-5.\u003c/p\u003e\n\u003cp\u003e(33) Ghezzi F, Cromi A, Uccella S, Siesto G, Giudici S, Serati M, et al. Laparoscopic versus open surgery for endometrial cancer: a minimum 3-year follow-up study. Ann Surg Oncol. 2010;17:271-8.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"High-risk endometrial cancer, laparoscopic surgery, survival.","lastPublishedDoi":"10.21203/rs.3.rs-263938/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-263938/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCould the Long-Term Oncological Safety of Laparoscopic Surgery in Low Risk Endometrial Cancer be also valid for the High Intermediate and High-Risk Patients? A Multi-center Turkish Gynecologic Oncology Group Study Conducted with 2745 Endometrial Cancer Cases. (TRSGO-End-001)\u003c/p\u003e\u003cp\u003e\u003cb\u003eAim\u003c/b\u003e: to compare the long-term oncological outcomes of laparotomy and laparoscopic surgeries in endometrial cancer under the light of 2016 ESMO-ESGO-ESTRO risk classification system with particular focus on the high intermediate and high-risk categories.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e: Using multicentric database between January 2005 and January 2016, disease-free and overall survivals of 2745 endometrial cancer cases were compared according to the surgery route, laparotomy vs laparoscopy. The high intermediate and high-risk patients were defined with respect to the 2016 ESMO-ESGO-ESTRO risk classification system and they were analyzed with respect to difference in survival rates.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e: Of the 2745 patients 1743 (63.5%) were operated by laparotomy, and the remaining were operated with laparoscopy. The total numbers of high intermediate and high-risk endometrial cancer cases were 734 (45%) patients in the LT group and 307 (30.7%) patients in the LS group. Disease-free and overall survivals were not statistically different when compared between laparoscopy and laparotomy groups in terms of low, intermediate, high intermediate and high-risk endometrial cancer.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e: Regardless of the endometrial cancer risk category, long-term oncological outcomes of laparoscopic approach were found to be comparable to those treated with laparotomy. Our results are encouraging to consider laparoscopic surgery for high intermediate and high-risk endometrial cancer cases.\u003c/p\u003e","manuscriptTitle":"Could the Long-Term Oncological Safety of Laparoscopic Surgery in Low Risk Endometrial Cancer be also valid for the High Intermediate and High-Risk Patients? A Multi-center Turkish Gynecologic Oncology Group Study Conducted with 2745 Endometrial Cancer Cases. 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