Impact of Obesity on the Outcomes and Cost of Robotic Surgery for Stage IA Endometrial Cancer: A Regional Perspective from Japan

Impact of Obesity on the Outcomes and Cost of Robotic Surgery for Stage IA Endometrial Cancer: A Regional Perspective from Japan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Obesity on the Outcomes and Cost of Robotic Surgery for Stage IA Endometrial Cancer: A Regional Perspective from Japan Mika Mizuno, Shinichi Togami, Mai Nakazono, Yuriko Higashi, Nozomi Furuzono, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5978535/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 May, 2025 Read the published version in International Journal of Clinical Oncology → Version 1 posted 5 You are reading this latest preprint version Abstract Background The incidence of endometrial cancer in Japan has more than doubled over the past 2 decades because of increasing obesity rates and the unique physiological traits of Asian populations. The aim of this retrospective study was to examine the impact of obesity on surgical outcomes, prognosis, and costs. Methods A total of 197 patients with stage IA endometrial cancer who underwent robot-assisted hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy/biopsy from 2018 onward were included. Patients were divided into the BMI < 30 kg/m² group (n = 117) and the BMI ≥ 30 kg/m² group (n = 80). The clinical and pathological factors, surgical outcomes, perioperative complications, and treatment costs were compared. The median follow-up period was 34.9 months (range: 6.1–84.2). Results In the BMI ≥ 30 kg/m² group, significant differences in comorbidities, including diabetes mellitus (19.7% vs. 51.3%), hypertension (43.6% vs. 58.8%), and hyperlipidemia (29.9% vs. 50%), were detected. However, no significant differences were found in operative time, blood loss volume, perioperative complication rates, or 5-year cancer-specific survival rates (97.6% vs. 100%). Surgical and hospitalization costs were higher in the BMI ≥ 30 kg/m² group, indicating a financial burdensome for both patients and healthcare facilities. Additionally, a higher prevalence of newly developed lifestyle-related diseases, such as cardiovascular diseases and diabetes, was observed during the follow-up (2.5% vs. 10%). Conclusions While obesity (BMI ≥ 30) did not significantly impact surgical outcomes or cancer prognoses, it did increase treatment costs and the risk of lifestyle-related diseases. Thus, preventive strategies, including lifestyle counseling, are needed to reduce obesity-related health burdens. Robotic surgery Endometrial cancer Obesity Surgical outcomes Medical expenses Figures Figure 1 Introduction Uterine corpus cancer is one of the most common gynecological malignancies worldwide, with endometrial carcinoma representing most cases. According to GLOBOCAN 2020 data, it is the seventh most common cancer among women, with 417,367 new cases diagnosed and an incidence of 8.7 per 100,000 (age-standardized rate globally) reported in 2020 [ 1 ]. Although historically low in Asia, the incidence of endometrial cancer in Japan has increased significantly over the past 20–30 years. In 2000, there were 5,609 new cases, with an age-standardized incidence rate of 8.0 per 100,000 people. By 2020, these numbers had increased to 17,779 cases and an incidence rate of 27.4 per 100,000 people [ 2 ]. This trend is linked to lifestyle changes, an aging population, and regional differences in lifestyles and diets. Interestingly, the unique physiological and metabolic characteristics of Asians, particularly their high body fat percentage at a given BMI, is likely a key factor contributing to the increased incidence of EMC among Asians [ 3 – 6 ]. A meta-analysis using CT-based measurements showed that Japanese individuals have significantly greater abdominal visceral fat relative to subcutaneous fat compared to Caucasians, even after adjusting for age and sex (p < 0.05). This suggests ethnic differences in fat distribution that may contribute to metabolic risk [ 7 ]. In addition, a large-scale prospective cohort study of approximately 34,000 Japanese women demonstrated that a BMI > 23 is significantly associated with an increased risk of endometrial cancer (HR per 5 kg/m² increase = 1.80; 95% CI, 1.28–2.54). The study also found that weight gain since age 20 and sedentary behavior at the workplace were linked to a higher risk of endometrial cancer [ 3 ]. Although the average BMI in Asia is 22.9 kg/m²—which is lower than the 26.4 kg/m² reported in Australia and New Zealand—the metabolic risks associated with the distinctive fat distribution in Asian populations remain significant [ 6 ]. For example, the risks for cardiovascular disease, hypertension (HT), diabetes mellitus (DM), and EMC are notable even in individuals with BMIs indicating a healthy weight (23–25 kg/m²). This has prompted scholars to consider lowering the BMI threshold for obesity in Asian populations. The World Health Organization (WHO) defines obesity as a BMI ≥ 30 (class 1 obesity) [ 8 ], whereas in Japan, obesity guidelines classify a BMI > 25 as Grade 1 obesity, with individuals having obesity-related conditions categorized as having "obesity disease" [ 9 ]. In terms of treatment, robotic surgery, following laparoscopic surgery, has been widely accepted for EMC in recent years, with many reports emphasizing its effectiveness, particularly in managing patients with obesity [ 10 – 17 ]. In Japan, insurance coverage of laparoscopic and robotic procedures for stage IA EMC has increased, enabling many designated medical institutions to offer these advanced treatment options. Japan’s universal health coverage ensures all residents have access to medical services [ 18 ]. Funded primarily through national taxes and premiums paid by citizens, this system provides affordable medical care, with patients responsible for copayments ranging from 0–30% of the total cost. Additionally, out-of-pocket expenses are capped, allowing equitable access to expensive treatments, including advanced surgeries and high-cost drugs. Hospitalization costs are determined by two systems: Diagnosis Procedure Combination (DPC) and fee-for-service (FFS). With the DPC system, a fixed daily rate is set on the basis of the patient’s diagnosis and treatment, covering most inpatient services, whereas with the FFS system, each procedure or treatment is charged individually. With this system, costs are generally standardized if the same surgical procedure is performed for the same disease under the fixed-point system. At our institution, which serves local cities and remote islands, the median BMI of stage IA EMC patients treated in the past five years was 28, indicating a higher obesity rate than in other facilities in Japan. In this study, we retrospectively analyzed the impact of obesity on the outcomes and cost of treatment for stage IA EMC to identify challenges and propose solutions for perioperative management in the context of obesity. Materials and methods Between April 2018 and September 2023, 301 patients diagnosed preoperatively with stage IA grade 1–2 EMC underwent surgery at our institution. The median BMI was 27.3 (range: 16.4–53.1). Among these patients, 24 (7.9%) underwent open surgery, 67 (22.3%) underwent laparoscopic surgery, and 210 (69.7%) underwent robotic surgery. A total of 197 robotic-assisted hysterectomies (RHs) performed using the da Vinci® surgical system were analyzed in this study. Patients who were converted to open surgery due to severe adhesions (n = 6) and those who underwent robotic surgery with another robotic system (hinotori™, n = 7) were excluded from the analysis. This study was approved by the Ethics Committee of Kagoshima University (approval number: 220184) prior to registration. Informed consent was obtained through an opt-out system, ensuring the protection of participants' rights and autonomy. The study was conducted in adherence to the principles outlined in the Declaration of Helsinki. Patients were classified into two groups on the basis of their BMI: <30 kg/m² and ≥ 30 kg/m². The clinical characteristics, surgical outcomes (operative time, perioperative complications, and prognosis), and hospitalization costs, including surgical fees, were assessed and compared between the two groups. Perioperative complications were evaluated using the Common Terminology Criteria for Adverse Events (CTCAE) ver.5. translated by the Japan Clinical Oncology Group (JCOG), and postoperative complications were classified using Clavien-Dindo classification) ver.2, developed by JCOG. Statistical analyses were performed using IBM® SPSS® Statistics ver.24. The chi-square test, t test, and Mann-Whitney U test were used for comparisons between the two groups. Survival rates were evaluated via Kaplan‒Meier survival curves. Results Patient characteristics The median values for age, height, weight, and BMI for the entire cohort of 197 patients were 57.5 years (range: 28–89), 155.8 cm (range: 135.5–173), 66.8 kg (range: 40–136), and 28 kg/m² (range: 16.7–53.1), respectively. Patients were classified into categories on the basis of their obesity status determined by the BMI. Among the patients, 67% had a BMI > 25, and 20% had a BMI > 35. Moreover, 18.2% had a BMI < 23, and 14.7% had a BMI between 23 and 24. The distributions of body weight and BMI are illustrated in Fig. 1 . The demographics and clinical characteristics of the patients in the two groups, the BMI < 30 (n = 117) group and the BMI ≥ 30 (n = 80) group, are summarized in Table 1 . Significant differences were observed in age, parity, sexual experience, and preoperative pathological diagnosis between the two groups. With respect to comorbidities, DM, HT, and hyperlipidemia (HL) were significantly more prevalent in the BMI ≥ 30 group, with DM being particularly notable (51.3%). The American Society of Anesthesiologists Physical Status (ASA-PS) classification indicated a significantly higher predicted risk in the BMI ≥ 30 group, reflecting the increased prevalence of obesity and associated comorbidities. Both groups had a similar history of prior abdominal surgeries, with approximately 40% of patients in each group, and no significant differences were observed in this parameter. Table 1 Patient Demographics and Clinical Characteristics Variables BMI < 30 (n = 117) BMI ≥ 30 (n = 80) P N % N % Median Age (y.o.) 58 (32–89) 56 (28–86) 0.019 Median Hight (cm) 156 (137–173) 153.5 (135.5-167.1) 0.190 Parity 82 70.1 40 50 0.003 Sexual experience 107 91.5 60 75 0.0017 Preoperative diagnosis Atypical endometrial hyperplasia 0 0 6 7.5 0.004 Endometrial cancer stage IA 117 100 74 92.5 Comorbidities Diabetes mellitus 23 19.7 41 51.3 <0.0001 Hypertension 51 43.6 47 58.8 0.026 Hyperlipidemia 35 29.9 40 50 0.003 Psychiatric disorder 13 11.1 8 10.2 0.488 Antithrombotic agents 9 7.7 5 6.4 0.484 Past medical history Abdominal surgery 51 43.6 27 33.8 0.108 Malignant disease 18 15.4 10 12.5 0.362 Lifestyle history Smoking history 15 12.8 12 15 0.407 Alcohol consumption 16 13.8 3 3.8 0.016 ASA-PS classification* 1 50 42.7 0 0.0 < 0.001 2 56 47.9 50 64.1 3 10 8.5 28 35.9 4 1 0.9 0 0.0 All items: Yes *American Society of Anesthesiologists Physical Status Surgical outcomes A comparison of factors associated with surgery is presented in Table 2 . Table 2 Comparison of Factors Associated with Surgery Variables BMI < 30 (n = 117) BMI ≥ 30 (n = 80) P N % N % Primary surgical procedure RH + BSO + PLN biopsy (SNNS) 100 85.5 64 80.0 0.08 RH + BSO + PLN dissection (± SNNS) 14 12.0 8 10.0 RH + BSO 3 2.6 8 10.0 Additional surgeries Lower abdominal mini-laparotomy a 5 4.3 2 2.5 0.282 Episiotomy and vaginal wall laceration with suturing a 10 8.5 6 7.5 Vaginal wall reconstruction for pelvic organ prolapses 3 2.6 0 0.0 Others b 9 7.7 5 4.9 Surgical time Median [range] Total operative time, min 200 (101–348) 209 (84–555) 0.402 Console time, min 151 (70–267) 155(53–453) 0.483 Open/closure time, min 46(11–150) 44 (8-104) Blood loss volume Median (range)g 20 (5-335) 20 (2-453) 0.315 Postoperative length of hospital stay Median (range) days 5 (4–35) 5 (4–15) 0.947 RH: Robot-assisted hysterectomy, BSO: Bilateral salpingo-oophorectomy, PLN: Pelvic lymph node, SNNS: Sentinel lymph node navigation surgery, PLN biopsy (SNNS): sentinel node biopsy only. PLN dissection (± SNNS): lymphadenectomy performed due to undetected sentinel nodes or positive sentinel nodes metastasis. a: Procedures related to the retrieval of the resected uterus, b: Repair of organ injury, severe adhesion detachment, ovarian or vulvar tumor resection Approximately 80% of patients in both groups underwent RH, bilateral salpingo-oophorectomy (BSO), and pelvic lymph node biopsy with sentinel lymph node navigation surgery, whereas approximately 10% underwent pelvic lymphadenectomy. No significant differences were observed between the groups regarding additional intraoperative procedures, such as mini-laparotomy for uterus retrieval, perineal or vaginal wall incisions, or vaginal wall lacerations. Similarly, there were no significant differences in operative time, blood loss volume, or postoperative length of hospital stay between the groups. Perioperative complications A summary of perioperative complications requiring medical intervention is presented in Table 3 according to BMI group (< 30 vs. ≥30). Intraoperatively, 1.5% of patients experienced CTCAE grade 1 events, and 0.5% experienced grade 2 events. Postoperatively, 0.5% experienced grade I, 9.1% grade II, and 0.5% grade IIIa complications. None of the patients required adjustment of the Trendelenburg position (25–30 degrees) due to pulmonary ventilation issues. Three patients were admitted to the ICU as a precaution due to severe obesity or comorbidities, but all recovered without severe complications. There was no significant difference in the overall incidence of intraoperative or postoperative adverse events between the BMI groups (p = 0.699 and p = 0.262, respectively). However, patients with a BMI > 35 had a significantly higher rate of postoperative infectious complications (17.5% vs. 7%), with an odds ratio of 2.82 (95% CI: 1.02–7.80, p = 0.047). Post-treatment outcomes Postoperative staging and adjuvant therapy are presented in Supplementary Table 1, with no significant differences observed between the groups. Among all the cases, 82.7% were classified as stage IA (including two cases of AEH that were upstaged to EMC), 7.1% as stage IB, 2.0% as stage II, 2.5% as stage IIIA, and 3.5% as stage IIIC. Adjuvant therapy was administered to 17.8% of patients, including chemotherapy to 28 patients and radiation therapy to 7 patients. The median follow-up period was 34.9 months (range: 6.1–84.2). The posttreatment outcomes are summarized in Table 4 . EMC recurred in 5 patients, 2 of whom died. The remaining 3 patients exhibited remission after treatment. Among the five patients who experienced recurrence, four had identifiable pathological risk factors, including stage IIIA (peritoneal dissemination in the pouch of Douglas), stage IIIC (lymph node metastasis), stage II (cervical stromal invasion), and stage IA with positive ascites cytology. There was no significant difference in the 5-year disease-free survival rate between the BMI < 30 and BMI ≥ 30 groups (97.1% vs. 96.7%, p = 0.986), and the 5-year cancer-specific survival rate was also comparable between the two groups (97.6% vs. 100%, p = 0.255; Supplementary Fig. 1). Six patients (3%) developed new malignant diseases during the follow-up period, with no significant difference between the groups. However, the BMI ≥ 30 group showed a trend toward a higher incidence of severe lifestyle-related diseases requiring treatment with or without hospitalization than the BMI < 30 group (8 vs. 3 patients; 10% vs. 1.5%, p = 0.055). Both patients who required dialysis had BMIs of 23.7 and 27.7, respectively, and suffered from renal failure caused by DM. Additionally, thrombotic events included severe pulmonary thromboembolism and cerebral infarction. Table 4 Outcomes of All Patients Clinically Significant Events Requiring Treatment N, % BMI < 30 (n = 117) BMI ≥ 30 (n = 80) P EMCa recurrence (including pT2,3) 5 2.5% 3 2 1.0 Death 2 1% 2 0 Disease-free survival 3 1.5% 1 2 Other organ cancer 6 3% 5 1* 0.429 Lifestyle-related diseases 11 5.6% 3 8 0.055 Initiation of dialysis 2 1% 2 0 Thrombosis 2 1% 0 2 Diabetes, liver disease, etc. 7 3.5% 1 6 Fractures/orthopedic surgery 3 1.5% 1 2 - Others 2 1% 2 0 - Total 27 13 14 EMCa; endometrial cancer. A: A patient with a BMI of 53 developed lung cancer. Subsequently, their BMI increased to 60, leading to worsening respiratory impairment due to severe obesity. This made treatment challenging, and the patient unfortunately passed away. One notable case involved a 61-year-old patient with mild intellectual disability and a BMI of 53 who experienced severe respiratory issues and had poor weight control, leading to the cancellation of planned surgery. After weight loss, the patient underwent RH with good outcomes but later regained weight, reaching a BMI of 60. The patient developed early-stage lung cancer 2 years later, but severe obesity and respiratory impairment limited treatment, ultimately resulting in death. Medical cost As mentioned, the total cost of EMC surgery consists of the hospitalization fee under the DPC system and the surgery fee, including anesthesia, drugs, and procedures required during surgery, under the FFS system. Moreover, medications administered and procedures performed in the ward before or after surgery are included in the fixed DPC fee. This system ensures both efficiency and transparency in terms of healthcare costs. Table 5 presents the hospitalization costs (in Japanese yen) for EMC patients who underwent RH over a two-year period, categorized by BMI < 30 and BMI ≥ 30. The costs billed under the DPC system (actual billed amounts) were compared with those re-calculated solely under the FFS system (reference values). The average costs were significantly higher in the BMI ≥ 30 group, under both the DPC and FFS system (p < 0.05). The average difference between DPC and FFS costs was -¥6,692 in the BMI < 30 group and -¥18,139 in the BMI ≥ 30 group—approximately 2.7 times greater. Although not statistically significant, the cost difference was larger in the BMI ≥ 30 group. The difference between these two cost systems represents an indirect financial burden that the hospital must bear. Additionally, the average additional surgical cost, which reflects actual charges, was ¥24,074 in the BMI < 30 group and ¥35,172 in the BMI ≥ 30 group, revealing a 1.46-fold higher cost in the latter. Table 5 Comparison of Total Hospitalization Costs: The DPC System (Actual Billed Amounts) vs. Recalculated Using FFS (Reference Values) Variables 1) BMI < 30 (n = 60) 2) BMI ≥ 30 (n = 42) 2) − 1) P A: DPC (JPY) Mean ± SE A1 A2 + 34,142.9 ± 1,663 0.043 95%CI 116–6,713 B: FFC (JPY) a Mean B1 B2 + 36,275.3 ± 1,767 0.040 95%CI 121–7,134 B-A (JPY) Mean -6692.5 ± 19861.6 -18139.5 ± 4242.5 -11450 ± 7640 0.137 95%CI -2,661 − 372 Total hospitalization costs in Japanese yen are determined using the Diagnosis Procedure Combination (DPC) and fee-for-service (FFS), a ; represents an estimated amount recalculated entirely under the FFS system. The actual values of A1, A2, B1, and B2 are confidential information; therefore, only the differences between the two groups are presented in the table. SE: standard error, 95%CI: 95% Confidence Interval, a; represents an estimated amount recalculated entirely under the FFS system. Preoperative approaches for obese patients In three patients, surgeries were postponed due to poor weight and diabetes control, prompting a focus on optimizing preoperative conditions. In addition to routine exams, comprehensive assessments were introduced for patients with HbA1c > 7.5 or newly diagnosed DM, such as intensified insulin therapy. During the 2–3 month waiting period before surgery, with strategies such as family-accompanied nutritional counseling, exercise guidance, follow-up calls implemented for those with mild-to-moderate obesity, and hospitalization for those with severe obesity. Anesthesiologists have also evaluated perioperative risks. As a result of these measures, among 48 patients given weight loss instructions (median weight: 93.7 kg; range: 69–139 kg), 37 actively participated, achieving a median weight loss of 4.25 kg (range: 1–22 kg), with 5 losing 10 kg or more, enabling surgeries to be performed without complications. Discussion Obesity is a well-established risk factor for EMC, and many studies have revealed that the average BMI of patients undergoing surgery for EMC exceeds 30 [ 10 , 13 – 17 , 19 – 26 ]. According to 2017–2018 data from the National Health and Nutrition Examination Survey, 27.5% of American women are overweight (BMI 25–29), and 41.9% are obese (BMI > 30) [ 27 ]. In contrast, the average BMI of Japanese women is approximately 22, and 22.3% have a BMI > 25, with no significant change over the past two decades. Reports from Japan show that the average BMI of EMC patients ranges from 23 to 26 [ 28 , 29 ], similar to other East Asian populations [ 30 , 31 ]. In EMC patients, HT is reported in more than 50% of those with a BMI > 30 and 58–74% of those with a BMI > 40, although significant differences according to obesity category are often not observed [ 13 , 20 , 26 , 32 , 33 ]. In contrast, the prevalence of DM varies across studies depending on BMI, ranging from 21.6–39.5% for individuals with a BMI > 30 [ 13 , 20 , 26 , 32 , 33 ]. In this study, the prevalence of DM was 51.3% in individuals with a BMI > 30, similar to Japanese data revealing a prevalence of 46% in individuals with a BMI 30–39 [ 21 ]. While the prevalence of DM is typically reported to be 7–18% in individuals with a BMI < 30 [ 21 , 26 , 34 , 35 ], our data revealed a higher prevalence of 35.8%, even in patients with a BMI ranging from 25–29. These findings suggest that Japanese patients tend to have a higher prevalence of DM than other populations do, especially if they have a BMI > 25. Obesity is generally associated with worse surgical outcomes, and the incidence of complications tends to increase with increasing BMI [ 36 ]. However, many reports have revealed that RA, as a minimally invasive surgery, is associated with a lower incidence of complications than conventional laparotomy is and can be performed safely and effectively in obese patients [ 5 , 12 , 16 , 17 , 23 , 24 , 36 , 37 ], but the operation time is longer than that of conventional laparotomy [ 12 , 23 , 38 ]. In our hospital, the operative time tended to be shorter for minimally invasive procedures than for open surgery, possibly due to a high level of surgical experience and reduced closure times in obese patients (data not shown). Many studies have revealed that there are no significant differences in operative outcomes or perioperative complication rates of RA, regardless of BMI [ 11 , 13 , 19 , 20 , 26 , 33 ]. Our data similarly revealed differences between obese patients (BMI > 30) and those with a BMI 40 [ 13 ]. Similarly, our data revealed a significantly higher rate of Class II postoperative pelvic infections in patients with a BMI > 35. Survival outcomes for EMC are generally favorable, with many reports indicating no significant differences between laparotomy and laparoscopic surgery [ 14 , 15 , 25 ]. In addition, a prospective study conducted in Australia investigated the long-term prognosis of 760 obese cancer patients who underwent laparotomy or laparoscopic surgery, with approximately 60% having a BMI of 30 or more and a follow-up period of 4.5 years [ 24 ]. The study revealed no difference in recurrence rates, which were approximately 8%. Across all the cases, new cancers were observed in approximately 8.4% of patients, with 3.9% of deaths attributed to EMC and 3.1% attributed to other causes. Similarly, our data revealed a relatively favorable survival outcome for EMC, with a mortality rate of 1% during a median follow-up period of 3 years. However, research suggested that new cancers, as well as obesity- and diabetes-related conditions such as cardiovascular disease and renal failure, may impact long-term survival outcomes. In terms of costs, while robotic surgery is highly effective, many reports highlight its higher cost compared to laparotomy and laparoscopic surgery, raising concerns about the financial burden on healthcare systems [ 12 , 17 , 19 , 23 , 39 , 40 ]. On the other hand, studies have revealed that higher annual surgical volumes could improve cost-effectiveness [ 12 ], and robotic surgery in patients aged 70 and older has been reported to provide overall good cost-performance [ 35 ]. Our healthcare cost data revealed that both the actual billed amount and surgical costs were significantly higher for patients with a BMI ≥ 30. As previously mentioned, the difference between the costs billed under the DPC system (actual billed amounts) and those recalculated under the FFS system (reference values) was greater in patients with a BMI ≥ 30 than in those with a BMI < 30. This is likely due to an increase in non-billable medical procedures under the DPC system, such as the additional use of medications, intravenous fluids, and interventions required for higher body weight and comorbidities. These findings suggest that patients with a BMI ≥ 30 may impose a greater financial burden not only on themselves but also on hospitals and national healthcare resources. Furthermore, we speculate that non-quantifiable factors - such as the increased workload for healthcare staff related to patient transfer and repositioning - may also contribute to the overall cost. In this study, robotic surgery was performed safely across BMI categories, suggesting that obesity alone may not adversely impact surgical safety in a well-managed perioperative setting. This raises the question: Is preoperative weight loss truly necessary? While our data did not show a direct link between weight reduction and surgical outcomes, previous studies have demonstrated that morbid obesity (BMI > 40) is associated with an increased risk of perioperative complications. Additionally, anesthesiologists and gynecologic surgeons may experience greater psychological and physical stress when managing severely obese patients in the steep Trendelenburg position. As noted earlier, preoperative weight loss may help reduce the use of medical resources, prevent the progression of obesity-related comorbidities, and lessen the physical burden on healthcare personnel. Therefore, we believe that preoperative weight management remains an important element of comprehensive perioperative care in patients with obesity. At the same time, while this study does not propose specific policy recommendations, our findings suggest that investing in public health efforts to prevent obesity and lifestyle-related diseases may ultimately be more cost-effective than focusing solely on the treatment of complications using advanced medical technologies. In light of these findings, we believe that future healthcare policies should consider balancing investments in high-cost treatments with broader public health initiatives aimed at preventing obesity and improving population health. The limitations of this study include its retrospective design, use of single-institution data, and its relatively small sample of cases. Healthcare costs cannot be definitively assessed only on the basis of these data, and larger studies are needed. However, with an average height of 155.3 cm and a high proportion of obese patients, our findings offer valuable insights into the outcomes and cost of robotic surgery for obese EMC patients, particularly in Japanese and Asian populations. Conclusion In this study, patients with a BMI > 30 tended to have higher rates of comorbidities, such as DM, HT, and HL, but there were no significant differences in surgical outcomes or perioperative complications. These findings suggest that robotic surgery and comprehensive preoperative management may be effective in mitigating perioperative risks. However, healthcare costs were higher for obese patients, who also appeared to have a higher incidence of severe lifestyle-related diseases after treatment, indicating the importance of preventive measures targeting obesity and related conditions. Declarations Acknowledgments We would like to thank the patients who participated in this study and a hospitalization expense accounting officer. We would also like to thank AJE (www.aje.com) for English language editing. Statements and declarations The authors declare that no funds, grants, or other support was received during the preparation of this manuscript. Ethics approval This study was approved by the Ethics Committee of Kagoshima University (approval number: 220184) prior to registration. Informed consent was obtained through an opt-out system, ensuring the protection of participants' rights and autonomy. Availability of data and materials All the data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author. Authors’ contribution MIKA MIZUNO; design, research, medical examination, data analysis, interpretation, writing, Shinichi Togami, Mai Nakazono, Yuriko Higash, Nozomi Furuzono, Mika Fukuda,: data collection and interpretation, and Hiroaki Kobayashi is a principal investigator. Data interpretation: all authors. 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PLoS ONE 9(9):e108361. 10.1371/journal.pone.0108361 Coronado PJ, Fasero M, Magrina JF, Herraiz MA, Vidart JA (2014) Comparison of perioperative outcomes and cost between robotic-assisted and conventional laparoscopy for transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL). J Minim Invasive Gynecol 21(4):674–681. 10.1016/j.jmig.2014.01.023 Ministry of health law (2025) The health insurance. https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_iryou/iryouhoken/index.html Ontario Health (Quality) (2023) Robotic-assisted hysterectomy for endometrial cancer in people with obesity: a health technology assessment. Ont Health Technol Assess Ser 23(6):1–70 Joshi R, Bora RR, Sonwani T (2024) Robotic-assisted surgery for endometrial cancer: a comparison of surgical and oncologic outcomes in patients with low and high BMI at an Indian tertiary care center. J Robot Surg 18(1):7. 10.1007/s11701-023-01747-z Asanoma K, Yahata H, Okugawa K et al (2022) Impact of obesity on robotic-assisted surgery in patients with stage IA endometrial cancer and a low risk of recurrence: An institutional study. J Obstet Gynaecol Res 48(12):3226–3232. 10.1111/jog.15434 Cusimano MC, Simpson AN, Dossa F et al (2019) Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: a systematic review and meta-analysis of conversions and complications. Am J Obstet Gynecol 221(5):410–428e419. 10.1016/j.ajog.2019.05.004 Silva ESA, de Carvalho JPM, Anton C, Fernandes RP, Baracat EC, Carvalho JP (2018) Introduction of robotic surgery for endometrial cancer into a Brazilian cancer service: a randomized trial evaluating perioperative clinical outcomes and costs. Clinics (Sao Paulo) 73 (suppl 1):e522s. 10.6061/clinics/2017/e522s Janda M, Gebski V, Davies LC et al (2017) 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 317(12):1224–1233. 10.1001/jama.2017.2068 Chen SH, Li ZA, Huang R, Xue HQ (2016) Robot-assisted versus conventional laparoscopic surgery for endometrial cancer staging: a meta-analysis. Taiwan J Obstet Gynecol 55(4):488–494. 10.1016/j.tjog.2016.01.003 Akbayir O, Esmer AC, Numanoglu C et al (2012) Influence of body mass index on clinicopathologic features, surgical morbidity and outcome in patients with endometrial cancer. Arch Gynecol Obstet 286(5):1269–1276. 10.1007/s00404-012-2431-2 Overweight NIDDK (2025) & obesity statistics, according to 2017–2018 data from the National Health and Nutrition Examination Survey. https://www.niddk.nih.gov/health-information/health-statistics/overweight-obesity . Accessed January Aiko K, Kanno K, Yanai S et al (2020) Short-term outcomes of robot-assisted versus conventional laparoscopic surgery for early-stage endometrial cancer: a retrospective, single-center study. J Obstet Gynaecol Res 46(7):1157–1164. 10.1111/jog.14293 Baba T, Mandai M, Nishi H et al (2019) Early feasibility surveillance of gynecologic robotic-assisted surgeries in Japan. J Obstet Gynaecol Res 45(4):787–793. 10.1111/jog.13923 Chiou HY, Chiu LH, Chen CH, Yen YK, Chang CW, Liu WM (2015) Comparing robotic surgery with laparoscopy and laparotomy for endometrial cancer management: a cohort study. Int J Surg 13:17–22. 10.1016/j.ijsu.2014.11.015 Jung YW, Lee DW, Kim SW et al (2010) Robot-assisted staging using three robotic arms for endometrial cancer: comparison to laparoscopy and laparotomy at a single institution. J Surg Oncol 101(2):116–121. 10.1002/jso.21436 Gruhl SL, Yusoff MA, Chin HMS, Nadarajah R (2024) An eight-year analysis of robotic surgery in morbidly obese women with endometrial cancer in a tertiary center in Singapore. Eur J Obstet Gynecol Reprod Biol X 23:100330. 10.1016/j.eurox.2024.100330 Lechartier C, Bernard J, Renaud MC, Plante M (2023) Robotic-assisted surgery for endometrial cancer is safe in morbidly and extremely morbidly obese patients. Gynecol Oncol 172:15–20. 10.1016/j.ygyno.2023.02.014 Seror J, Bats A-S, Huchon C, Bensaïd C, Douay-Hauser N, Lécuru F (2014) Laparoscopy vs robotics in surgical management of endometrial cancer: comparison of intraoperative and postoperative complications. J Minim Invasive Gynecol 21(1):120–125. 10.1016/j.jmig.2013.07.015 Lindfors A, Åkesson Å, Staf C, Sjöli P, Sundfeldt K, Dahm-Kähler P (2018) Robotic vs Open Surgery for Endometrial Cancer in Elderly Patients: Surgical Outcome, Survival, and Cost Analysis. Int J Gynecol Cancer 28(4):692–699. 10.1097/igc.0000000000001240 Orekoya O, Samson ME, Trivedi T, Vyas S, Steck SE (2016) The Impact of Obesity on Surgical Outcome in Endometrial Cancer Patients: A Systematic Review. J Gynecol Surg 32(3):149–157. 10.1089/gyn.2015.0114 Gehrig PA, Cantrell LA, Shafer A, Abaid LN, Mendivil A, Boggess JF (2008) What is the optimal minimally invasive surgical procedure for endometrial cancer staging in the obese and morbidly obese woman? Gynecol Oncol 111(1):41–45. 10.1016/j.ygyno.2008.06.030 Somashekhar SP, Jaka RC, Zaveri SS (2014) Prospective randomized study comparing robotic-assisted hysterectomy and regional lymphadenectomy with traditional laparotomy for staging of endometrial carcinoma –initial indian experience. Indian J Surg Oncol 5(3):217–223. 10.1007/s13193-014-0321-8 Gracia M, García-Santos J, Ramirez M, Bellón M, Herraiz MA, Coronado PJ (2020) Value of robotic surgery in endometrial cancer by body mass index. Int J Gynaecol Obstet 150(3):398–405. 10.1002/ijgo.13258 Blake EA, Sheeder J, Behbakht K, Guntupalli SR, Guy MS (2016) Factors impacting use of robotic surgery for treatment of endometrial cancer in the United States. Ann Surg Oncol 23(11):3744–3748. 10.1245/s10434-016-5252-x Supplementary Files SupplementaryFigure1.tif Supplementary Fig. 1; Kaplan–Meier survival curves for patients stratified by BMI group (<30 vs. ≥30), A: 5-year disease-free survival rate, B: 5-year cancer-specific survival rate. SupplementaryTable1OB.docx Cite Share Download PDF Status: Published Journal Publication published 05 May, 2025 Read the published version in International Journal of Clinical Oncology → Version 1 posted Editorial decision: Accept 16 Apr, 2025 Reviewers agreed at journal 23 Mar, 2025 Reviewers invited by journal 23 Mar, 2025 Editor assigned by journal 23 Mar, 2025 First submitted to journal 20 Mar, 2025 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. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5978535","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":432810743,"identity":"29e96a7c-ae14-4dc8-8a08-69ea3d9176db","order_by":0,"name":"Mika Mizuno","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYDACZgjFA2b/MLCRAzEOPCBaC0NBmjFYSwLxNn44nNgAYuHTotvO/ky6oGKbjPyM3IOPCwyY0+eHHX4ItMVOTrcBuxazwwxp0jPO3OZhnJGXbDzDgC134+00A6CWZGOzAzi1HJPmbbvNwyyRYybBY8CTu3F2AkjLgcRtOLUwtoG1sEG0SKQbzk7/QEALMxtYCw9QizSPgUGCvHQOIVvYmK15gH6R4HljbDjDIMFwg3ROwYEEAzx+OX/84W2eitv28u05hg8+/PkvLz87ffOHDxV2cri0YAIDsEoDYpWDgHwDKapHwSgYBaNgJAAALUVZfJw/SiAAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-3151-8315","institution":"Kagoshima University Faculty of Medicine: Kagoshima Daigaku Igakubu","correspondingAuthor":true,"prefix":"","firstName":"Mika","middleName":"","lastName":"Mizuno","suffix":""},{"id":432810744,"identity":"e4a6096b-aa58-466d-80f9-467a21636caf","order_by":1,"name":"Shinichi Togami","email":"","orcid":"","institution":"Kagoshima University Faculty of Medicine: Kagoshima Daigaku Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Shinichi","middleName":"","lastName":"Togami","suffix":""},{"id":432810745,"identity":"363ca2d8-a915-40ca-b90a-992a1e5f5810","order_by":2,"name":"Mai Nakazono","email":"","orcid":"","institution":"Kagoshima University Faculty of Medicine: Kagoshima Daigaku Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Mai","middleName":"","lastName":"Nakazono","suffix":""},{"id":432810746,"identity":"b6dc55ee-8605-4176-843a-ecfdb5cceb5a","order_by":3,"name":"Yuriko Higashi","email":"","orcid":"","institution":"Kagoshima University Faculty of Medicine: Kagoshima Daigaku Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Yuriko","middleName":"","lastName":"Higashi","suffix":""},{"id":432810747,"identity":"27d4825b-e995-4f40-b453-fb3a8d2c19b8","order_by":4,"name":"Nozomi Furuzono","email":"","orcid":"","institution":"Kagoshima University Faculty of Medicine: Kagoshima Daigaku Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Nozomi","middleName":"","lastName":"Furuzono","suffix":""},{"id":432810748,"identity":"fc49e868-f6e0-49a3-ae5c-10d27d0a4796","order_by":5,"name":"Mika Fukuda","email":"","orcid":"","institution":"Kagoshima University Faculty of Medicine: Kagoshima Daigaku Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Mika","middleName":"","lastName":"Fukuda","suffix":""},{"id":432810749,"identity":"453200db-5e40-4cb7-bf7e-7ce3f698fc4e","order_by":6,"name":"Hiroaki Kobayashi","email":"","orcid":"https://orcid.org/0000-0003-2491-2189","institution":"Kagoshima University Faculty of Medicine: Kagoshima Daigaku Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Hiroaki","middleName":"","lastName":"Kobayashi","suffix":""}],"badges":[],"createdAt":"2025-02-07 07:04:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5978535/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5978535/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10147-025-02772-8","type":"published","date":"2025-05-05T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79322034,"identity":"6fff989b-89fe-41fd-985d-5799c3be0b24","added_by":"auto","created_at":"2025-03-27 04:37:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":63419,"visible":true,"origin":"","legend":"\u003cp\u003eBody Composition Distribution of All Cases\u003c/p\u003e","description":"","filename":"Figure1obesityn.png","url":"https://assets-eu.researchsquare.com/files/rs-5978535/v1/ecd28f66436d55dfd8f5647f.png"},{"id":82537520,"identity":"ea7ce81d-2f24-405d-95be-7ad1ea402bc0","added_by":"auto","created_at":"2025-05-12 16:07:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1041480,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5978535/v1/38fc6cca-f5ef-4c92-9055-7911f1b875fd.pdf"},{"id":79322036,"identity":"9abe8f27-625f-41f3-b50e-14ff62862596","added_by":"auto","created_at":"2025-03-27 04:37:45","extension":"tif","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":100552,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Fig. 1; \u003c/strong\u003eKaplan–Meier survival curves for patients stratified by BMI group (\u0026lt;30 vs. ≥30), A: 5-year disease-free survival rate, B: 5-year cancer-specific survival rate.\u003c/p\u003e","description":"","filename":"SupplementaryFigure1.tif","url":"https://assets-eu.researchsquare.com/files/rs-5978535/v1/c57b1c12e2c5bd3808489c69.tif"},{"id":79322035,"identity":"63ba4292-8841-45d8-9717-a1ad12d0c5c6","added_by":"auto","created_at":"2025-03-27 04:37:45","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":18305,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1OB.docx","url":"https://assets-eu.researchsquare.com/files/rs-5978535/v1/2e8efa6714a16c47b4e00f4c.docx"}],"financialInterests":"","formattedTitle":"Impact of Obesity on the Outcomes and Cost of Robotic Surgery for Stage IA Endometrial Cancer: A Regional Perspective from Japan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUterine corpus cancer is one of the most common gynecological malignancies worldwide, with endometrial carcinoma representing most cases. According to GLOBOCAN 2020 data, it is the seventh most common cancer among women, with 417,367 new cases diagnosed and an incidence of 8.7 per 100,000 (age-standardized rate globally) reported in 2020 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although historically low in Asia, the incidence of endometrial cancer in Japan has increased significantly over the past 20\u0026ndash;30 years. In 2000, there were 5,609 new cases, with an age-standardized incidence rate of 8.0 per 100,000 people. By 2020, these numbers had increased to 17,779 cases and an incidence rate of 27.4 per 100,000 people [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This trend is linked to lifestyle changes, an aging population, and regional differences in lifestyles and diets. Interestingly, the unique physiological and metabolic characteristics of Asians, particularly their high body fat percentage at a given BMI, is likely a key factor contributing to the increased incidence of EMC among Asians [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A meta-analysis using CT-based measurements showed that Japanese individuals have significantly greater abdominal visceral fat relative to subcutaneous fat compared to Caucasians, even after adjusting for age and sex (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This suggests ethnic differences in fat distribution that may contribute to metabolic risk [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In addition, a large-scale prospective cohort study of approximately 34,000 Japanese women demonstrated that a BMI\u0026thinsp;\u0026gt;\u0026thinsp;23 is significantly associated with an increased risk of endometrial cancer (HR per 5 kg/m\u0026sup2; increase\u0026thinsp;=\u0026thinsp;1.80; 95% CI, 1.28\u0026ndash;2.54). The study also found that weight gain since age 20 and sedentary behavior at the workplace were linked to a higher risk of endometrial cancer [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although the average BMI in Asia is 22.9 kg/m\u0026sup2;\u0026mdash;which is lower than the 26.4 kg/m\u0026sup2; reported in Australia and New Zealand\u0026mdash;the metabolic risks associated with the distinctive fat distribution in Asian populations remain significant [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. For example, the risks for cardiovascular disease, hypertension (HT), diabetes mellitus (DM), and EMC are notable even in individuals with BMIs indicating a healthy weight (23\u0026ndash;25 kg/m\u0026sup2;). This has prompted scholars to consider lowering the BMI threshold for obesity in Asian populations. The World Health Organization (WHO) defines obesity as a BMI\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;30 (class 1 obesity) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], whereas in Japan, obesity guidelines classify a BMI\u0026thinsp;\u0026gt;\u0026thinsp;25 as Grade 1 obesity, with individuals having obesity-related conditions categorized as having \"obesity disease\" [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn terms of treatment, robotic surgery, following laparoscopic surgery, has been widely accepted for EMC in recent years, with many reports emphasizing its effectiveness, particularly in managing patients with obesity [\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In Japan, insurance coverage of laparoscopic and robotic procedures for stage IA EMC has increased, enabling many designated medical institutions to offer these advanced treatment options. Japan\u0026rsquo;s universal health coverage ensures all residents have access to medical services [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Funded primarily through national taxes and premiums paid by citizens, this system provides affordable medical care, with patients responsible for copayments ranging from 0\u0026ndash;30% of the total cost. Additionally, out-of-pocket expenses are capped, allowing equitable access to expensive treatments, including advanced surgeries and high-cost drugs. Hospitalization costs are determined by two systems: Diagnosis Procedure Combination (DPC) and fee-for-service (FFS). With the DPC system, a fixed daily rate is set on the basis of the patient\u0026rsquo;s diagnosis and treatment, covering most inpatient services, whereas with the FFS system, each procedure or treatment is charged individually. With this system, costs are generally standardized if the same surgical procedure is performed for the same disease under the fixed-point system.\u003c/p\u003e \u003cp\u003eAt our institution, which serves local cities and remote islands, the median BMI of stage IA EMC patients treated in the past five years was 28, indicating a higher obesity rate than in other facilities in Japan. In this study, we retrospectively analyzed the impact of obesity on the outcomes and cost of treatment for stage IA EMC to identify challenges and propose solutions for perioperative management in the context of obesity.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eBetween April 2018 and September 2023, 301 patients diagnosed preoperatively with stage IA grade 1\u0026ndash;2 EMC underwent surgery at our institution. The median BMI was 27.3 (range: 16.4\u0026ndash;53.1). Among these patients, 24 (7.9%) underwent open surgery, 67 (22.3%) underwent laparoscopic surgery, and 210 (69.7%) underwent robotic surgery. A total of 197 robotic-assisted hysterectomies (RHs) performed using the da Vinci\u0026reg; surgical system were analyzed in this study. Patients who were converted to open surgery due to severe adhesions (n\u0026thinsp;=\u0026thinsp;6) and those who underwent robotic surgery with another robotic system (hinotori\u0026trade;, n\u0026thinsp;=\u0026thinsp;7) were excluded from the analysis.\u003c/p\u003e \u003cp\u003eThis study was approved by the Ethics Committee of Kagoshima University (approval number: 220184) prior to registration. Informed consent was obtained through an opt-out system, ensuring the protection of participants' rights and autonomy. The study was conducted in adherence to the principles outlined in the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003ePatients were classified into two groups on the basis of their BMI: \u0026lt;30 kg/m\u0026sup2; and \u0026ge;\u0026thinsp;30 kg/m\u0026sup2;. The clinical characteristics, surgical outcomes (operative time, perioperative complications, and prognosis), and hospitalization costs, including surgical fees, were assessed and compared between the two groups. Perioperative complications were evaluated using the Common Terminology Criteria for Adverse Events (CTCAE) ver.5. translated by the Japan Clinical Oncology Group (JCOG), and postoperative complications were classified using Clavien-Dindo classification) ver.2, developed by JCOG.\u003c/p\u003e \u003cp\u003eStatistical analyses were performed using IBM\u0026reg; SPSS\u0026reg; Statistics ver.24. The chi-square test, t test, and Mann-Whitney U test were used for comparisons between the two groups. Survival rates were evaluated via Kaplan‒Meier survival curves.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eThe median values for age, height, weight, and BMI for the entire cohort of 197 patients were 57.5 years (range: 28\u0026ndash;89), 155.8 cm (range: 135.5\u0026ndash;173), 66.8 kg (range: 40\u0026ndash;136), and 28 kg/m\u0026sup2; (range: 16.7\u0026ndash;53.1), respectively. Patients were classified into categories on the basis of their obesity status determined by the BMI. Among the patients, 67% had a BMI\u0026thinsp;\u0026gt;\u0026thinsp;25, and 20% had a BMI\u0026thinsp;\u0026gt;\u0026thinsp;35. Moreover, 18.2% had a BMI\u0026thinsp;\u0026lt;\u0026thinsp;23, and 14.7% had a BMI between 23 and 24. The distributions of body weight and BMI are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe demographics and clinical characteristics of the patients in the two groups, the BMI\u0026thinsp;\u0026lt;\u0026thinsp;30 (n\u0026thinsp;=\u0026thinsp;117) group and the BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 (n\u0026thinsp;=\u0026thinsp;80) group, are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Significant differences were observed in age, parity, sexual experience, and preoperative pathological diagnosis between the two groups. With respect to comorbidities, DM, HT, and hyperlipidemia (HL) were significantly more prevalent in the BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 group, with DM being particularly notable (51.3%). The American Society of Anesthesiologists Physical Status (ASA-PS) classification indicated a significantly higher predicted risk in the BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 group, reflecting the increased prevalence of obesity and associated comorbidities. Both groups had a similar history of prior abdominal surgeries, with approximately 40% of patients in each group, and no significant differences were observed in this parameter.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Demographics and Clinical Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eBMI\u0026thinsp;\u0026lt;\u0026thinsp;30 (n\u0026thinsp;=\u0026thinsp;117)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;30 (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian Age\u003c/b\u003e (y.o.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e58 (32\u0026ndash;89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e56 (28\u0026ndash;86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian Hight\u003c/b\u003e (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e156 (137\u0026ndash;173)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e153.5 (135.5-167.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.190\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSexual experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtypical endometrial hyperplasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrial cancer stage IA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e92.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e51.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperlipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychiatric disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.488\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntithrombotic agents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.484\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePast medical history\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e33.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignant disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.362\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLifestyle history\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.407\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol consumption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA-PS classification*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e64.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e35.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eAll items: Yes *American Society of Anesthesiologists Physical Status\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical outcomes\u003c/h3\u003e\n\u003cp\u003eA comparison of factors associated with surgery is presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Factors Associated with Surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eBMI\u0026thinsp;\u0026lt;\u0026thinsp;30 (n\u0026thinsp;=\u0026thinsp;117)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;30 (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary surgical procedure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRH\u0026thinsp;+\u0026thinsp;BSO\u0026thinsp;+\u0026thinsp;PLN biopsy (SNNS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRH\u0026thinsp;+\u0026thinsp;BSO\u0026thinsp;+\u0026thinsp;PLN dissection (\u0026plusmn;\u0026thinsp;SNNS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRH\u0026thinsp;+\u0026thinsp;BSO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdditional surgeries\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower abdominal mini-laparotomy \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.282\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpisiotomy and vaginal wall laceration with suturing \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal wall reconstruction for pelvic organ prolapses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical time \u003c/b\u003e Median [range]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal operative time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e200 (101\u0026ndash;348)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e209 (84\u0026ndash;555)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.402\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsole time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e151 (70\u0026ndash;267)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e155(53\u0026ndash;453)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.483\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen/closure time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e46(11\u0026ndash;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e44 (8-104)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood loss volume \u003c/b\u003e Median (range)g\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e20 (5-335)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e20 (2-453)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.315\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative length of hospital stay \u003c/b\u003eMedian (range) days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5 (4\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e5 (4\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.947\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eRH: Robot-assisted hysterectomy, BSO: Bilateral salpingo-oophorectomy, PLN: Pelvic lymph node, SNNS: Sentinel lymph node navigation surgery, PLN biopsy (SNNS): sentinel node biopsy only. PLN dissection (\u0026plusmn;\u0026thinsp;SNNS): lymphadenectomy performed due to undetected sentinel nodes or positive sentinel nodes metastasis. a: Procedures related to the retrieval of the resected uterus, b: Repair of organ injury, severe adhesion detachment, ovarian or vulvar tumor resection\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eApproximately 80% of patients in both groups underwent RH, bilateral salpingo-oophorectomy (BSO), and pelvic lymph node biopsy with sentinel lymph node navigation surgery, whereas approximately 10% underwent pelvic lymphadenectomy. No significant differences were observed between the groups regarding additional intraoperative procedures, such as mini-laparotomy for uterus retrieval, perineal or vaginal wall incisions, or vaginal wall lacerations. Similarly, there were no significant differences in operative time, blood loss volume, or postoperative length of hospital stay between the groups.\u003c/p\u003e\n\u003ch3\u003ePerioperative complications\u003c/h3\u003e\n\u003cp\u003eA summary of perioperative complications requiring medical intervention is presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e according to BMI group (\u0026lt;\u0026thinsp;30 vs. \u0026ge;30). Intraoperatively, 1.5% of patients experienced CTCAE grade 1 events, and 0.5% experienced grade 2 events. Postoperatively, 0.5% experienced grade I, 9.1% grade II, and 0.5% grade IIIa complications. None of the patients required adjustment of the Trendelenburg position (25\u0026ndash;30 degrees) due to pulmonary ventilation issues. Three patients were admitted to the ICU as a precaution due to severe obesity or comorbidities, but all recovered without severe complications. There was no significant difference in the overall incidence of intraoperative or postoperative adverse events between the BMI groups (p\u0026thinsp;=\u0026thinsp;0.699 and p\u0026thinsp;=\u0026thinsp;0.262, respectively). However, patients with a BMI\u0026thinsp;\u0026gt;\u0026thinsp;35 had a significantly higher rate of postoperative infectious complications (17.5% vs. 7%), with an odds ratio of 2.82 (95% CI: 1.02\u0026ndash;7.80, p\u0026thinsp;=\u0026thinsp;0.047).\u003c/p\u003e \u003cp\u003e\u003cimg 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\" height=\"511\" width=\"584\"\u003e\u003c/p\u003e\n\u003ch3\u003ePost-treatment outcomes\u003c/h3\u003e\n\u003cp\u003ePostoperative staging and adjuvant therapy are presented in Supplementary Table\u0026nbsp;1, with no significant differences observed between the groups. Among all the cases, 82.7% were classified as stage IA (including two cases of AEH that were upstaged to EMC), 7.1% as stage IB, 2.0% as stage II, 2.5% as stage IIIA, and 3.5% as stage IIIC. Adjuvant therapy was administered to 17.8% of patients, including chemotherapy to 28 patients and radiation therapy to 7 patients.\u003c/p\u003e \u003cp\u003eThe median follow-up period was 34.9 months (range: 6.1\u0026ndash;84.2). The posttreatment outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. EMC recurred in 5 patients, 2 of whom died. The remaining 3 patients exhibited remission after treatment. Among the five patients who experienced recurrence, four had identifiable pathological risk factors, including stage IIIA (peritoneal dissemination in the pouch of Douglas), stage IIIC (lymph node metastasis), stage II (cervical stromal invasion), and stage IA with positive ascites cytology. There was no significant difference in the 5-year disease-free survival rate between the BMI\u0026thinsp;\u0026lt;\u0026thinsp;30 and BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 groups (97.1% vs. 96.7%, p\u0026thinsp;=\u0026thinsp;0.986), and the 5-year cancer-specific survival rate was also comparable between the two groups (97.6% vs. 100%, p\u0026thinsp;=\u0026thinsp;0.255; Supplementary Fig.\u0026nbsp;1). Six patients (3%) developed new malignant diseases during the follow-up period, with no significant difference between the groups. However, the BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 group showed a trend toward a higher incidence of severe lifestyle-related diseases requiring treatment with or without hospitalization than the BMI\u0026thinsp;\u0026lt;\u0026thinsp;30 group (8 vs. 3 patients; 10% vs. 1.5%, p\u0026thinsp;=\u0026thinsp;0.055). Both patients who required dialysis had BMIs of 23.7 and 27.7, respectively, and suffered from renal failure caused by DM. Additionally, thrombotic events included severe pulmonary thromboembolism and cerebral infarction.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcomes of All Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinically Significant Events Requiring Treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eN, %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBMI\u0026thinsp;\u0026lt;\u0026thinsp;30 (n\u0026thinsp;=\u0026thinsp;117)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;30 (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEMCa recurrence (including pT2,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisease-free survival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther organ cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.429\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLifestyle-related diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInitiation of dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThrombosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, liver disease, etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFractures/orthopedic surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eEMCa; endometrial cancer. A: A patient with a BMI of 53 developed lung cancer. Subsequently, their BMI increased to 60, leading to worsening respiratory impairment due to severe obesity. This made treatment challenging, and the patient unfortunately passed away.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOne notable case involved a 61-year-old patient with mild intellectual disability and a BMI of 53 who experienced severe respiratory issues and had poor weight control, leading to the cancellation of planned surgery. After weight loss, the patient underwent RH with good outcomes but later regained weight, reaching a BMI of 60. The patient developed early-stage lung cancer 2 years later, but severe obesity and respiratory impairment limited treatment, ultimately resulting in death.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMedical cost\u003c/h2\u003e \u003cp\u003eAs mentioned, the total cost of EMC surgery consists of the hospitalization fee under the DPC system and the surgery fee, including anesthesia, drugs, and procedures required during surgery, under the FFS system. Moreover, medications administered and procedures performed in the ward before or after surgery are included in the fixed DPC fee. This system ensures both efficiency and transparency in terms of healthcare costs.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents the hospitalization costs (in Japanese yen) for EMC patients who underwent RH over a two-year period, categorized by BMI\u0026thinsp;\u0026lt;\u0026thinsp;30 and BMI\u0026thinsp;\u0026ge;\u0026thinsp;30. The costs billed under the DPC system (actual billed amounts) were compared with those re-calculated solely under the FFS system (reference values). The average costs were significantly higher in the BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 group, under both the DPC and FFS system (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The average difference between DPC and FFS costs was -\u0026yen;6,692 in the BMI\u0026thinsp;\u0026lt;\u0026thinsp;30 group and -\u0026yen;18,139 in the BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 group\u0026mdash;approximately 2.7 times greater. Although not statistically significant, the cost difference was larger in the BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 group. The difference between these two cost systems represents an indirect financial burden that the hospital must bear. Additionally, the average additional surgical cost, which reflects actual charges, was \u0026yen;24,074 in the BMI\u0026thinsp;\u0026lt;\u0026thinsp;30 group and \u0026yen;35,172 in the BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 group, revealing a 1.46-fold higher cost in the latter.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Total Hospitalization Costs: The DPC System (Actual Billed Amounts) vs. Recalculated Using FFS (Reference Values)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1) BMI\u0026thinsp;\u0026lt;\u0026thinsp;30 (n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2) BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 (n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2) \u0026minus;\u0026thinsp;1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eA: DPC (JPY)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e+\u0026thinsp;34,142.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1,663\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e116\u0026ndash;6,713\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eB: FFC (JPY)\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e+\u0026thinsp;36,275.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1,767\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e121\u0026ndash;7,134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eB-A (JPY)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-6692.5\u0026thinsp;\u0026plusmn;\u0026thinsp;19861.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-18139.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4242.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-11450\u0026thinsp;\u0026plusmn;\u0026thinsp;7640\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.137\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2,661\u0026thinsp;\u0026minus;\u0026thinsp;372\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eTotal hospitalization costs in Japanese yen are determined using the Diagnosis Procedure Combination (DPC) and fee-for-service (FFS), \u003cb\u003ea\u003c/b\u003e; represents an estimated amount recalculated entirely under the FFS system. The actual values of A1, A2, B1, and B2 are confidential information; therefore, only the differences between the two groups are presented in the table. SE: standard error, 95%CI: 95% Confidence Interval, a; represents an estimated amount recalculated entirely under the FFS system.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePreoperative approaches for obese patients\u003c/h3\u003e\n\u003cp\u003eIn three patients, surgeries were postponed due to poor weight and diabetes control, prompting a focus on optimizing preoperative conditions. In addition to routine exams, comprehensive assessments were introduced for patients with HbA1c\u0026thinsp;\u0026gt;\u0026thinsp;7.5 or newly diagnosed DM, such as intensified insulin therapy. During the 2\u0026ndash;3 month waiting period before surgery, with strategies such as family-accompanied nutritional counseling, exercise guidance, follow-up calls implemented for those with mild-to-moderate obesity, and hospitalization for those with severe obesity. Anesthesiologists have also evaluated perioperative risks. As a result of these measures, among 48 patients given weight loss instructions (median weight: 93.7 kg; range: 69\u0026ndash;139 kg), 37 actively participated, achieving a median weight loss of 4.25 kg (range: 1\u0026ndash;22 kg), with 5 losing 10 kg or more, enabling surgeries to be performed without complications.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eObesity is a well-established risk factor for EMC, and many studies have revealed that the average BMI of patients undergoing surgery for EMC exceeds 30 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. According to 2017\u0026ndash;2018 data from the National Health and Nutrition Examination Survey, 27.5% of American women are overweight (BMI 25\u0026ndash;29), and 41.9% are obese (BMI\u0026thinsp;\u0026gt;\u0026thinsp;30) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In contrast, the average BMI of Japanese women is approximately 22, and 22.3% have a BMI\u0026thinsp;\u0026gt;\u0026thinsp;25, with no significant change over the past two decades.\u003c/p\u003e \u003cp\u003eReports from Japan show that the average BMI of EMC patients ranges from 23 to 26 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], similar to other East Asian populations [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn EMC patients, HT is reported in more than 50% of those with a BMI\u0026thinsp;\u0026gt;\u0026thinsp;30 and 58\u0026ndash;74% of those with a BMI\u0026thinsp;\u0026gt;\u0026thinsp;40, although significant differences according to obesity category are often not observed [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In contrast, the prevalence of DM varies across studies depending on BMI, ranging from 21.6\u0026ndash;39.5% for individuals with a BMI\u0026thinsp;\u0026gt;\u0026thinsp;30 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In this study, the prevalence of DM was 51.3% in individuals with a BMI\u0026thinsp;\u0026gt;\u0026thinsp;30, similar to Japanese data revealing a prevalence of 46% in individuals with a BMI 30\u0026ndash;39 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. While the prevalence of DM is typically reported to be 7\u0026ndash;18% in individuals with a BMI\u0026thinsp;\u0026lt;\u0026thinsp;30 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], our data revealed a higher prevalence of 35.8%, even in patients with a BMI ranging from 25\u0026ndash;29. These findings suggest that Japanese patients tend to have a higher prevalence of DM than other populations do, especially if they have a BMI\u0026thinsp;\u0026gt;\u0026thinsp;25.\u003c/p\u003e \u003cp\u003eObesity is generally associated with worse surgical outcomes, and the incidence of complications tends to increase with increasing BMI [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. However, many reports have revealed that RA, as a minimally invasive surgery, is associated with a lower incidence of complications than conventional laparotomy is and can be performed safely and effectively in obese patients [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], but the operation time is longer than that of conventional laparotomy [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In our hospital, the operative time tended to be shorter for minimally invasive procedures than for open surgery, possibly due to a high level of surgical experience and reduced closure times in obese patients (data not shown). Many studies have revealed that there are no significant differences in operative outcomes or perioperative complication rates of RA, regardless of BMI [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Our data similarly revealed differences between obese patients (BMI\u0026thinsp;\u0026gt;\u0026thinsp;30) and those with a BMI\u0026thinsp;\u0026lt;\u0026thinsp;30. Moreover, some have noted that the incidence of complications increase with increasing BMI [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], as evidenced by a higher incidence of wound infections in patients with a BMI\u0026thinsp;\u0026gt;\u0026thinsp;40 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Similarly, our data revealed a significantly higher rate of Class II postoperative pelvic infections in patients with a BMI\u0026thinsp;\u0026gt;\u0026thinsp;35.\u003c/p\u003e \u003cp\u003eSurvival outcomes for EMC are generally favorable, with many reports indicating no significant differences between laparotomy and laparoscopic surgery [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In addition, a prospective study conducted in Australia investigated the long-term prognosis of 760 obese cancer patients who underwent laparotomy or laparoscopic surgery, with approximately 60% having a BMI of 30 or more and a follow-up period of 4.5 years [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The study revealed no difference in recurrence rates, which were approximately 8%. Across all the cases, new cancers were observed in approximately 8.4% of patients, with 3.9% of deaths attributed to EMC and 3.1% attributed to other causes. Similarly, our data revealed a relatively favorable survival outcome for EMC, with a mortality rate of 1% during a median follow-up period of 3 years. However, research suggested that new cancers, as well as obesity- and diabetes-related conditions such as cardiovascular disease and renal failure, may impact long-term survival outcomes.\u003c/p\u003e \u003cp\u003eIn terms of costs, while robotic surgery is highly effective, many reports highlight its higher cost compared to laparotomy and laparoscopic surgery, raising concerns about the financial burden on healthcare systems [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. On the other hand, studies have revealed that higher annual surgical volumes could improve cost-effectiveness [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and robotic surgery in patients aged 70 and older has been reported to provide overall good cost-performance [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Our healthcare cost data revealed that both the actual billed amount and surgical costs were significantly higher for patients with a BMI\u0026thinsp;\u0026ge;\u0026thinsp;30. As previously mentioned, the difference between the costs billed under the DPC system (actual billed amounts) and those recalculated under the FFS system (reference values) was greater in patients with a BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 than in those with a BMI\u0026thinsp;\u0026lt;\u0026thinsp;30. This is likely due to an increase in non-billable medical procedures under the DPC system, such as the additional use of medications, intravenous fluids, and interventions required for higher body weight and comorbidities. These findings suggest that patients with a BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 may impose a greater financial burden not only on themselves but also on hospitals and national healthcare resources. Furthermore, we speculate that non-quantifiable factors - such as the increased workload for healthcare staff related to patient transfer and repositioning - may also contribute to the overall cost.\u003c/p\u003e \u003cp\u003eIn this study, robotic surgery was performed safely across BMI categories, suggesting that obesity alone may not adversely impact surgical safety in a well-managed perioperative setting. This raises the question: Is preoperative weight loss truly necessary? While our data did not show a direct link between weight reduction and surgical outcomes, previous studies have demonstrated that morbid obesity (BMI\u0026thinsp;\u0026gt;\u0026thinsp;40) is associated with an increased risk of perioperative complications. Additionally, anesthesiologists and gynecologic surgeons may experience greater psychological and physical stress when managing severely obese patients in the steep Trendelenburg position. As noted earlier, preoperative weight loss may help reduce the use of medical resources, prevent the progression of obesity-related comorbidities, and lessen the physical burden on healthcare personnel. Therefore, we believe that preoperative weight management remains an important element of comprehensive perioperative care in patients with obesity.\u003c/p\u003e \u003cp\u003eAt the same time, while this study does not propose specific policy recommendations, our findings suggest that investing in public health efforts to prevent obesity and lifestyle-related diseases may ultimately be more cost-effective than focusing solely on the treatment of complications using advanced medical technologies. In light of these findings, we believe that future healthcare policies should consider balancing investments in high-cost treatments with broader public health initiatives aimed at preventing obesity and improving population health.\u003c/p\u003e \u003cp\u003eThe limitations of this study include its retrospective design, use of single-institution data, and its relatively small sample of cases. Healthcare costs cannot be definitively assessed only on the basis of these data, and larger studies are needed. However, with an average height of 155.3 cm and a high proportion of obese patients, our findings offer valuable insights into the outcomes and cost of robotic surgery for obese EMC patients, particularly in Japanese and Asian populations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, patients with a BMI\u0026thinsp;\u0026gt;\u0026thinsp;30 tended to have higher rates of comorbidities, such as DM, HT, and HL, but there were no significant differences in surgical outcomes or perioperative complications. These findings suggest that robotic surgery and comprehensive preoperative management may be effective in mitigating perioperative risks. However, healthcare costs were higher for obese patients, who also appeared to have a higher incidence of severe lifestyle-related diseases after treatment, indicating the importance of preventive measures targeting obesity and related conditions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the patients who participated in this study and a hospitalization expense accounting officer. We would also like to thank AJE (www.aje.com) for English language editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatements and declarations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support was received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Kagoshima University (approval number: 220184) prior to registration. Informed consent was obtained through an opt-out system, ensuring the protection of participants' rights and autonomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors’ contribution\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMIKA MIZUNO; design, research, medical examination, data analysis, interpretation, writing, Shinichi Togami, Mai Nakazono, Yuriko Higash, Nozomi Furuzono, Mika Fukuda,: data collection and interpretation, and Hiroaki Kobayashi is a principal investigator. Data interpretation: all authors. Reviewing/editing the manuscript: all authors. Final approval of the manuscript: all authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL et al (2021) Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. 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Ann Surg Oncol 23(11):3744\u0026ndash;3748. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1245/s10434-016-5252-x\u003c/span\u003e\u003cspan address=\"10.1245/s10434-016-5252-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\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":"international-journal-of-clinical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijco","sideBox":"Learn more about [International Journal of Clinical Oncology](http://link.springer.com/journal/10147)","snPcode":"10147","submissionUrl":"https://www.editorialmanager.com/ijco/default2.aspx","title":"International Journal of Clinical Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Robotic surgery, Endometrial cancer, Obesity, Surgical outcomes, Medical expenses","lastPublishedDoi":"10.21203/rs.3.rs-5978535/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5978535/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe incidence of endometrial cancer in Japan has more than doubled over the past 2 decades because of increasing obesity rates and the unique physiological traits of Asian populations. The aim of this retrospective study was to examine the impact of obesity on surgical outcomes, prognosis, and costs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 197 patients with stage IA endometrial cancer who underwent robot-assisted hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy/biopsy from 2018 onward were included. Patients were divided into the BMI\u0026thinsp;\u0026lt;\u0026thinsp;30 kg/m\u0026sup2; group (n\u0026thinsp;=\u0026thinsp;117) and the BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u0026sup2; group (n\u0026thinsp;=\u0026thinsp;80). The clinical and pathological factors, surgical outcomes, perioperative complications, and treatment costs were compared. The median follow-up period was 34.9 months (range: 6.1\u0026ndash;84.2).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn the BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u0026sup2; group, significant differences in comorbidities, including diabetes mellitus (19.7% vs. 51.3%), hypertension (43.6% vs. 58.8%), and hyperlipidemia (29.9% vs. 50%), were detected. However, no significant differences were found in operative time, blood loss volume, perioperative complication rates, or 5-year cancer-specific survival rates (97.6% vs. 100%). Surgical and hospitalization costs were higher in the BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u0026sup2; group, indicating a financial burdensome for both patients and healthcare facilities. Additionally, a higher prevalence of newly developed lifestyle-related diseases, such as cardiovascular diseases and diabetes, was observed during the follow-up (2.5% vs. 10%).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWhile obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;30) did not significantly impact surgical outcomes or cancer prognoses, it did increase treatment costs and the risk of lifestyle-related diseases. Thus, preventive strategies, including lifestyle counseling, are needed to reduce obesity-related health burdens.\u003c/p\u003e","manuscriptTitle":"Impact of Obesity on the Outcomes and Cost of Robotic Surgery for Stage IA Endometrial Cancer: A Regional Perspective from Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-27 04:37:40","doi":"10.21203/rs.3.rs-5978535/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2025-04-16T21:00:46+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-03-24T01:12:15+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-23T22:43:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-23T16:22:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Clinical Oncology","date":"2025-03-20T08:05:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijco","sideBox":"Learn more about [International Journal of Clinical Oncology](http://link.springer.com/journal/10147)","snPcode":"10147","submissionUrl":"https://www.editorialmanager.com/ijco/default2.aspx","title":"International Journal of Clinical Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"9a3f2cfb-ac35-4270-8ff5-a676b60a51c7","owner":[],"postedDate":"March 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-12T16:01:44+00:00","versionOfRecord":{"articleIdentity":"rs-5978535","link":"https://doi.org/10.1007/s10147-025-02772-8","journal":{"identity":"international-journal-of-clinical-oncology","isVorOnly":false,"title":"International Journal of Clinical Oncology"},"publishedOn":"2025-05-05 15:57:30","publishedOnDateReadable":"May 5th, 2025"},"versionCreatedAt":"2025-03-27 04:37:40","video":"","vorDoi":"10.1007/s10147-025-02772-8","vorDoiUrl":"https://doi.org/10.1007/s10147-025-02772-8","workflowStages":[]},"version":"v1","identity":"rs-5978535","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5978535","identity":"rs-5978535","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}