Insights in Gynecologic Oncology
Open Access

Gynecologic oncology; Minimally invasive surgery; Robotic surgery; Endometrial cancer; Ovarian cancer; Surgical outcomes; Complications; Hospital stay; Precision surgery; Training

Introduction

Surgery is the primary treatment modality for most gynecologic cancers, with over 80% of endometrial cancer patients and 60% of ovarian cancer patients undergoing surgical intervention [1]. Traditionally, open laparotomy was the standard approach, but it is associated with significant morbidity, including prolonged recovery and higher complication rates. The advent of minimally invasive surgery (MIS), including laparoscopy and robotic-assisted surgery, has revolutionized gynecologic oncology, improving patient outcomes while maintaining oncologic efficacy [2]. This article synthesizes evidence from clinical studies, compares MIS and open surgery, and discusses challenges and future innovations in surgical techniques.

Discussion

Laparoscopic surgery, introduced in the 1990s, significantly reduced blood loss and hospital stays compared to open surgery for endometrial cancer [3]. The GOG-LAP2 trial demonstrated that laparoscopy achieved equivalent oncologic outcomes to laparotomy, with a 40% reduction in postoperative complications. However, laparoscopy’s technical demands, including limited dexterity, prompted the adoption of robotic-assisted surgery, particularly with the da Vinci system. Robotic surgery offers enhanced visualization, precision, and ergonomics, making it ideal for complex procedures like lymphadenectomy and ovarian cancer debulking [4]. The LACC trial, while controversial for suggesting worse survival in cervical cancer with MIS, confirmed robotic surgery’s safety in endometrial cancer, with 5-year survival rates comparable to open surgery (90% vs. 89%) [5]. A meta-analysis of 20 studies reported that robotic surgery reduced blood loss by 200 mL and hospital stays by 2 days compared to laparotomy. Challenges include the high cost of robotic systems ($1.5–2 million) and maintenance, limiting access in low-resource settings. Surgeon training is another barrier, with a learning curve of 20–30 cases required for proficiency. Emerging innovations, such as intraoperative near-infrared imaging and artificial intelligence for surgical planning, promise to enhance precision and reduce complications. For ovarian cancer, robotic debulking is feasible in select early-stage cases, but open surgery remains standard for advanced disease due to tumor burden.

Results

Clinical trials and meta-analyses show that MIS, particularly robotic surgery, significantly improves outcomes. The GOG-LAP2 trial reported a 15.6% complication rate with laparoscopy versus 25.7% with laparotomy in endometrial cancer [6]. Robotic surgery further reduced complications to 10–12% in multiple studies, with median blood loss of 100 mL compared to 300 mL for open surgery [7]. Hospital stays averaged 2 days for robotic surgery versus 4–5 days for laparotomy [8]. Oncologic outcomes, including 5-year overall survival, were equivalent (90% for MIS vs. 89% for open). Costs were 20–30% higher for robotic surgery due to equipment and maintenance [9]. Training programs reduced the learning curve, with proficiency achieved after 25 cases. Early-stage ovarian cancer debulking via robotics achieved 95% optimal cytoreduction rates [10].

Conclusion

Minimally invasive and robotic-assisted surgery have transformed gynecologic oncology, offering reduced complications, shorter hospital stays, and equivalent oncologic outcomes compared to open surgery. While costs and training remain barriers, innovations like enhanced imaging and AI integration hold promise for further improvements. Expanding access to MIS through training and cost-effective technologies will be critical to ensuring equitable care. Continued research into patient selection and advanced-stage applications will solidify the role of surgical innovations in gynecologic cancer management.