Objective: To determine if the type of operative incision influences the adequacy of surgical staging in patients with uterine cancer.
Methods: All patients with uterine cancer referred to the Swedish Medical Center Cancer Institute for adjuvant radiotherapy between June 1, 1989, and June 1, 1999, who underwent comprehensive surgical staging and for whom complete records could be obtained were eligible. Data on type of incision, weight, medical comorbidities, histology, total number and distribution of lymph nodes (LN), estimated blood loss, complications, and length of stay were abstracted retrospectively. Statistical analysis with two-tailed Student t test, chi(2), Fisher's exact, and Kaplan-Meier survival curves were performed.
Results: Five hundred four women with uterine cancers were referred to the Cancer Institute with 332 meeting inclusion criteria. A vertical midline incision (ML) was used in 236 (72%) while 96 (28%) received a Pfannenstiel incision (PI). No panniculectomies were performed. There were no statistically significant differences in age, weight, stage, histology, comorbidities, or estimated blood loss between the ML and PI groups. ML was associated with significantly more intraoperative and postoperative complications (34 vs. 7; P = 0.003). When compared to ML a greater number of total LN (21.0 vs. 16.8; P = 0.001) and a comparable number of pelvic LN (13.7 vs. 12.2; P = 0.14) were procured through a PI. More patients with a ML (72% vs. 63%; P = 0.13) had para-aortic lymph nodes (PALN) dissected; however, when obtained equivalent numbers of nodes were removed (3.52 vs. 4.36; P = 0.14). Overall, the median length of stay was statistically shorter for those patients operated on via a PI (4 vs. 3 days; P = 0.007). The projected 5-year disease-free (83% vs. 85%) and disease-specific (87% vs. 85%) survival was unaffected by incision. In the heaviest quartile of patients (>180 lb), a statistically greater number of total LN (23.3 vs. 16.5; P = 0.005) and pelvic LN (16.7 vs. 11.5; P = 0.05) were obtained with a PI. Again, PALN were sampled more frequently (67% vs. 56%; P = 0.45) in patients with a ML, but the mean LN yield was no different (3.91 vs. 5.20; P = 0.37). Likewise, in this heaviest quartile, there were no statically significant differences in operative complications (7 vs. 1; P = 0.43) with either incision.
Conclusions: Comprehensive surgical staging for uterine cancers can be adequately performed through a PI without greater morbidity or mortality. By using this surgical approach, patients with uterine cancer can benefit from the inherent benefits previously described for PI. Appropriate patient selection, however, is necessary.