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Feasibility and Outcomes of Laparoscopic Cytoreduction in Patients With Localized Recurrent Epithelial Ovarian Cancer
S78
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
196
197
Feasibility and Outcomes of Laparoscopic Cytoreduction in Patients With Localized Recurrent Epithelial Ovarian Cancer Paik ES, Heo EJ, Choi HJ, Yoon A, Lee Y-Y, Choi C, Kim T-J, Lee J-W, Kim B-G, Bae D-S, Choi DS. Department of Obstetrics and Gynecology, Samsung Medical Center, Seoul, Korea
Cost-Effectiveness of Laparoscopic Hysterectomy With Morcellation Compared to Abdominal Hysterectomy for Presumed Benign Leiomyomata Siedhoff MT,1 Rutstein SE,2 Wheeler SB,2 Geller EJ,3 Doll KM,4 Wu JM,3 Clarke-Pearson DL.4 1Minimally Invasive Gynecologic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 2 Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 3Female Pelvic Medicine and Reconstructive Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 4Gynecologic Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Study Objective: To assess the feasibility and outcomes of laparoscopic cytoreduction in patients with localized recurrent epithelial ovarian cancer (EOC). Design: Retrospective study of recurrent EOC patients treated in Samsung Medical Center between 2002 to2013. Patients: We performed a retrospective analysis of 125 EOC patients who had localized recurrent sites, as demonstrated by CT scan, MRI, or PET/CT scan; no ascites; had been disease-free for 12 or more months; and who had undergone secondary or tertiary cytoreduction (laparoscopy in 38, laparotomy in 87). Measurements and Main Results: By reviewing the electric medical records, we investigated patient baseline characteristics, surgical characteristics, and surgical outcomes. For comparison, survival analysis and multivariate analysis were performed. There were no statistically significant differences between the two groups of patients in terms of age, BMI, tumor type, initial stage, grade, recurrence site, types of adjuvant chemotherapy, or disease-free interval from previous treatment. With regard to surgical outcome, the laparoscopic approach provided similar or beneficial outcomes compared to laparotomy. Reduced operating time, decreased EBL, and shorter hospital stay were achieved in the laparoscopic group. Survival analysis showed better result for PFS after cytoreduction in the laparoscopy group. Significant prognostic factors in multivariate analysis were initial tumor grade for PFS and complete debulking for OS in these patients. Conclusion: Although the present study is limited by its retrospective design and selection bias, the laparoscopic approach is feasible without compromising morbidity and survival in selected groups of patients with recurrent EOC. Reduced operating time, decreased EBL, and shorter hospital stay were achieved in the laparoscopic group. The laparoscopic method provides beneficial or similar outcomes in these patients compared to laparotomy. Surgical outcomes of two surgical groups
Operating time, min, Mean (SD) EBL, ml, Mean (SD) Hospital stay, days, Mean (SD) Intraoperative complications, n (%) Complete debulking, n(%)
Laparoscopy (N=38)
Laparotomy (N=87)
p-value
145.95 (105.19)
195.6 (100.89)
0.014
165.95 (162.35) 7.71 (3.38)
415.86 (859.73) 0.076 13.11 (4.62) \0.001
4 (10.5)
12(13.8)
0.774
38 (100)
83(95.4)
0.322
Student’s t test, Chi-square, or Fisher’s exact test were used to calculate p-value. EBL; estimated blood loss
Progression free survival and overall survival by surgical group
PFS of patients at 3 years, % (SD) OS of patients at 3 years, % (SD)
Laparoscopy (N=38)
Laparotomy (N=87)
p-value
41.5(14.1)
31.2(5.9)
0.035
96.6(3.4)
85.9(4.3)
0.091
Study Objective: Laparoscopic hysterectomy (LH) with morcellation is an appealing alternative to abdominal hysterectomy (AH), but may result worse outcomes in the setting of occult leiomyosarcoma. We evaluated cost-effectiveness of LH versus AH. Design: Decision-analytic model from a hospital perspective across fiveyears, comparing cost-effectiveness of LH to AH. Cost and probability data were drawn from literature and groups compared by incremental cost-effectiveness ratio (ICER) in dollar per quality adjusted life-year (QALY) gained. Patients: We modeled 100,000 premenopausal women undergoing LH or AH for presumed benign leiomyomata. Measurements and Main Results: Our model estimated fewer deaths in LH vs AH (98 vs 103). Death due to leiomyosarcoma was more common in LH vs AH (86 vs 71). Base-case assumptions estimated average per person costs lower in LH vs AH, a savings of $2,193 ($24,181 vs $26,374). Over five years, women in LH group experienced 4.99 QALY, versus women in AH group with 4.91 QALY (incremental gain of 0.085 QALYs). LH dominated AH in base-case estimates - LH being both less expensive and yielding greater QALY gains. The ICER was sensitive to operative costs for LH and AH. In one-way sensitivity analyses, varying LH operative costs results in AH being dominated (minimum) to an ICER of $120,259/QALY gained (maximum). Varying operative costs of AH yielded an ICER of $87,651/QALY gained (minimum) to AH being dominated (maximum). Probabilistic sensitivity analyses, in which all input parameters and costs were varied simultaneously, demonstrated a relatively robust model. The AH approach was dominated 68.9% of the time. 17.4% of simulations fell above the willingness-to-pay threshold of $50,000/QALY gained. Conclusion: Considering total hospital costs, complications, and morbidity, LH was less costly and yielded more QALYs gained versus AH. LH with morcellation may be a more cost-effective and less invasive alternative to AH and should remain an option for women needing hysterectomy for leiomyomata.
198
Open Communications 15 - Laparoscopy (12:05 PM - 1:05 PM)
A Preliminary Report of a Prospective Randomized Controlled Study: Effects of Water-Jet in Laparoscopic Nerve Sparing Radical Hysterectomy for Patients with Cervical Cancer Wu M, Ma SQ, Tan XJ. Department of Obstetrics & Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China Study Objective: To determine the effects of water-jet in laparoscopic nerve sparing radical hysterectomy. Design: Prospective randomized controlled study. Setting: Peking Union Medical College Hospital. Patients: Patients with cervical cancer undergoing laparoscopic nerve sparing radical hysterectomy performed by the author and his assistants between 2013 and 2015. The study will include 120 of cases which will be enrolled randomizedly into two arms: water-jet(research) and conventional instruments(control).
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
196
197
Feasibility and Outcomes of Laparoscopic Cytoreduction in Patients With Localized Recurrent Epithelial Ovarian Cancer Paik ES, Heo EJ, Choi HJ, Yoon A, Lee Y-Y, Choi C, Kim T-J, Lee J-W, Kim B-G, Bae D-S, Choi DS. Department of Obstetrics and Gynecology, Samsung Medical Center, Seoul, Korea
Cost-Effectiveness of Laparoscopic Hysterectomy With Morcellation Compared to Abdominal Hysterectomy for Presumed Benign Leiomyomata Siedhoff MT,1 Rutstein SE,2 Wheeler SB,2 Geller EJ,3 Doll KM,4 Wu JM,3 Clarke-Pearson DL.4 1Minimally Invasive Gynecologic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 2 Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 3Female Pelvic Medicine and Reconstructive Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 4Gynecologic Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Study Objective: To assess the feasibility and outcomes of laparoscopic cytoreduction in patients with localized recurrent epithelial ovarian cancer (EOC). Design: Retrospective study of recurrent EOC patients treated in Samsung Medical Center between 2002 to2013. Patients: We performed a retrospective analysis of 125 EOC patients who had localized recurrent sites, as demonstrated by CT scan, MRI, or PET/CT scan; no ascites; had been disease-free for 12 or more months; and who had undergone secondary or tertiary cytoreduction (laparoscopy in 38, laparotomy in 87). Measurements and Main Results: By reviewing the electric medical records, we investigated patient baseline characteristics, surgical characteristics, and surgical outcomes. For comparison, survival analysis and multivariate analysis were performed. There were no statistically significant differences between the two groups of patients in terms of age, BMI, tumor type, initial stage, grade, recurrence site, types of adjuvant chemotherapy, or disease-free interval from previous treatment. With regard to surgical outcome, the laparoscopic approach provided similar or beneficial outcomes compared to laparotomy. Reduced operating time, decreased EBL, and shorter hospital stay were achieved in the laparoscopic group. Survival analysis showed better result for PFS after cytoreduction in the laparoscopy group. Significant prognostic factors in multivariate analysis were initial tumor grade for PFS and complete debulking for OS in these patients. Conclusion: Although the present study is limited by its retrospective design and selection bias, the laparoscopic approach is feasible without compromising morbidity and survival in selected groups of patients with recurrent EOC. Reduced operating time, decreased EBL, and shorter hospital stay were achieved in the laparoscopic group. The laparoscopic method provides beneficial or similar outcomes in these patients compared to laparotomy. Surgical outcomes of two surgical groups
Operating time, min, Mean (SD) EBL, ml, Mean (SD) Hospital stay, days, Mean (SD) Intraoperative complications, n (%) Complete debulking, n(%)
Laparoscopy (N=38)
Laparotomy (N=87)
p-value
145.95 (105.19)
195.6 (100.89)
0.014
165.95 (162.35) 7.71 (3.38)
415.86 (859.73) 0.076 13.11 (4.62) \0.001
4 (10.5)
12(13.8)
0.774
38 (100)
83(95.4)
0.322
Student’s t test, Chi-square, or Fisher’s exact test were used to calculate p-value. EBL; estimated blood loss
Progression free survival and overall survival by surgical group
PFS of patients at 3 years, % (SD) OS of patients at 3 years, % (SD)
Laparoscopy (N=38)
Laparotomy (N=87)
p-value
41.5(14.1)
31.2(5.9)
0.035
96.6(3.4)
85.9(4.3)
0.091
Study Objective: Laparoscopic hysterectomy (LH) with morcellation is an appealing alternative to abdominal hysterectomy (AH), but may result worse outcomes in the setting of occult leiomyosarcoma. We evaluated cost-effectiveness of LH versus AH. Design: Decision-analytic model from a hospital perspective across fiveyears, comparing cost-effectiveness of LH to AH. Cost and probability data were drawn from literature and groups compared by incremental cost-effectiveness ratio (ICER) in dollar per quality adjusted life-year (QALY) gained. Patients: We modeled 100,000 premenopausal women undergoing LH or AH for presumed benign leiomyomata. Measurements and Main Results: Our model estimated fewer deaths in LH vs AH (98 vs 103). Death due to leiomyosarcoma was more common in LH vs AH (86 vs 71). Base-case assumptions estimated average per person costs lower in LH vs AH, a savings of $2,193 ($24,181 vs $26,374). Over five years, women in LH group experienced 4.99 QALY, versus women in AH group with 4.91 QALY (incremental gain of 0.085 QALYs). LH dominated AH in base-case estimates - LH being both less expensive and yielding greater QALY gains. The ICER was sensitive to operative costs for LH and AH. In one-way sensitivity analyses, varying LH operative costs results in AH being dominated (minimum) to an ICER of $120,259/QALY gained (maximum). Varying operative costs of AH yielded an ICER of $87,651/QALY gained (minimum) to AH being dominated (maximum). Probabilistic sensitivity analyses, in which all input parameters and costs were varied simultaneously, demonstrated a relatively robust model. The AH approach was dominated 68.9% of the time. 17.4% of simulations fell above the willingness-to-pay threshold of $50,000/QALY gained. Conclusion: Considering total hospital costs, complications, and morbidity, LH was less costly and yielded more QALYs gained versus AH. LH with morcellation may be a more cost-effective and less invasive alternative to AH and should remain an option for women needing hysterectomy for leiomyomata.
198
Open Communications 15 - Laparoscopy (12:05 PM - 1:05 PM)
A Preliminary Report of a Prospective Randomized Controlled Study: Effects of Water-Jet in Laparoscopic Nerve Sparing Radical Hysterectomy for Patients with Cervical Cancer Wu M, Ma SQ, Tan XJ. Department of Obstetrics & Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China Study Objective: To determine the effects of water-jet in laparoscopic nerve sparing radical hysterectomy. Design: Prospective randomized controlled study. Setting: Peking Union Medical College Hospital. Patients: Patients with cervical cancer undergoing laparoscopic nerve sparing radical hysterectomy performed by the author and his assistants between 2013 and 2015. The study will include 120 of cases which will be enrolled randomizedly into two arms: water-jet(research) and conventional instruments(control).