1. INTRODUCTION
The primary treatment for early-stage, low-grade endometrial cancer is a
total laparoscopic hysterectomy (TLH) with bilateral
salpingo-oophorectomy (BSO)1–3. During this
procedure, uterine manipulators are commonly used. These instruments
facilitate transection of uterine pedicles, delineation of vaginal
fornices, colpotomy, and maintenance of
pneumoperitoneum4,5. Amongst the numerous manipulators
available, the vast majority possesses an intrauterine (IU) tip. Only
few are without IU tip, such as the McCartney tube6.
Especially manipulators with tip provide the added advantage of optimal
uterine mobilization and enhanced exposure of the surgical field.
Therefore, using IU manipulators may minimalize damage during surgery to
surrounding tissues, including the ureters4. However,
the use of uterine devices for malignant diseases has been subject to
controversy. Some surgeons have argued that using IU manipulators may
cause iatrogenic lymph vascular space invasion (LVSI) and spillage of
malignant cells into the peritoneal cavity, which have both been
associated with poor outcome in endometrial
cancer7–11.
Several studies demonstrated that using IU manipulators during
hysterectomy did not influence the incidence of LVSI, peritoneal
cytology, recurrence rate, and survival in endometrial
cancer12–14. On the contrary, Padilla-Iserte et al.
previously showed that oncological outcome was worse when IU
manipulators were used in terms of recurrence rate and survival.
However, this association was only observed in early-stage
cancer15. In line with the latter results,
Siegenthaler et al. showed that positive peritoneal cytology (PPC)
conversion occurred in 8% of endometrial cancer patients following
laparoscopic surgery with IU manipulators, which had a negative impact
on oncological outcome16.
While there has been growing interest in the effect of uterine
manipulators on oncological outcome in endometrial cancer, none of the
previous studies specifically compared IU with non-IU manipulators. IU
manipulators are theoretically more likely to cause dissemination of
tumour cells than non-IU manipulators due to potential tumour
manipulation. In light of this, it should be stressed that the
introduction of TLH as a safe approach for endometrial cancer is
predominantly based on studies in which non-IU manipulators were
used1,2,17. Furthermore, while tumour stage, grade,
and histotype are important prognostic factors, most of the studies did
not restrict their focus to one consistent subset of patients.
The aim of this study was to determine whether hospital manipulator
preference for IU manipulators or non-IU manipulators during TLH
influences oncological outcome in early-stage, low-grade endometrioid
endometrial cancer (EEC).