3. RESULTS
A total of 5,995 patients were identified with early-stage, low-grade
EEC who received TLH between 2010 and 2020 from the NCR database. After
linkage of the NCR database with the PALGA records, 86 patients did not
meet the inclusion criteria. Moreover, 49 patients were excluded based
on concurrent adnexal malignancy and 45 patients were excluded due to
(partly) missing histopathology records. The online survey was
distributed to 70 national hospitals. Amongst the hospitals, 9 underwent
a change in hospital manipulator preference between 2010 and 2020.
Therefore, these hospitals were seen as independent institutions before
and after the date of change in manipulator preference, resulting in a
total of 79 hospitals between 2010 and 2020. Of these hospitals, 5 were
excluded from the analysis due to absence of response or inadequate data
regarding hospital manipulator preference (N = 420 patients), and 4
because of simultaneous use of IU and non-IU manipulators (N = 190
patients). The remaining 70 (88.6%) hospitals, comprised of 5,205
patients (89.5%), were included in the analysis (Figure S1).
Of the total study population, 1,524 (29.3%) patients underwent surgery
in hospitals that preferred non-IU manipulators (non-IU group) and 3,681
(70.7%) in hospitals that preferred IU manipulators (IU group). TLH
with BSO was performed in 94.1% of patients in the non-IU group and
93.5% of patients in the IU group. The remaining patients underwent no
or other types of (salpingo-)oophorectomy due to unknown reasons. In the
non-IU group, 330 patients received adjuvant radiotherapy (21.7%), 1
patient received chemotherapy (0.1%), and 13 patients received
(neo)adjuvant hormone therapy (0.8%). In the IU-group, 890 patients
received adjuvant radiotherapy (24.2%), 1 patient underwent
chemotherapy (0.0%), and 11 patients received adjuvant hormone therapy
(0.3%). Mean age at diagnosis was 65.5 years (SD 10 years) in the
non-IU group and 66.5 years (SD 9.7 years) in the IU group (p=0.001). In
both non-IU and IU groups, most patients were diagnosed with FIGO IA
disease (70.8% vs 67.8%, respectively, p=0.034) and without LVSI
(89.5% vs 87.3%, p=0.036). No significant difference was observed
between groups in maximum tumour diameter (p=0.485) (Table 1).
A total of 195 (3.7%) patients experienced recurrence of cancer during
follow-up, involving 49/1524 (3.2%) patients in the non-IU group and
146/3681 (4.0%) patients in the IU group. There were no significant
differences in site of recurrence (p=0.778). In both groups, the
majority of the recurrences were distant (46.9% vs 41.8%,
respectively), followed by local (32.7% vs 37.0%) and regional
recurrences (20.4% vs 19.9%) (Table 2). There were 456 deaths during
follow-up, including 142/1524 (9.3%) deaths in the non-IU group and
314/3681 (8.5%) in the IU group.
The median follow-up time was 64 months (interquartile range [IQR]
42.1–86.5 months) for the whole study population. Five-year DFS was
89.9% in the non-IU group and 89.5% in the IU group (Figure 1A).
Five-year OS was 91.0% in the non-IU group and 91.5% in the IU group
(Figure 1B). On univariable analysis, the risk of recurrence was
comparable between the IU and non-IU groups (HR 1.04, 95% CI
0.87–1.23). After adjusting for age at onset, FIGO stage, type of
hospital, and presence of LVSI, the risk of recurrence remained similar
in both groups (HR 0.93, 95% CI 0.78–1.11). Similarly, manipulator
preference did not affect the risk of death by any cause both at
univariable (HR 1.02, 95% CI 0.85–1.22) and multivariable analyses (HR
0.90, 95% CI 0.75–1.09).
Of all patients, 1907 were treated in general hospitals, 2979 in
teaching hospitals, and 319 in academic hospitals. The majority of
patients seen in academic hospitals were treated with non-IU
manipulators (66.8%), while patients in general and teaching hospitals
were mainly operated on with IU manipulators (84.2% and 66.1%,
respectively) (Table 3).