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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Laparoscopically assisted versus open surgery for endometrial cancer: a meta-analysis of randomized controlled trials

F Lin, QJ Zhang, FY Zheng, HQ Zhao, QQ Zeng, MH Zheng, and HY Zhu.

Review published: 2008.

CRD summary

This review compared laparoscopically assisted surgery (LAS) and open surgery in endometrial cancer patients. LAS had fewer intraoperative complications, lower incidence of transfusion, less blood loss and shorter hospital stay, but longer surgical times. The conclusions regarding safety were cautious due to concerns in validity evaluation and the small number of studies analysed, and they might not be reliable.

Authors' objectives

To compare the effectiveness of laparoscopically assisted surgery (LAS) and open surgery in endometrial cancer patients in terms of postoperative outcomes, complications and survival rate.


Medline, EMBASE, CBM and The Cochrane Library were searched without language restrictions up to May 2007. Search terms were reported. References of retrieved articles were handsearched.

Study selection

Randomised controlled trials (RCT) were considered for inclusion. Studies that compared LAS and open surgery approaches in patients with endometrial cancer were eligible. There were no restrictions in age, cancer staging and length of follow-up. Recurrences, overall and disease-free survival, incidence of intraoperative (not defined in the article) and postoperative complications (urinary tract infection, haematoma, fever >38ºC, ileus, wound infection and transfusion) represented primary outcomes for inclusion. Operative parameters (hemoglobin drop, blood loss, surgical time, number of harvested pelvic and para-aortic lymph nodes and hospital stay) were also obtained.

Four studies were selected. Mean age of patients ranged from 61.2 to 68.3 years. Follow-up was stated in three articles and ranged from six to 44 months. Most patients had FIGO stage I endometrial cancer.

The authors did not state how articles were selected for the review.

Assessment of study quality

Two reviewers independently assessed study quality using a validated scale (Jadad), with items on randomisation, blinding and withdrawal/dropouts rates. The scale scored from 2 to 10. The authors considered a score of 3 or higher to be high quality.

Data extraction

Two authors independently extracted data in a predefined review form. One of the reviewers was blinded to the source and author's names. Disagreements were solved by discussion. Odds ratios (ORs), weighted mean differences (WMDs) and 95% confidence intervals (CI) were calculated for each study.

If the same institution and/or authors reported two or more studies, only the study with higher quality rating was included in the analysis.

In case of studies that had zero events in any of the treatment arms, the authors added the value 0.5 in each cell of the 2x2 table for the study in question. If the rate of the event was zero in both arms, that outcome was discarded from the meta-analysis.

Methods of synthesis

The pooled odds ratios for dichotomous data or WMD for continuous data, with corresponding 95% CI, were calculated using a fixed-effect meta-analysis; where there was evidence of statistically significant heterogeneity a random effects model was used. Statistical heterogeneity was evaluated using the Χ2. P<0.1 was considered significant. Publication bias was assessed using a funnel plot.

Results of the review

Four RCT were included in the review (331 patients). One study was excluded because it was from the same center as another and had a lower quality score. Different outcomes of one of the trials were published in two articles, but they were analysed as one. Three studies had a Jadad score of 5 or more; one had the lowest possible score of 2. Mean follow-up ranged from six to 44 months.

Statistically significant heterogeneity was noted for overall postoperative complications, blood loss and operation time.

Primary outcomes: Recurrence, overall survival and disease-free survival were reported by three studies and no significant difference was shown in any of them. Three studies reported intraoperative complications, for which LAS was associated with fewer intraoperative complications than open surgery (OR 0.33 95% CI 0.13 to 0.84).

Postoperative complications: All studies reported this outcome. Overall postoperative complications were lower in the LAS group (OR 0.34, 95% CI 0.13 to 0.89). The sole individual postoperative complication that showed a significant difference was a lower incidence of transfusion in the LAS group (OR 0.14, 95% CI 0.05 to 0.39). There were no statistically significant differences in incidence of urinary tract infection, haematoma, fever above 38ºC, ileus or wound infection.

Operative parameters: Three studies reported these outcomes. There was no significant difference in hemoglobin drop; however, blood loss was significantly lower in the LAS group (WMD -263.58 mL, 95% CI -467.71 to -59.45). Operation time was shorter in the open surgery group (WMD 37.78 minutes, 95% CI 10.5 to 65.68, p<0.05), with statistically significant heterogeneity (p=0.02). Neither harvested para-aortic or pelvic lymph nodes showed statistically significant differences. Hospital stay was significantly shorter in the LAS group (WMD -3.35 days, 95% CI -3.84 to -2.86).

Funnel plot analysis was performed only for urinary tract infection.

Authors' conclusions

In endometrial cancer patients, LAS was associated with fewer postoperative complications, lower incidence of transfusion, less blood loss, longer operation times and shorter hospital stay. No significant differences were found for survival and recurrence. When performed by suitable specialised surgeons in selected patients, LAS appeared to be a better choice than open surgery.

CRD commentary

This was a well-performed review that addressed a well-defined question in terms of patients, interventions and study designs. Relevant databases were searched. Efforts to minimize biases and errors were made by independently extracting data and using predesigned extraction forms. Quality evaluation was performed with a validated scale that went from 2 to 10. However, the authors considered a score of 3 or more to be high quality, which might not have best reflected the potential for bias in the included trials. Characteristics of included studies were presented clearly and methods used to pool results were appropriate. It appeared that the review was underpowered to reach conclusions about relevant outcomes or safety of the technique and it was noticeable that most differences were found in analyses where heterogeneity was significant. Given these considerations, the results must be taken with caution. The authors of the review acknowledged the limitations of their study and the clinical heterogeneity of the results; consequently, their conclusions reflected the data presented and seem reliable.

Implications of the review for practice and research

Practice: When performed by suitable specialised surgeon in selected patients, LAS appeared to be a safe and feasible alternative to open surgery. Open surgery remained a good choice in endometrial cancer patients.

Research: Larger RCT should be performed with extended follow-up and better definitions of outcomes.


Not stated.

Bibliographic details

Lin F, Zhang QJ, Zheng FY, Zhao HQ, Zeng QQ, Zheng MH, Zhu HY. Laparoscopically assisted versus open surgery for endometrial cancer: a meta-analysis of randomized controlled trials. International Journal of Gynecological Cancer 2008; 18(6): 1315-1325. [PubMed: 18217968]



Indexing Status

Subject indexing assigned by NLM


Endometrial Neoplasms /surgery; Female; Humans; Laparoscopy; Postoperative Complications; Randomized Controlled Trials as Topic; Treatment Outcome



Date bibliographic record published


Date abstract record published


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 18217968

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