title: Laparoscopic hysterectomy is preferred over laparotomy in early endometrial cancer patients, however not cost effective in the very obese.
abstract: BACKGROUND
  Total laparoscopic hysterectomy (TLH) is safe and cost effective in early stage endometrial cancer when compared to total abdominal hysterectomy (TAH). In non-randomised data it is often hypothesised that older and obese patients benefit most from TLH. Aim of this study is to analyse whether data support this assumption to advice patients, clinicians and policy makers.
  
  
  METHODS
  Data of 283 patients enrolled in a randomised controlled trial comparing TAH versus TLH in early stage endometrial cancer were re-analysed. Randomisation by sequential number generation was done centrally, with stratification by trial centre. Using multivariate analysis, predictors of major complications and conversions to laparotomy were assessed. For the cost effectiveness analysis, subgroups of patients were constructed based on age and body mass index (BMI). For each subgroup, costs per major complication-free patient were estimated, using incremental cost effect ratios (extra costs per additional effect).
  
  
  RESULTS
  Older (odds ratio (OR): 1.05; 1.01-1.09) and obese (OR: 1.05; 1.01-1.10) patients had a higher risk to develop complications, for both groups. In obese (OR: 1.17; 1.09-1.25) patients and patients with a previous laparotomy (OR: 3.45; 1.19-10.04) a higher risk of conversion to laparotomy was found. For patients>70 years of age and patients with a BMI over 35 kg/m2, incremental costs per major complication-free patients were €16 and €54 for TLH compared to TAH, respectively.
  
  
  CONCLUSIONS
  In general, TLH should be recommended as the standard surgical procedure in early stage endometrial cancer, also in patients>70 years of age. In obese patients with a BMI>35 kg/m2 TLH is not cost effective because of the high conversion rate. A careful consideration of laparoscopic treatment is needed for this subgroup. Surgeon experience level may influence this choice.
authors.affiliation: Department of Gynaecology, University Medical Center Groningen, University of Groningen, The Netherlands.
authors.forename: Claudia B M
authors.initials: CB
authors.lastname: Bijen
authors.forename: Geertruida H
authors.initials: GH
authors.lastname: de Bock
authors.forename: Karin M
authors.initials: KM
authors.lastname: Vermeulen
authors.forename: Henriëtte J G
authors.initials: HJ
authors.lastname: Arts
authors.forename: Henk G
authors.initials: HG
authors.lastname: ter Brugge
authors.forename: Rob
authors.initials: R
authors.lastname: van der Sijde
authors.forename: Arjen A
authors.initials: AA
authors.lastname: Kraayenbrink
authors.forename: Marlies Y
authors.initials: MY
authors.lastname: Bongers
authors.forename: Ate G J
authors.initials: AG
authors.lastname: van der Zee
authors.forename: Marian J E
authors.initials: MJ
authors.lastname: Mourits
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D003362:Cost-Benefit Analysis; D016889:Endometrial Neoplasms / Q000601:surgery*; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D057194:Intention to Treat Analysis; D010535:Laparoscopy / Q000191:economics* / Q000379:methods; D007813:Laparotomy / Q000191:economics* / Q000379:methods; D008875:Middle Aged; D009765:Obesity / Q000150:complications / Q000191:economics*; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000191:economics; D012189:Retrospective Studies