Journal of Cancer Therapy, 2010, 1, 181-191
doi:10.4236/jct.2010.14028 Published Online December 2010 (http://www.scirp.org/journal/jct)
181
Surgical Treatment of Endometrial Cancer
Malgorzata Lanowska1, Verena Brink-Spalink1, Kati Hasenbein1, Achim Schneider1,
Simone Marnitz 2, Christhardt Köhler 1
1Department of Gynecology, Charité University Medicine Berlin, Campus Mitte; 2Department of Radiooncology, Charité University
Medicine Berlin.
Received July 23rd, 2010; revised July 26th, 2010; accepted August 3rd, 2010.
ABSTRACT
Each year endometrial cancer is diagnosed in approximately 11.700 women in Germany. Operation is the therapy of
choice in the primary treatment of patients with endometrial cancer. The traditional abdominal approach, vaginal,
laparoscopic and ro botic-assisted methods are available for the surgical treatment of EC today. Th is article compares
and evaluates these different treatment options. With rising incidence of obesity, number of patients with endometrial
cancer will also increase. However, operations in obese patients are more challenging. Laparotomy as standard ther-
apy in endometrial cancer patients stage I and II should be replaced by laparoscopic approaches. Laparoscopy is on-
cologically adequate to open procedures and offers many advantages to patients. Robotic surgery in the treatment of
endometrial cancer is still under eva luation. Most controversial po ints of treatment today are indication and extention
of lymphadenectomy in different stages. In advanced tumor stages, optimal debulking should be performed in order to
improve effectiveness of adjuvant chemotherapeutic and/or radiation therapy.
Keywords: Endometrial Cancer, Operative Therapy, Laparoscopic Treatment, Robotic–assisted Hysterectomy, Fertil-
ity-preserving Therapy
1. Introduction
Each year endometrial cancer (EC) is diagnosed in ap-
proximately 11. 700 women in Germany. More than 80%
are, fortunately, detected in the prognostic favourable
stages I and II [1]. In comparison 41.200 women were
diagnosed with EC in the United States in 2006, a sub-
stantial increased from 35.000 in 1987 [2]. The most
important risk factors for the development of EC are
obesity, postmenopausal status and unopposed estrogen
use (Type I EC). Despite the lack of systematic data for
the steady rise of overweight patients in Germany there
seems to be a similar trend for the incidence of adipos ity
comparable to America (Figure 1). Fewer patients with
EC are rather thin, have no history of exogenous estro-
gen exposure (Type II EC), are perimenopausal (20-25%)
or younger than 40 year s.
The average age of women with EC is 68 years.
Therefore many patients are affected by additional rele-
vant co-morbidities [3]. Combination of uterine corpus
cancer with adiposity, hypertension, diabetes, coronary
heart disease and/or other internal diseases increases sur-
gical-anesthesiological risk is the major gynaecologic
oncologic challenge in the current century. However,
chronological age by itself is not a reason for higher pe-
rioperative morbidity and mortality [4].
In addition to the traditional abdominal approach,
vaginal, laparoscopic and robotic-assisted methods are
also available for the surgical treatment of EC today.
Obesity Trends* Among U.S. Adults
BRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’4”person)
No Data <10% 10%–14%15%–19% 20%–24% 25%–29% ≥30%
Germany:
BMI >30 2005 14%
Increase of 2%
compared to 1999
Figure 1. Obesity trend US 2008.

Surgical Treatment of Endometrial Cancer
182
This article compares and evaluates these different
treatment options.
2. Fertility Preserving Operat ion
Approximately 5% of the patients affected by EC are
younger than 40 years. Some of them wish to preserve
fertility. The decision for uterus conservation is compli-
cated by the fact that in patients with EC stage IA grad-
ing 1 one can find in 10%-45% synchronous ovarian tu-
mors. Additionally, in up to 10% of cases myometrial
infiltration is histologically confirmed in spite of a nega-
tive MRI and a higher grading than in the D&C is de-
tected in nearly 20% of cases. The accuracy of MRI to
detect myometrial invasion is 70% [5]. Until today there
are only a few case series or case reports available. All
patients described in these publications were staged by
imaging systems, even though PET-CT has been shown
(in a small study) to have a sensitivity for detection of
pelvic lymph node metastasis of only 67% [6].
The range of described conservative therapy modali-
ties is broad and comprises gestagen therapy, intrauterin e
insertion of MIRENA®, oral application of aromatase
inhibitors, GnRH analoga or hysteroscopic resection of
EC in combination with hormon al treatment. It is impor-
tant to advise these patients carefully about individual
treatment, thus high compliance and understanding are
paramount. After informed consent has been obtained,
following criteria must be fulfilled:
 gradin g 1 carcinoma
 no myometrial infiltration in MRI or sonogra-
phy
 no detection of suspicious pelvic or paraaortic
lymph nodes
 no evidence of adnexal tumos
 no contraindica tion for ho r monal treat ment
 agreement for close follow-up (curettage every
3 month)
 stage adjusted therapy after finishing desire for
childbearing
Chiva et al. summarized data of 133 women with fer-
tility preserving therapy in EC. 76% of patients re-
sponded to hormonally therapy. However, 34% of
women developed recurrence after a mean of 20 months.
In 24% of patients there was no response to hormonal
therapy. 53 pregnancies occurred but also 4 treatment-
related deaths [7] .
It is advisable, that young patients with clinical stage
IA G1 EC should undergo staging laparoscopy after in-
formed counselling to exclude secondary ovarian neop la-
sia and lymph node metastases before starting hormonal
therapy. After finishing family planning stage-adjusted
operative (and radiation) therapy has to be initiated, fre-
quently resulting in the discovery of higher tumor stages
than initially diagnosed [8]. Ovarian preservation during
surgical management of early stage endometrial cancer is
still under debate and should be done only individually
after extensive discussion and informed consent with the
patient [9-11].
3. Operative Therapy Stage I Endometrial
Cancer
The German Gynecologic Oncology Group’s (AGO)
guideline for surgical treatment of endometroid EC, in
line with many international guidelines, includes an in-
traperitoneal cytology sample, total hysterectomy, bilat-
eral adnexectomy and pelvic (at least 15 lymph nodes)
and paraaortic (at least 10 lymph nodes) lymphadenec-
tomy up to the renal vessels. In case of uterine papil-
lary-serous carcinoma or clear cell carcinoma it is man-
datory to extract multiple perito n eal samples as well as to
perform omentectomy [12]. In clinical stages IA G1 and
G2 and IB G1 and G2 lymphadenectomy is optional. In
patients with relevant co-morbidities it is acceptable to
omit lymphadenectomy, even in higher clinical stages.
Systematic surgical staging, including simple hysterec-
tomy with bilateral adnexectomy and p elvic and paraaor-
tic lymphonodectomy is for most of the women affected
by EC the baseline therapy and allows clear decision for
stage-related adjuvant therapy. More extensive pa-
rametrial resection (radical hysterectomy) does not im-
prove oncologic outcome in patients with stage I endo-
metrial cancer [13]. However, definitive histologic grad-
ing, myometrial invasion and lymph node involvement
differ in a substantial rate from intraoperative gross as-
sessment (up to 15%) and frozen section result (up to
25%) [14,15]. Therefore decision on comprehensiveness
of surgical treatment is challenging.
3.1. Abdominal Hysterectomy with Bilateral
Salpingoophorectomy (BSO)
Most patients affected by histological proven EC today
still undergo surgical treatment by abdominal approach.
In most cases a midline longitudinal laparotomy is per-
formed that starts above the pubic symphysis and (de-
pending on the extension of the lymphadenectomy) ex-
pands until the x iph oid. Alternativ e ways of lap aroto mies
are a wide Pfannenstiel incision (optionally with trans-
section of the Mm. recti) or laparotomy including a pan-
niculectomy [16]. With increasing BMI rate of successful
lymphadenectomies is however significantly decreasing.
The estimated blood loss rises and duration of surgery
extends [17]. In morbidly obese patients noninfectious
wound breakdown occurs in up to 10% (Figure 2) [18].

Surgical Treatment of Endometrial Cancer
183
Figure 2. Complete wound breakdown after surgical treat-
ment of a patient with EC stage IIIc wi th a BM I of 56.
3.2. Vaginal Hysterectomy
In cases of considerable limited operability, vaginal hys-
terectomy is a feasible alternative to abdominal appro ach.
Lelle et al. demonstrated in 60 patients with EC under-
going vaginal hysterectomy 5- and 10-year survival rates
of 91% and 87%, respectively [19]. Despite refraining
from bilateral adnexectomy in 50% of the women treated
with vaginal hysterectomy, Chan et al. published similar
oncologic results with respect to 5-year survival [20].
The disadvantage of the exclusive vaginal approach is
the impossibility of performing a lymphadenectomy. A
possible combination of vaginal hysterectomy and open
extraperitonal lymphadenectomy was described by Massi
et al., though without demonstrating oncologic results
[21]. Dowdy et al. [22] successfully performed laparo-
scopic extraperitoneal paraaortic lymphadenectomy as
second procedure in 90% of women with high risk en-
dometrial cancer after previous vaginal hysterectomy.
3.3. Laparoscopic Assisted Vaginal Hysterec-
tomy and Total Laparoscopic Hysterectomy
While laparoscopic approach is already the standard ap-
proach in treating benign gynecological diseases, it is
only more recently used in gynecological oncology, in-
cluding in the therapy of EC [23]. This was possible fol-
lowing secure ability to perform laparoscopic pelvic and
paraaortic lymphadenectomy at the end of the last cen-
tury [24,25]. The trocar placement is standardized (Fig-
ure 3). So far, the results of laparoscopic therapy of EC
have been evaluated in about 50 prospective and retro-
spective, studies, predominantly designed as monocenter
studies. More important data are available from 5 pro-
spective randomized trials. One major argument against
Figure 3. Scheme of trocar placement for conventional
laparoscopic operations (laparoscopic assisted vaginal hys-
terectomy-LAVH and total laparoscopic hysterectomy-TLH)
in patients with EC.
laparoscopic treatment of EC, occurrence of port-side
metastasis, could be invalidated. Martinez et al. found
after 1216 laparoscopic procedures, including 295 for EC,
an incidence of trocar metastasis of 0.33%. Excluding
patients with peritoneal carcinomatosis rate drops down
to 0.16% [26].
All studies performing either laparoscopic assisted
vaginal hysterectomy or total laparoscopic hysterectomy
with or without lymphadenectomy report similar and
consistent results, demonstrating that laparoscopic ap-
proach is a safe and oncologic adequate way of surgical
treatment in patients with EC stage I. Laparoscopic stag-
ing in EC provides substantial benefits for the patients:
 less blood loss
 less transfusion rate
 reduced duration of hospital stay
 faster recovery to normal daily activity
 less postoperative demand on analgetics
 higher or equal number of removed lymph
nodes
 less complications.
Disadvantages are the longer duration of surgery, espe-
cially when lymphadenectomy is performed, and the
overcoming of the learning curve [27-38]. Conversion
rate in the randomized studies varies between 7-20%.
Nevertheless it could be shown that particular older pa-
tients with additional co-morbidity [39] and obese pa-
tients [40] benefited mostly from laparoscopic approach.
The advantages lasting at least six months [41].
More importantly, oncologic results (OS, DFS) of the
laparoscopic surgery are equivalent to conventional ab-
dominal surgery. This has been shown with the highest
evidence level in 5 prospective randomized studies and
related meta-analyses [42-48]. Unfortunately these 5
Trocar placement(LAVH and TLH)

Surgical Treatment of Endometrial Cancer
184
studies include only 238 patients in the groups that un-
derwent laparoscopic surgery. If the results of further
randomized studies like the Dutch multicenter trial NTR
821 and GOG LAP II should confirm these results, every
patient affected by EC stage I should be offered a
laparoscopic surgical therapy, and abdominal approach
should only be chosen and accepted in cases of severe
contraindication s [ 49,50].
3.4. Robotic-assisted Hysterectomy
With approval of the DaVinci® Surgical System by the
FDA in 2005, a new era of laparoscopic technique in
gynecology began. This technique will potentially be
able to overcome prejudices and resistances against
laparoscopic oncological surgery.
Robotic-assisted laparoscopy offers substantial advan-
tages such as a three-dimensional vision system, im-
proved precision of instruments combined with poten-
tially more degrees of freedom, tremor-free manipulation,
an advanced ergonomic positioning of the surgeon and a
faster learning curve, which is helpful in particular in
complex gynecological procedures. The disadvantages of
robotic-assisted surgery are the absence of tactile feed-
back, the large size of robotic equipment, the lack of
vaginal access and larger skin incisions for inserting tro-
cars [51-55]. Moreover, costs for robotic staging of EC
patients are significant higher, approximately 1300$ per
operation, due to longer operating room time and dis-
posable instruments compared to traditional laparoscopy
[56]. After passing the learning curve of about 20 opera-
tions [57] many authors consider robotic-assisted surgery
to be an ideal combination of the advantages of abdomi-
nal and laparoscopic approach [58-60]. This new method
of surgery is advantageous in comparison to the conven-
tional abdominal approach and might even perform better
than the conventional-laparoscopic surgery in relation to
operative times, blood loss and postoperative hospital
stay [61-63] which has however still to be confirmed by
further studies. De Nardis et al. compared 2008 the sur-
gical morbidity of 56 patients affected by EC clinical
stage I after undergoing robotic-assisted laparoscopic
hysterectomy with lymphadenectomy with a group of
106 patients who underwent abdominal approach. Three
(5.4%) originally planned robotic-assisted operations
needed to be converted to abdominal approach. Intraop-
erative blood loss, rate of perioperative complications
(3.6% vs. 20.8%) and duration of hospital stay were sig-
nificantly favorable in the DaVinci-group, but operative
times were substantially longer. The lymph node yields
were comparable. These results have to be interpreted
cautiously because of differences in the characteristics of
the groups of patients, with the group achieving ro-
botic-assisted surgery containing younger and slimmer
women with less co-morbidities and earlier clinical
stages of EC [64].
Veljovich et al. performed a similar study and com-
pared 118 patients after robotic operations with 131
women undergoing an open abdominal surgery and could
demonstrate longer operative times for robotic surgery
but also a significantly lower blood loss and a considera-
bly shorter hospital stay. The lymph node yields were as
well comparable [65]. Boggess et al. compared three
possible ways to performing an extensive EC staging:
abdominal approach (n = 138), conventional laparoscopic
(n = 81) und robotic-assisted (n = 103). The blood loss
was lowest in the DaVinci-group, the lymph
node yields were significantly higher and the hospital
stays shortest. The operative times were comparable in
the robotic-assisted and conventional laparoscopy, but
longer than by laparotomy. Boggess inserted five trocars
for his operation (Figure 4); a placement, that is now
used by many other centres.
The complication rates of the robotic-assisted opera-
tions were significantly lower than in the laparotomy
group (5.9% vs. 29.7%). There was no difference in the
conversion rates between conventional and robotic- as-
sisted laparoscopy [66]. Analyzing the subgroup of obese
and morbid obese patients, there is an considerable ad-
vantage in using the robot compared to conventional
laparoscopy, including shorter operative times, less blood
loss and higher lymph node yields [67]. Comparable fa-
vorable results were demonstrated by Seamon et al. 2008.
Only 12.4% of the o riginally planned 105 rbotic-assisted
operations had to be converted, especially in morbid
obese patients. The mean operative time was 242 minutes,
the blood loss 99 cc, the lymph node yields 29. 24 hours
later most of the patients were in the condition to get dis-
Port placement
robotic staging
endometrial cancer
Endoscop12 mm
Additional trocar12 mm
DaVinci trocars8 mm
8-10 cm
23 –25 cm up to symphysis
Figure 4. Schematic demonstration of the port-placement in
robotic-assisted operation for endometrial carcinoma.

Surgical Treatment of Endometrial Cancer
185
Autthor/YearnOR-timeBlood lossLymph nodesfollow-up
Bell200840184 min77 cc17n.s.
Denardis 200856177 min105 cc19n.s.
Boggess 2008103191 min75 cc33n.s.
Seamon 2008105242 min100 cc21n.s.
Veljovich 200825283 min67 cc-n.s.
Denardis 200856177 min105 cc19n.s.
Hoekstra 200932195 min50 cc17n.s.
Lowe 2009405170 min88 cc16n.s.
Jung 201028193 minn.s.21n.s.
Cardenas 2010102237 min109 cc22n.s.
Peiretti200980182 minn.s.24n.s
Cardenas 2010102237 min109 cc22n.s..
Figure 5. Summary of operative data for robotic staging in
endometrial cancer patients.
charged [68]. More recently Cardenas-Goicoechea and
co-workers demonstrated similar results by analyzing
102 patients with EC after robotic-assisted staging (Fig-
ure 5) [63].
Up to now there are no oncologic follow up date after
robotic assisted staging in EC patients available. Ulti-
mately, the 5-year survival rate must be the decisive on-
cologic criterion for robotic surgery [69].
4. Lymphadenectomy Yes or No?
The role of pelvic and paraaortic lymphadenectomy is
currently the most controversial and internationally most
inconsistently used element of the surgical approach to
endometrial carcinoma. Following FIGO women with
histological confirmed EC requires comprehensive stag-
ing that includes total hysterectomy, bilateral salpin-
goovarectomy, peritoneal washing and locoregional
lymphadenectomy. This is the on ly way stage IIIc (nodal
positive) can be identified and the appropriate radiation
therapy can be subsequently initiated or avoided. In
addition,systematic lymphadenectomy seems to have a
therapeutic effect in women with EC [70-72]. However,
extend (sampling or complete) and level (only pelvic,
pelvic and paraaortic-inframesenteric/ intrarenal) of
lymphadenectomy and are not mandatorily defined.
Guidelines for surgical treatment of EC vary between
countries. German recommendation is to perform com-
prehensive pelvic and paraaortic lymphadenectomy up to
the renal vessels in all patients except stage IA G1[12].
In stages IB G1, IA G2 and IB G2 lymph node dissection
is optional, an all other cases obligatory according to
retrospective Mayo data, that demonstrated a high per-
centage of pelvic and (sometimes isolated) paraaortic
lymph node metastasis [73].
These results could, however, not be confirmed in
other analysis. In the current FIGO - report 2006 pelvic
lymph node metastases are detected in stage I EC in
1.4-37.2% of patients and paraaortic lymph node metas-
tases in 0.3-12.6% (in correlation to grading and myo-
metrial invasion) (see Figures 6 and 7) [74]. A similar
distribution of lymph node metastases in 349 patients
was found by Chi at al. 2008 in a retrospective monoin-
stitutional analysis [75]. All together one can expect
lymph node metastases in 10-12% of women affected by
stage I endometrioid endometrial carcinoma [73-75].
Additionally, pelvic and infrarenal paraaortic lym-
phadenectomy in patients with relevant co-morbidities
and obesity is often associated with increased rate of
early and late postoperative complications or cannot be
performed at all [76]. Furthermore, lymph node metasta-
ses of endometrial carcinoma are often not macroscopical
enlarged [77].
In contrast there are the results of two prospective
randomized studies including more than 2000 patients
that could not demonstrate an oncological advantage (OS,
DSF) comparing patients that had a pelvic lym-
phadenectomy with those having not [76,78]. Though
these two studies (with a high eviden ce level) reach id en-
tical conclusions, the results have to be interpreted care-
fully. In both studies only pelvic lymphadenectomy was
performed. In the ASTEC study the mean lymph node
yield was just 12 lymph nodes. A systematic paraaortic
G1(%) G2 (%)G3 (%)
Endometri um
T1a 1,47,2 16,1
Myometrium
< 50 % T1b2,1 69,7
Myometrium
> 50 % T1c10,721 37,2
FIGO 2007Report on the Results of Treatment in Gynecological Cancer
I n ci dence
Incidence of of pelvic pelvic lymph lymph no de node metastases metastases
Figure 6. Incidence of pelvic lymph node metastases in cor-
relation to tumor stage und grading in patients wi th EC.
FIGO 2007Report on the Resultsof Treatment in Gynecological Cancer
Incidence
I
nc
id
ence of o
f
para pa r a- -aortic aort
i
clymp h
l
ymp
h
node
no
d
e
metastases
metastases
G1(%) G2 (%)G3 (%)
Endometrium
T1a 0,42,4 5,4
Myometrium
< 50 % T1b0,3 1,8 4,3
Myometrium
> 50 % T1c2,25,9 12,6
Figure 7. Incidence of paraaortic lymph node metastases in
correlation to tumor stage und grading in patients wi th EC.
Robotic-assisted o
p
erations in

Surgical Treatment of Endometrial Cancer
186
lymph node dissection was not required. The adjuvant
therapy was inconsistent (due to a lack of definition) and
the participating centers had discretion in choosing the
right adjuvant therapy. In addition, statistical assump-
tions are justifiable to only a limited extent.
Therefore the possible spectrum of lymph node staging
comprises no lymphadenectomy, exclusive pelvic lymph
node sampling, additional inframesentric paraaortic sam-
pling and complete pelvic and infrarenal paraaortic lym-
phadenectomy. The incidence of isolated paraoartic
lymph node metastasis in case of negative pelvic nodes is
very low (Figure 8) [79].
In summary it can be said, therefore, that these differ-
ing research results might rather increase the level of
confusion than clarifying the evidence for performing
pelvic and paraaortic lymphadenectomy in patients with
endometrioid endometrial cancer stage I and II. Further
research, in particular prospective randomized studies are
required to evaluate the significance of systematic
paraaortic lymphadenectomy in correlation to pelvi-
clymph node status as part of surgical treatment of en-
dometrial carcinoma to be able to indicate appropriate
adjuvant therapy [80-83]. Outside of studies lymphade-
nectomy is not adequate in low and intermediate risk EC
patients because risk-benefit balance seemsrather in fa-
vor of not performing surgical staging. In contrast
high-risk patients seem to profit from complete pelvic
and paraaortic lymphadenectomy [84].
6. Operation for Stage II Endometrial
Cancer
In case of confirmed infiltration of the cervix uteri (stage
pTIIb) in an endometrial carcinoma the few available
studies demonstrate an increased survival rate when per-
forming a radical hysterectomy (Figure 9 and 10) so that
the parametrics also should be resected as the guidelines
recommend [11]. Sartori et al. retrospectively compared
135 patients receiving a simple hysterectomy to 68 pa-
I ncidence
Incidence of of isolated isolated pa r a pa ra- -aortic aorticlym ph lymphnode node
metastases
metastases with with negative negative pelv ic pelviclymph lymph node s node s
G1(%) G2 (%)G3 (%)All grades
Endometrium
T1a 0,0 1.6 0.0 0.6
Myometri um
< 50 % T1b0.31 0.322.340.62
Myometri um
> 50 % T1c0.37 0.842.87 1.56
BoronowRC. Gynecol Oncol. 2008 Oct;111(1):3-6.
Figure 8. Incidence of isolated paraaortic lymph node me-
tastasis in patients with negative pelvic lymph nodes corre-
lated to tumor stage und grading.
Adaption of
Adaption of parametrial parametrial resection resection
Type II
Figure 9. Schematic graph of parametrial resection in radi-
cal hysterectomy type II as operative treatment of stage IIb
EC1.
Adaption of
Adaption of parametrial parametrialres ection resection
Type II
Figure 10. Intraoperative situs as described in Figure 9.
tients undergoing radical hysterectomy in stage pTIIb.
They detected a significant difference in the 10 - year-
survival in favor of radical hys terectomy (94% versus
74%), while adjuvant radiation was without effect [85].
Almost the same results were demonstrated by Cohn et al.
They retrospectively evaluated 162 patients affected by
endometrial cancer stage II. 75% were treated with sim-
ple hysterectomy and 25% with radical hysterectomy.
5-year-survival-rate was 94% in the radical hysterectomy
group and 76% (p = 0,05) in the simple hysterectomy
group [86]. However, other study groups demonstrated
only marginal differences in survival rate [87].
7. Value of Operative Therapy in Advanced
Cancer Stages
Prognosis of patients with an advanced endometrial can-
cer is unfavorable. The few availab le studies n evertheless
demonstrate a significant survival benefit if maximum
tumor debulking could be achieved. Bristow et al. de-
tected in 65 patients in stage IVb a survival of 34 months
after reducing tumors to below 1 cm. If remaining tumor
were larger than 1 cm the survival was only about 11
months irrespective of adjuvant radiation and/or chemo-
therapy [90]. Similar results were demonstrated by Ay-

Surgical Treatment of Endometrial Cancer
187
han et al. in 37 patients in stage IVb. If tumor could be
reduced below 1 cm survival was 25 months. In case of
no macroscopic residual tumor survival was even 48
months. In contrast women who did achieve only subop-
timal tumor reduction survived only 13 months [90]. In
advanced stages maximum tumor debulking should thus
be performed in order to improve effectiveness of adju-
vant chemotherapeutic and/or radiation therapy [12].
Combination of maximum cytoreductive surgery and
adjuvant use of radiation and chemotherapy sequentially
or concomitant seems to be the most potential treatment
in patients with advanced endometrial cancer [91-93].
8. Conclusion
Operation is the therapy of choice in the primary treat-
ment of patients with endometrial cancer. With rising
incidence of obesity number of patients with endometrial
cancer will also increase. However, operations in obese
patients are more challenging. Laparotomy as standard
therapy in endometrial cancer patients stage I and II
could be replaced by laparoscopic approaches. Laparo-
scopy is oncologic adequate to open procedures and of-
fers many advantages to patients–less blood loss, lower
complication rate, shorter hospital stay and better quality
of life, especially those with relevant co-morbidity. Ro-
botic surgery in the treatment of endometrial cancer is
still under evaluation. Most controversial points of
treatment today are indication and extend of lym-
phadenectomy in different stages. In advanced tumor
stages, optimal debulking should be performed in order
to improve effectiveness of adjuvant chemotherapeutic
and/or radiation therapy.
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