Association between obesity and cervical intraepithelial neoplasia: results from a case control study in south western Uganda.

BACKGROUND: Though obesity has been said to be associated with a number of malignancies including cervical cancer, its association with cervical intraepithelial neoplasia (CIN) is still a contentious issue. This study was designed to determining the prevalence and association between obesity and CIN. METHODS: This was an unmatched case control study, involving women with cervical intraepithelial neoplasia (cases) and those negative for intraepithelial lesions or malignancy (controls) at the cervical cancer clinic of Mbarara Regional Referral Hospital, in south-western Uganda, between April and November 2022. Cases and controls provided written informed consent and were recruited in a ratio of 1:1. Cases were identified by visual inspection with acetic acid (VIA) and subsequent confirmation with cytology and/or histology. Demographic information was collected using an enrolment form and height, weight and waist circumference were recorded. We calculated body mass index (BMI) and identified obese women as those with body mass index of ≥ 30 kg/m2 from both case and control groups. Central obesity was defined as waist: height ration of ≥ 0.5. Data was analysed using STATA version 17. Categorical variables were analysed using proportions, chi-square and logistic regression analysis to determine association between obesity and CIN. Our level of statistical significance was set at ≤ 0.05. RESULTS: The prevalence of general and central obesity among cases was 25.5% (24/94) and 0% (0/94) respectively while the prevalence of general and central obesity among controls was 33.3% (37/111) and 0% (0/111) respectively. There was an increased prevalence of general obesity among women with low grade squamous intraepithelial lesions (LSIL). However, there was no statistically significant association between general obesity and CIN. Factors associated with general obesity included residing in Mbarara city (AOR 2.156, 95%CI 1.085-4.282, P-value 0.028), age group of 31-45 years (AOR 2.421, 95%CI 1.577-9.705, P-value 0.003) and ≥ 46 years (AOR 1.971, 95%CI 1.022-11.157, P-value 0.046). CONCLUSION: We observed an increased prevalence of general obesity among women with LSIL. However, there was no association between obesity and CIN. Factors associated with general obesity included residing in Mbarara city, and being in the age groups of 31-40 and ≥ 46 years. This highlights the need to rethink management of CIN to control other non-communicable diseases that could arise due to general obesity.

Worthy of further consideration: An updated meta-analysis to address the feasibility, acceptability, safety and efficacy of thermal ablation in the treatment of cervical cancer precursor lesions.

Treatment of preinvasive lesions is critical to the success of secondary prevention of cervical cancer. In many settings, however, excision or ablation of preinvasive lesions can prove challenging. Thermal ablation (TA) is a form of treatment for cervical precancer that may present fewer logistical challenges in resource limited settings. In 2013, Dolman and colleagues wrote a meta-analysis of publications reporting cure rates from TA. This included only one article from a low or middle-income country (LMIC). We updated Dolman's meta-analysis to include more recent articles from LMICs. A formal review of the world literature was performed for the years 2014-2017. Article titles and abstracts were reviewed for relevance; full articles were assessed for quality. The primary endpoint was treatment outcome for cervical intraepithelial neoplasia grade 2 or higher (CIN2+). The I2 statistic was used to assess heterogeneity between studies. Studies were stratified by geographic region, decade that the study was published, World Bank economic classification of the country where the study was performed, and other factors. We reviewed 34 total reports and included 23 in our meta-analysis, including 10,995 and 6371 patients, respectively. A total of 7 studies were performed in LMICs, including 6 studies included in the meta-analysis. The overall response rate for TA treatment of biopsy proven CIN2+ was 93.8%. Consistent with the wide variety of settings and patient populations, there was significant heterogeneity between studies. TA appears to be an effective treatment for CIN2+ across a variety of settings, including in LMICs.

Cancer and the world's poor: What's a gynecologic cancer specialist to do?

Women in low- and middle-income countries (LMICs) face a drastically increased burden of cervical cancer and the same burden of other gynecologic cancers as do women in high-income countries, yet there are few resources or specialists to meet their needs. 85% of deaths from cervical cancer occur in LMICs. As the population of these regions age, and as death from infectious diseases decrease, this burden will increase further without strong intervention. There are few cancer specialists in LMICs and training in gynecologic cancer care is rare. Gynecologic cancer specialists are uniquely positioned to meet this challenge as advocates, educators and experts. On behalf of the SGO International Committee, we call on our colleagues to meet this historic challenge.

Health Care Disparities in Hereditary Ovarian Cancer: Are We Reaching the Underserved Population?

OPINION STATEMENT: Ovarian cancer is an uncommon but deadly disease. There is no effective screening for the disease, and the majority of women with ovarian cancer present in advanced stage and eventually die from their disease. The majority of families with multiple cases of breast and ovarian cancer are found to carry germline mutations in BRCA1/2. Recent, more sensitive sequencing techniques have shown that nearly 20 % of ovarian cancer is associated with germline mutations in cancer susceptibility genes, with approximately 15 % accounted for by deleterious mutations in BRCA1/2. Women found to have mutations in BRCA1/2 can be empowered to make decisions on reproduction, cancer prevention, or treatment that may either avoid cancer or prolong survival. Though initial studies suggested that African American (AA) women were significantly less likely than White women to have mutations in BRCA1/2, this has been found to be untrue. Despite this revelation, and the clear importance of BRCA1/2 mutation status to appropriate clinical management, AA women still undergo genetic counseling and testing at much lower rates than do comparable White women. This disparity is not explained by factors such as calculated risk of a mutation, insurance coverage, or previous knowledge of the availability of testing. To date, no effective strategies have been identified that can overcome this disparity. Possible approaches include use of patient navigators, online social media, or EMR-based decision support aids. Funders should support research in this area, as it represents an actionable means to decrease the burden of ovarian and breast cancer in AA women.

Sister Society Meeting on Global Education Development and Collaboration: Meeting Report.

OBJECTIVES: To identify common barriers to teaching and training and to identify strategies that would be useful in developing future training programs in gynecologic oncology in low- and middle- income countries. METHODS: There is a lack of overall strategy to meet the needs of education and training in gynecologic oncology in low- and middle- income countries, the leaderships of sister societies and global health volunteers met at the European Society of Gynecologic Oncology in October 23, 2015. The challenges of the training programs supported by gynecologic oncology societies, major universities and individual efforts were presented and discussed. Strategies to improve education and training were identified. RESULTS: Major challenges include language barriers, limited surgical equipment, inadequate internet access, lack of local support for sustainability in training programs, inadequate pathology and radiation oncology, finance and a global deficiency in identifying sites and personnel in partnering or developing training programs. The leaderships identified various key components including consultation with the local Ministry of Health, local educational institutions; inclusion of the program into existing local programs, a needs assessment, and the development of curriculum and regional centers of excellence. CONCLUSIONS: Proper preparation of training sites and trainers, the development of global curriculum, the establishment of centers of excellence, and the ability to measure outcomes are important to improve education and training in gynecologic oncology in low- and middle- income countries.

Adnexal masses in the premenopausal patient.

Practitioners may frequently encounter adnexal masses in premenopausal women. Adnexal masses can represent a wide variety of etiologies, and therefore they can represent a diagnostic dilemma. When an adnexal mass is found the initial work up must focus on identifying acute pathology followed by determining the risk of a malignancy. Pelvic ultrasound remains the mainstay for evaluation of adnexal masses in premenopausal patients. If ultrasounds findings are indeterminate magnetic resonance imaging (MRI) is the next imaging modality of choice. The evaluation for malignancy should include serum marker screening. Aspiration of adnexal masses is generally avoided, due to the lack of therapeutic benefit and risk of seeding a tumor. When ultrasound findings are suggestive of benign disease, conservative management, including repeat imaging, should be considered. If the clinical suspicion for malignancy is high referral to a gynecologic oncologist is warranted. In other patients whom the evaluation of their adnexal mass remains unclear surgical excision with care not to disrupt the integrity of the mass should be performed for pathologic diagnosis.

Effect of metabolic syndrome and its components on the risk and prognosis of cervical cancer: A literature review.

Despite the global implementation of preventive strategies against Human Papilloma Virus (HPV) infection, the incidence of invasive cervical cancer rose by nearly 1.3-fold, from 471,000 annual cases in 2000 to 604,000 cases in 2020. With over 340,000 deaths annually, cervical cancer is the fourth leading cause of cancer mortality in women globally. There is a need to understand other factors besides HPV such as metabolic syndrome (MetS) that potentially influence the onset and progression of cervical cancer. In this narrative review, we describe evidence showing that Metabolic syndrome (MetS) increases the risk for cervical cancer and worsens its prognosis. Combined screening for MetS and cervical cancer has potential to significantly reduce morbidity and mortality in women with cervical cancer.

Late Stage at Diagnosis of Cervical Cancer and Its Correlates at a Large Regional Referral Hospital in Uganda: A Cross-Sectional Study.

Background The stage of disease at diagnosis is one of the major determinants of survival in women with cervical cancer. Most women with cervical cancer in low- and middle-income countries (LMICs) present to hospitals with advanced stages, thus reducing their survivorship following the diagnosis. Factors correlated with late-stage disease at diagnosis are not completely explored. This study aimed to describe the association between sociodemographic, clinical, and metabolic characteristics with late-stage disease at diagnosis in women with cervical cancer attending the Mbarara Regional Referral Hospital in Southwestern Uganda. Methodology We conducted a cross-sectional study of women with histological diagnoses of invasive cervical cancer between November 2022 and August 2023. Women who presented to the hospital with the International Federation of Gynecology and Obstetrics stage IIb and above were considered to have late-stage cervical cancer while those with stage IIa and below were considered to have early-stage disease. We used modified Poisson regression to determine the factors independently associated with the outcome. Results We enrolled 157 women. The average age of the participants was 52.4 years. The majority of the participants (83.4%) had late-stage disease at diagnosis. Women with adenocarcinoma (adjusted prevalence ratio (aPR) = 1.18, 95% confidence interval (CI) = 1.10-1.38) and those with lymphovascular space involvement on histology (aPR = 1.30, 95% CI = 1.05-1.60) were more likely to have late-stage disease at diagnosis while women living with human immunodeficiency virus (aPR = 0.83, 95% CI = 0.71-0.97) were less likely to present with late-stage disease at diagnosis. None of the sociodemographic and metabolic characteristics were associated with late-stage disease at diagnosis. Conclusions The number of women presenting with late-stage cervical cancer is high. Efforts to increase the availability and uptake of cervical cancer screening services in LMICs should be reinforced. Cervical cancer treatment services should be decentralized to increase accessibility.

Development of a customized m-Health-based intervention to reduce loss to follow-up among patients undergoing treatment for cervical lesions at a rural referral Hospital, South Western Uganda.

Background: Loss to follow-up (LTFU) in individuals undergoing cervical cancer treatment is a major challenge in many low resource settings. We describe development of a customized and tailored mHealth intervention for reducing LTFU among patients undergoing cervical cancer treatment at Mbarara Regional Referral Hospital (MRRH). Methods: We interviewed all health care providers (HCPs) at the cervical cancer clinic of MRRH, between April and May 2023. Transcripts were subsequently derived, reviewed and coded to generate themes and categories using inductive content analytic approach. Four medical experts used this data to develop relevant SMS content, which was incorporated into an app. Results: HCPs had owned a phone for 13.8 ≤ years, had worked at the clinic for 5 ≤ years, and used text messages regularly. Qualitative data revealed that the main challenge to re-engagement was absence of a reminder mechanism between HCPs and patients. HCPs preferred text and or audio mode of messaging to improve health care responsiveness to LTFUs, awareness, continuity of care, and health service uptake among the majority illiterate population; though with potential constraints of costs and workload. Identified key messaging content included; the importance of attending scheduled follow-ups, follow up visit date and clinic customization and tailoring the message to the intended recipient. SMS content was uploaded onto the cc-follow-up app platform and customized according to preferred language, day, frequency and time of delivery. Conclusion: Tailoring an mHealth messaging intervention could help re-engage and reduce LTFU through improved information sharing, awareness, responsiveness, care engagement and medical compliance. A pilot study is required for our intervention in South Western Uganda.

Prevalence of cervical intraepithelial lesions and associated factors among women attending a cervical cancer clinic in Western Uganda; results based on Pap smear cytology.

Introduction: There are high incidence and mortality rates of cervical cancer among females in East Africa. This is exacerbated by limited up-to-date data on premalignant lesions and associated factors in this setting. In this study, we determined the prevalence of cervical intraepithelial lesions and associated factors among women attending the Mbarara Regional Referral Hospital cervical cancer clinic in Southwestern Uganda. Methods: In this cross-sectional study, 364 participants were recruited from among women attending the Mbarara Regional Referral Hospital cervical cancer clinic from 1 April to 30 June 2023. On consent, the study nurse collected demographic data and Pap smears, which were microscopically examined and reported by a laboratory scientist and a pathologist following the Bethesda grading system (2014). Statistical analyses were done in STATA version 17, using proportions, Chi-square, bivariate, and multivariate logistic regression analysis to determine associated factors at ⩽0.05 significance level. Results: The mean age of participants was 41.9 years. A third of all study participants (37.6%, 132/351) were contraceptive users, mostly hormonal contraceptives (87.1%, 115/132). Almost 88% (307/351) had an unknown Human Papilloma Virus status. The prevalence of cervical intraepithelial lesions among our study participants was 6.6% (23/351), of which 73.9% (17/23) were low-grade squamous intraepithelial lesions. More than half (9/17, 52.9%) of low-grade squamous intraepithelial lesions were active hormonal contraceptive users. Use of hormonal contraceptives (OR: 3.032, p: 0.0253), use of intrauterine devices (OR: 6.284, p: 0.039), and any family history of cervical cancer (OR: 4.144, p: 0.049) were significantly associated with cervical intraepithelial lesions. Conclusion: The prevalence of cervical intraepithelial lesions was 6.6%, lower than global estimates. Use of hormonal and intrauterine device contraceptives, as well as family history of cervical cancer, were significantly associated with cervical intraepithelial lesions among our study population. Prospective studies are recommended to further understand associations between different types of intrauterine devices and hormonal contraceptives, and cervical lesions.

The diagnostic accuracy of serum and plasma microRNAs in detection of cervical intraepithelial neoplasia and cervical cancer: A systematic review and meta-analysis.

Studies suggest a need for new diagnostic approaches for cervical cancer including microRNA technology. In this review, we assessed the diagnostic accuracy of microRNAs in detecting cervical cancer and Cervical Intraepithelial Neoplasia (CIN). We performed a systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline for protocols (PRISMA-P). We searched for all articles in online databases and grey literature from 01st January 2012 to 16th August 2022. We used the quality assessment of diagnostic accuracy studies tool (QUADAS-2) to assess the risk of bias of included studies and then conducted a Random Effects Meta-analysis. We identified 297 articles and eventually extracted data from 24 studies. Serum/plasma concentration miR-205, miR-21, miR-192, and miR-9 showed highest diagnostic accuracy (AUC of 0.750, 0.689, 0.980, and 0.900, respectively) for detecting CIN from healthy controls. MicroRNA panels (miR-21, miR-125b and miR-370) and (miR-9, miR-10a, miR-20a and miR-196a and miR-16-2) had AUC values of 0.897 and 0.886 respectively for detecting CIN from healthy controls. For detection of cervical cancer from healthy controls, the most promising microRNAs were miR-21, miR-205, miR-192 and miR-9 (AUC values of 0.723, 0.960, 1.00, and 0.99 respectively). We report higher diagnostic accuracy of upregulated microRNAs, especially miR-205, miR-9, miR-192, and miR-21. This highlights their potential as stand-alone screening or diagnostic tests, either with others, in a new algorithm, or together with other biomarkers for purposes of detecting cervical lesions. Future studies could standardize quantification methods, and also study microRNAs in higher prevalence populations like in sub-Saharan Africa and South Asia. Our review protocol was registered in PROSPERO (CRD42022313275).

Magnitude and trends in cervical cancer at Mbarara Regional Referral Hospital in South Western Uganda: Retrospective analysis of data from 2017-2022.

High-income countries have documented a significant decline in the incidence and mortality of cervical cancer over the past decade but such data from low and middle-income countries such as Uganda is limited to ascertain trends. There is also paucity of data on the burden of cervical cancer in comparison to other gynaecologic malignancies and there is a likelihood that the incidence might be on the rise. To describe the current trends and magnitude of cervical cancer in comparison to other gynaecological malignancies histological types, we conducted a retrospective records review of charts of patients admitted with gynaecological malignancies on the gynaecological ward of Mbarara Regional Referral Hospital (MRRH) between January 2017 and December 2022. Of 875 patients with gynaecological malignancies admitted to the MRRH in the 6-year review period, 721 (82.4%) had cervical cancer. Patients with cervical cancer were significantly older than those with other gynaecological malignancies: (50.2±11.5 versus 43.8± 15.0 respectively, p<0.001). Between 2017 and 2022, cervical cancer rates increased by 17% annually compared to other gynaecological cancers (OR:1.17; 95% CI 1.06-1.28, p = 0.0046), with the majority of patients of cervical cancer patients (92.7%, n = 668) having squamous cell carcinoma. Most patients (87.9%, n = 634) had late-stage disease (stage 2 and above) and were referred to the Uganda Cancer Institute for chemoradiation. These results imply that there is a need to scale up screening services and other preventive measures such as vaccination against human papilloma virus.

Vulvar leiomyosarcoma: A case report.

Vulvar leiomyosarcoma is a rare malignant smooth muscle tumor and the most common type of vulvar sarcoma. It can mimic benign tumors, and misdiagnosis may delay appropriate treatment. A 35-year-old woman presented to the outpatient gynecology clinic at the Mirebalais Teaching Hospital for a right vulvar mass. A complete excision of the mass was performed. Histopathology with immunohistochemistry demonstrated leiomyosarcoma. We describe the contextual challenges that ultimately compromised her care, highlighting the challenges to safe delivery of cancer care in our setting.

High Rate of Loss to Follow-Up Among Patients Undergoing Treatment for Premalignant Cervical Lesions at Mbarara Regional Referral Hospital, Southwestern Uganda: A Retrospective Cohort Study.

BACKGROUND: For a cervical cancer control program to be effective in reducing the incidence of the disease, there should be high compliance to treatment and follow-up of women diagnosed with precursor lesions. Screening programs in low-resource countries such as Uganda are challenged by poor adherence to follow-up following treatment for premalignant cervical lesions. This study sought to describe the burden and factors associated with loss to follow-up among women undergoing treatment for premalignant cervical lesions at a tertiary hospital in southwestern Uganda. METHODS: This was a retrospective cohort study. We reviewed the registers at the Mbarara Regional Referral Hospital (MRRH) cervical cancer clinic for a period of four years from January 2017 to December 2020. Data on age, district of residence, diagnosis, date of diagnosis, date and type of initial treatment, and date of follow-up visit were collected. We also captured data on whether patients returned on the scheduled follow-up date or within three months after the scheduled follow-up date. We defined loss to follow-up as failure to return for follow-up either on the scheduled date or within three months after the scheduled date. RESULTS: Out of the 298 patients who underwent treatment for premalignant cervical lesions in the study period, 227 (76.2%) did not return for follow-up at one year. At bivariate analysis, failure to attend the review visit at six weeks predicted the loss to follow-up at one year following treatment for premalignant lesions almost perfectly (risk ratio (RR)=2.84, 95% confidence interval (CI): 2.18-3.71, p<0.001). Negative HIV serostatus and receiving thermocoagulation slightly increased the risk of getting lost to follow-up, while being more than 45 years old reduced the odds. At multivariate analysis, treatment with thermocoagulation (adjusted risk ratio (aRR)=1.21, 95% CI: 1.07-1.36, p=0.03) was associated with loss to follow-up at one year. CONCLUSION: The proportion of women who did not return for follow-up at one year following treatment for premalignant cervical lesions at Mbarara Regional Referral Hospital is very high. There is a need to implement strategies such as telephone-aided reminders to prompt patients to return for follow-up following treatment for premalignant cervical lesions.

Neurofibroma of the cervix presenting as cervical stenosis in a patient with neurofibromatosis type 1: a case report.

Neurofibromatosis type 1 is an autosomal dominant disorder characterized by the presence of cutaneous and subcutaneous neurofibromas as well as deep-seated plexiform neurofibromas. Although unusual, these lesions have been described in the gynecologic tract, including the cervix; however, when arising in this location, they are commonly asymptomatic or present with lower abdominal pain. Cervical neurofibromas presenting as cervical stenosis have not been described. Awareness by both the clinician and the pathologist of a patient's history is of great help when dealing with a specimen of a patient with neurofibromatosis type 1.

Racial differences in surgeons and hospitals for endometrial cancer treatment.

PURPOSE: To determine whether (1) black and white women with endometrial cancer were treated by different surgical specialties and in different types of hospitals and (2) differences in specialty and hospital type contributed to racial differences in survival. METHODS: Retrospective cohort study of 12,307 women aged 65 years and older who underwent surgical treatment of endometrial cancer between 1991 and 1999 in the 11 Surveillance Epidemiology and End Results registries. RESULTS: Black women were more likely to have a gynecologic oncologist to perform their surgery and to be treated at hospitals that were higher volume, larger, teaching, National Cancer Institute centers, urban, and where a greater proportion of the surgeries were performed by a gynecologic oncologist. In unadjusted models, black women were over twice as likely as white women who died because of cancer (hazards ratio [HR]: 2.33), but nearly all of the initial racial difference in survival was explained by differences in cancer stage, and grade as well as age and comorbidities at presentation (adjusted HR: 1.10). Surgical specialty was not associated with survival and, of the hospital characteristics studied, only surgical volume was associated with survival (P < 0.005). Adjusting for hospital characteristics did not change the racial difference in survival (HR: 1.10). Adjustment for the specific hospital where the woman was treated eliminated the association between race and surgeon specialty and slightly widened the residual racial difference in survival (HR: 1.23 vs. 1.10). CONCLUSIONS: In contrast to several studies suggesting that blacks with breast cancer, colon cancer, or cardiovascular disease are treated in hospitals with lower quality indicators, black women diagnosed with endometrial cancer in Surveillance Epidemiology and End Results regions between 1991 and 1999 were more likely to be treated by physicians with advanced training and in high volume, large, urban, teaching hospitals. However, except for a modest association with hospital surgical volume, these provider and hospital characteristics were largely unrelated to survival for women with endometrial cancer. The great majority of the difference in survival was explained by differences in tumor and clinical characteristics at presentation.

Reaching the women with the greatest needs: Two models for initiation and scale-up of gynecologic oncology fellowship trainings in low-resource settings.

Women in low- and middle-income countries (LMICs) are significantly more likely to develop and die from invasive cervical cancer, while rates of other gynecologic malignancies are comparable to those faced by women in high-income countries. Despite this increased need, there are few specialist physicians in LMICs available to treat women with gynecologic cancers. Training specialists in low-resource settings faces multiple challenges, including ensuring protected time from other clinical demands, access to best practice guidelines, training that is tailored to the specific challenges faced in the trainee's environment, and isolation from other fully trained professionals and securing support services. In addition, training specialists from LMICs in high-resource settings is costly and return of trainees to their own country is not guaranteed. Here we describe two approaches to gynecologic oncology training in LMICs. The International Gynecologic Cancer Society (IGCS) developed the Global Curriculum Mentorship and Training Program (Global Curriculum) to support gynecologic oncology fellowships in regions of the world that do not currently have formal training in gynecologic oncology. In India, on the other hand, leaders in world-class gynecologic oncology centers must find a way to meet the training needs of a vast and disparate country.

Surgical outcomes of robotic-assisted surgical staging for endometrial cancer are equivalent to traditional laparoscopic staging at a minimally invasive surgical center.

OBJECTIVE: To compare peri- and post-operative complications and outcomes of robotic-assisted surgical staging with traditional laparoscopic surgical staging for women with endometrial cancer. METHODS: A retrospective chart review of cases of women undergoing minimally invasive total hysterectomy and pelvic and para-aortic lymphadenectomy by a robotic-assisted approach or traditional laparoscopic approach was conducted. Major intraoperative complications, including vascular injury, enterotomy, cystotomy, or conversion to laparotomy, were measured. Secondary outcomes including operative time, blood loss, transfusion rate, number of lymph nodes retrieved, and the length of hospitalization were also measured. RESULTS: 275 cases were identified-102 patients with robotic-assisted staging and 173 patients with traditional laparoscopic staging. There was no significant difference in the rate of major complications between groups (p=0.13). The mean operative time was longer in cases of robotic-assisted staging (237 min vs. 178 min, p<0.0001); however, blood loss was significantly lower (109 ml vs. 187 ml, p<0.0001). The mean number of lymph nodes retrieved were similar between groups (p=0.32). There were no significant differences in the time to discharge, re-admission, or re-operation rates between the two groups. CONCLUSION: Robotic-assisted surgery is an acceptable alternative to laparoscopy for minimally invasive staging of endometrial cancer. In addition to the improved ease of operation, visualization, and range of motion of the robotic instruments, robotic surgery results in a lower mean blood loss, although longer operative time. More data are needed to determine if the rates of urinary tract injuries and other surgical complications can be reduced with the use of robotic surgery.