Association Between Minimally Invasive Surgery, Intraoperative Capsule Rupture, and Survival in Early-Stage Ovarian Cancer

INTRODUCTION: Minimally invasive surgery is increasingly incorporated in the management of patients with gynecological disease. In early-stage ovarian cancer, prior investigation showed that utilization of minimally invasive surgery increased from 19.8% to 34.9% between 2010 and 2015. Yet, there is scarcity in more recent data. OBJECTIVE: To examine the association between minimally invasive surgery, intraoperative capsule rupture, and survival in early-stage ovarian cancer in the United States. METHODS: This retrospective cohort study queried the Commission-on-Cancer’s National Cancer Database. Study population included 9,233 patients with stage IA or IC1 ovarian cancer with a unilateral lesion who had anti-cancer surgery from 2018 to 2022. Histology types included epithelial, sex cord-stromal, and germ cell tumors. At the primary-level analysis, exposure was set as the surgical modality, grouped as minimally invasive surgery at intent-level (robotic-assisted or laparoscopic) or open surgery, and the outcome measure was set as intraoperative capsule rupture. At the secondary-level analysis, exposure was set as occurrence of intraoperative capsule rupture (stage IC1), and outcome measure was set as overall survival. Propensity score inverse probability of treatment weighting was used to mitigate the differences between the exposure groups. RESULTS: A total of 4,509 (48.8%, 95% confidence interval [CI] 47.8–49.9) patients underwent minimally invasive surgery, including 2,401 (26.0%) laparoscopic and 2,108 (22.8%) robotic-assisted surgeries. Over the 5-year study period, the utilization of minimally invasive surgery increased by 14.9% from 44.9% in 2018 to 51.6% in 2022 (P-trend<.001; Fig. 1). Specifically, this cohort-level increase was attributed to an increase in robotic-assisted surgery (17.7% to 25.6%, P-trend<.001) but not laparoscopic surgery (27.2% to 25.9%, P-trend=.33). Minimally invasive surgery was associated increased risk of intraoperative capsule rupture (21.9% versus 19.2%, odds ratio [OR] 1.18, 95% CI 1.07–1.30). When assessed for histology type, increased risk of intraoperative capsule rupture was more prominent in malignant teratoma (24.2% versus 10.0%, OR 2.87, 95% CI 1.42–5.81), mucinous carcinoma (20.8% versus 12.6%, OR 1.82, 95% CI 1.46–2.26), and granulosa cell tumor (14.0% versus 9.5%, OR 1.55, 95% CI 1.11–2.17). Notably, the rate of intraoperative capsule rupture reached nearly 30% among laparotomy conversion cases from minimally invasive surgery (28.1% vs 19.2%, OR 1.64, 95% CI 1.31–2.06). Intraoperative capsule rupture was associated with decreased overall survival (4-year rates, 91.1% versus 92.5%, hazard ratio [HR] 1.41, 95% CI 1.08–1.83; Fig. 2). This survival association had an interaction to postoperative chemotherapy, and the survival detriment of intraoperative capsule rupture was observed when postoperative chemotherapy was omitted (4-year overall survival rates 87.4% versus 92.1%, HR 1.76, 95% CI 1.24–2.52), whereas overall survival was comparable when postoperative chemotherapy was administered (93.2% versus 93.2%, HR 1.08, 95% CI 0.78–1.51). CONCLUSIONS: The results of this cohort study suggest that minimally invasive surgery is increasingly incorporated in the management of early ovarian cancer in the United States with majority undergoing minimally invasive surgery in 2020s. These data also suggest that minimally invasive surgery is associated with increased risk of capsule rupture during surgery that is further associated with decreased survival. Careful patient selection criteria, surgical technique to reduce intraoperative capsule rupture, and prospective evaluation of postoperative chemotherapy for intraoperative capsule rupture warrant further development.Figure 1Figure 2