Objective: To assess the effects on oncological outcomes of intrauterine manipulator use during laparoscopic hysterectomy for endometrial cancer. Data sources: A systematic literature search was performed by an expert librarian in multiple electronic databases from inception to January 31, 2023. Study eligibility criteria: We included all studies in the English language that compared oncologic outcomes (recurrence-free, cause-specific, or overall survival) between endometrial cancer patients who underwent total laparoscopic or robotic hysterectomy for endometrial cancer with versus without the use of an intrauterine manipulator. Studies comparing only peritoneal cytology status or lymphovascular space invasion were summarized for completeness. No selection criteria were applied to the study design. Study appraisal and synthesis methods: Four reviewers independently reviewed studies for inclusion, assessed their risk of bias, and extracted data. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated for oncologic outcomes using the random effect model. Heterogeneity was quantified using the I2 tests. Publication bias was assessed by Funnel plot and Egger's test. Results: Out of 350 identified references, we included two randomized controlled trials and twelve observational studies for a total of 14 studies and 5,019 patients. The use of an intrauterine manipulator during hysterectomy for endometrial cancer was associated with a pooled HR for recurrence of 1.52 (95% CI: 0.99 - 2.33; p = 0.05; I2 = 31%; Chiˆ2 p-value = 0.22). Pooled HR for recurrence was 1.48 (95% CI: 0.25 - 8.76; p = 0.62; I2 = 67%; Chiˆ2 p-value = 0.08) when only randomized controlled trials were considered. Pooled HR for overall survival was 1.07 (95% CI: 0.65 - 1.76; p = 0.79; I2 = 44%; Chiˆ2 p-value = 0.17). The rate of positive peritoneal cytology or lymphovascular space invasion did not differ using an intrauterine manipulator. Conclusions: The intrauterine manipulator use during hysterectomy for endometrial cancer was not significantly associated with recurrence-free and overall survival nor with positive peritoneal cytology or lymphovascular space invasion, but further prospective studies are needed. Systematic review registration: PROSPERO: CRD42022310042.
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