Long-term survival outcomes of robotic-assisted versus traditional laparoscopy for the treatment of stage I endometrial cancer: a National Cancer Database analysis.

Long-term survival outcomes of robotic-assisted versus traditional laparoscopy for the treatment of stage I endometrial cancer: a National Cancer Database analysis - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Gynecol Oncol . Author manuscript; available in PMC: 2026 Jun 4. Published in final edited form as: Gynecol Oncol. 2026 Mar 16;207:66–73. doi: 10.1016/j.ygyno.2026.02.035 Long-term survival outcomes of robotic-assisted versus traditional laparoscopy for the treatment of stage I endometrial cancer: a National Cancer Database analysis Sarah J Boyle a, * , Allison Dona a , Rachel I Vogel a, b , Peter Argenta a Author information Article notes Copyright and License information a Department of Obstetrics, Gynecology and Women’s Health, University of Minnesota, 420 Delaware St. SE, MMC 395, Minneapolis, MN 55455, USA b Masonic Cancer Center, University of Minnesota, 420 Delaware St. SE, MMC 806, Minneapolis, MN 55455, USA * Corresponding author. david441@umn.edu (S.J. Boyle). Issue date 2026 Apr. PMC Copyright notice PMCID: PMC13231473  NIHMSID: NIHMS2168315  PMID: 41844495 The publisher's version of this article is available at Gynecol Oncol Abstract Objective. To compare the long-term survival outcomes of robotic-assisted versus traditional laparoscopic surgery for treatment of stage I endometrial cancer. Methods. We performed a retrospective cohort study using the National Cancer Database, including patients with stage I endometrial cancer diagnosed from 2010 to 2017 (with follow-up through 2020) who underwent treatment with either robotic-assisted or traditional laparoscopic surgery. Demographics, clinical characteristics, and outcomes were summarized using descriptive statistics. Overall survival (OS) was compared using a Cox proportional hazard model, adjusting for demographic and clinical factors; hazard ratios and 95% confidence intervals reported. Results. A total of 127,342 patients with stage I endometrial cancer who underwent minimally invasive surgery were included. The median follow-up among those still known to be alive was 69.7 months. Almost three-quarters (74.5%) received robotic-assisted surgery, while 25.5% received traditional laparoscopic surgery. Demographic and clinical factors were similar between groups. No differences in OS were observed by surgery modality (5-year OS: 91.7% for robotic vs. 91.4% for traditional laparoscopic surgery) and this remained after adjustment for demographic and clinical factors (HR = 1.00, 95% CI 0.96–1.04). Conclusions. There was no difference in OS for patients with stage I endometrial cancer treated with robotic-assisted versus traditional laparoscopic surgery. These data demonstrate excellent survival outcomes in this cohort and do not favor a robotic-assisted or traditional laparoscopic approach. However, the full extent of a route-of-surgery decision may not be detected given the potential for late recurrences and deaths, highlighting the need for large, prospective studies with long duration of follow-up. Keywords: Endometrial cancer, Uterine cancer, Laparoscopy, Robotic surgery, Minimally invasive surgery 1. Introduction Endometrial cancer is the most common gynecologic cancer in the United States, with over 69,000 new cases predicted in the United States in 2025 [ 1 ]. Most patients are diagnosed with low-grade and early-stage disease, imparting a generally favorable prognosis, but mortality has been increasing in recent years [ 1 ]. Minimally invasive surgery (MIS) plays a critical role in reducing the morbidity of treatment for endometrial cancer, especially in low-stage disease. The LAP2 trial demonstrated that among patients with stage I to IIA uterine cancer, laparoscopy improved peri-operative outcomes compared to laparotomy, with similar short-term oncologic outcomes [ 2 , 3 ]. The use of laparoscopy was further supported by the LACE trial, which demonstrated equivalent disease-free and overall survival (OS) at a median of 4.5 years between laparoscopic and abdominal hysterectomy for patients with stage I endometrioid endometrial cancer [ 4 ]. Currently, more than 80% of endometrial cancer surgeries at high volume centers are performed using a MIS approach, with the majority of these undertaken via a robotic-assisted approach [ 5 ]. Both traditional laparoscopy and robotic-assisted surgery have been utilized for the treatment of endometrial cancer, and multiple studies confirm that peri-operative and short-term oncologic outcomes between the two modalities appear similar [ 6 – 8 ]. However, the publication of two studies suggesting that patients with cervical cancer who were treated via MIS had inferior oncologic outcomes, despite similar peri-operative outcomes, when compared to patients treated via laparotomy has raised questions regarding the long-term impact of route-of-surgery decisions for other disease sites [ 9 , 10 ]. Studies investigating long-term outcomes of patients treated for low-stage endometrial cancer with MIS are variable in their inclusion criteria, typically single-institution, and have conflicting results with regard to oncologic outcomes ( Table 1 ) [ 8 , 11 – 13 ]. Table 1. Comparison of studies evaluating stage I patients. Argenta 2022 ( n = 1027) Lim 2023 * ( n = 1728) Dagher 2024 * ( n = 901) Present study ( n = 127,342) Years included Sample size 2006–2016 2009–2018 2009–2021 2010–2017 n = 1027 n = 1728 n = 901 n = 127,342 45% Lsc 20% Lsc 17% Lsc 25.5% Lsc 55% RA 80% RA 83% RA 74.5% RA Inclusion criteria Stage Pathologic stage I disease (FIGO 2009) Clinically uterine-confined (11% pathologic stage II-IV) Clinically uterine-confined (28% pathologic stage II-IV) Stage I disease by coding Histology All epithelial Endometrioid High-grade epithelial only All epithelial Exclusion criteria Stromal cancers, Synchronous tumors, Tumors of uncertain origin Clear extrauterine disease on pre-operative imaging Clear extrauterine disease on pre-operative imaging, Synchronous tumors Stromal cancers, In-situ disease, Previous cancer diagnosis, Conversion to open Lymph Node 67.7% ^ Lsc: 56.6% ^ Assessment RA: 72.8% ^ pLND Lsc: 8.6% Lsc: 17.0% RA: 6.8% RA: 9.5% sLN Lsc: 71.7% Lsc: 83.0% RA: 86.1% RA: 90.5% Use of adjuvant treatment Lsc: 18.2% Lsc: 40% Lsc: 91% RA: 20.4% RA: 35% RA: 86% Radiation Lsc: 19.2% RA: 18.8% Chemotherapy Lsc: 7.1% RA: 6.8% Median Follow-up (months) Lsc: 104 Lsc: 53 Lsc: 66 70 RA: 76 RA: 56 RA: 52 Recurrence Free Survival 2 year 5 year (PFS) 4 year (PFS) Not available Lsc: 96% Lsc: 91.0% Lsc: 75% RA: 92% RA: 88.5% RA: 70% 10 year 10 year Lsc: 84% Lsc: 86.5% RA: 78% RA: 85.9% Adjusted HR 1.41 (1.12–1.77) Unadjusted HR 1.2 (0.8–1.9) Adjusted HR 1.22 (0.86–1.72) Overall Survival 5 year 4 year 5 year Lsc: 92.4% Lsc: 82.8% Lsc: 91.4% RA: 92.5% RA: 78.4% RA: 91.7% 10 year 10 year Lsc: 78.7% Lsc: 81.5% RA: 79.6% RA: 81.7% Adjusted HR 1.39 (1.06–1.83) Unadjusted HR 0.9 (0.6–1.4) Unadjusted HR 1.29 (0.93–1.8) Adjusted HR 1.00 (0.96–1.04) Disease-Specific Survival 5 year 4 year Not available Lsc: 96.8% Lsc: 88.1% RA: 95.3% RA 81.5% Adjusted HR 3.51 (2.19–5.63) Unadjusted HR 1.3 (0.7–2.6) Unadjusted HR 1.19 (0.77–1.85) Time to recurrence (median, months) Lsc: 28.7 Lsc: 28 Lsc: 19.0 Not available RA: 16.3 RA: 18.5 RA: 13.5 Open in a new tab Lsc traditional laparoscopy; RA robotic assisted; HR hazard ratio; pLND pelvic lymphadenectomy +/− para-aortic lymphadenectomy; sLN sentinel lymph node mapping. * Overlapping data from same institution. ^ No distinction between full lymphadenectomy and sentinel lymph node mapping. Our objective was to compare long-term survival outcomes of patients with stage I endometrial cancer in the National Cancer Database (NCDB) who underwent robotic-assisted versus traditional laparoscopic surgery. 2. Methods This retrospective cohort study utilized the NCDB to identify patients diagnosed with stage I endometrial cancer in the United States from 2010 to 2017 (inclusive) to allow for a minimum of 3 years of potential follow-up. The NCDB is a national, hospital-based dataset maintained by the American Cancer Society and the Commission on Cancer of the American College of Surgeons. The data are provided by the Commission on Cancer accredited hospitals through a data use agreement with the American College of Surgeons. The NCDB currently captures 72% of all newly diagnosed cancers in the United States annually [ 14 ]. This study was deemed exempt by the University of Minnesota Institutional Review Board. Cases were identified using International Classification of Diseases for oncology, third edition topography (C540, C541, C542, C549, C559). The dataset was then further limited to patients with stage I disease and to those who had undergone MIS, with the primary exposure (surgical approach) determined using the variable RX_HOSP_SURG_APPR_2010, with 1 = robotic-assisted and 3 = traditional laparoscopy. Patients were excluded if they had a cancer with stromal histology, in-situ disease, a previous cancer diagnosis, conversion to an open procedure, or if there was missing vital status or time to last follow-up. The primary outcome for this analysis was OS, defined as time from initial diagnosis to death or date of last contact for those who were still alive. We identified numerous demographic, clinical and reporting facility characteristics as potential prognostic factors for OS in this cohort a priori based on existing literature and availability within the NCDB ( Table 2 ). Table 2. Adjustment variables included in the multi-variable model. Characteristic Source Variable in NCDB Details/Categorization Age at diagnosis AGE Continuous; truncated at 90 years for those 90+ years old at diagnosis Race RACE - American Indian/Alaskan Native (3) - Asian (4,5,6,8,10,11,12,13,14,15,16,17,96) - Black (2) - Hawaiian/Pacific Islander (7,20,21,22,25,26,27,28,30,31,32,97) - White (1) - Other(98) - Unknown (99) Ethnicity SPANISH_HISPANIC_ORIGIN - Spanish/Hispanic (1,2,3,4,5,6,7,8) - Non-Spanish/non-Hispanic (0) - Unknown (9) Insurance status INSURANCE_STATUS - Not insured - Private insurance / Managed Care - Medicaid - Medicare - Other government - Unknown Education (percentage of adults living in patient’s zip code without a high school degree, quartiles based on 2012 data) NO_HSD_QUAR_12 - 21.0% + - 13.0%–20.9% - 7.0%–12.9% - <7.0% - Not available Income (median household income in patienťs zip code, quartiles based on 2012 data) MED_INC_QUAR_12 - <$38,000 - $38,000–$47,999 - $48,000–$62,999 - $63,000 + - Not available Residence location (rural urban grouping) UR_CD_13 - Metro (1,2,3) - Urban (4,5,6,7) - Rural (8,9) - Not available Year of diagnosis YEAR_OF_DIAGNOSIS - 2010 - 2011 - 2012 - 2013 - 2014 - 2015 - 2016 - 2017 Comorbidities, total Charlson-Deyo score, NCDB version excludes cancer diagnosis and age from scoring CDCC_TOTAL_BEST - Score of 0 - Score of 1 - Score of 2 - Score of 3 or more Grade GRADE, GRADE_PATH - 1 - 2 - 3 - Unknown Regional lymph nodes assessed REGIONAL_NODES_EXAMINED - No (0) - Yes (1+) - Unknown (99) Radiation therapy administered as part of first course of treatment RAD_LOCATION_OF_RX - No (0) - Yes (1,2,3,4,8) - Unknown (9) Chemotherapy administered as part of first course of treatment RX_SUMM_CHEMO - No (0,82,85,86,87) - Yes (1,2,3) - Unknown (88,99) Reporting facility type FACILITY_TYPE_CD - Community Cancer Program - Comprehensive Community Cancer Program - Academic/Research Program [including National Cancer Institute (NCI) comprehensive cancer centers] - Integrated Network Cancer Program - Not available Reporting facility region FACILITY_LOCATION_CD - New England (CT,MA,ME,NH,RI,VT) - Middle Atlantic (NJ,NY,PA) - South Atlantic (DC,DE,FL,GA,MD,NC,SC,VA,WV) - East North Central (IL,IN,MI,OH,WI) - East South Central (aL,KY,MS,TN) - West North Central (IA,KS,MN,MO,ND,NE,SD) - West South Central (AR,LA,OK,TX) - Mountain (AZ,CO,ID,MT,NM,NV,UT,WY) - Pacific (AK,CA,HI,OR,WA) - Unknown Open in a new tab Demographic and clinical characteristics were summarized using descriptive statistics. Kaplan Meier plots, survival estimates, and 95% confidence intervals (CIs) were generated for OS by surgical approach. Multivariable Cox proportional hazards models examined the relationship between surgical approach and OS, adjusting for the following variables as defined in Table 2 : age, race, ethnicity, insurance status, income, education, rurality, Charlson-Deyo comorbidity score, year of diagnosis, disease grade, assessment of regional lymph nodes, receipt of radiation as part of first course of treatment, receipt of chemotherapy as part of first course of treatment, reporting facility type and facility region location. Hazard ratios (HRs) and 95% CIs are reported. P -values are two-sided with a significance level of 0.05. Statistical analyses were performed using SAS 9.4 (Cary, NC). 3. Results In total, 158,422 cases of stage I endometrial cancer treated via a MIS approach were identified in the NCDB from 2010 through 2017. From this total, 2559 were excluded because of having a stromal histology; 64 were excluded because of in-situ disease; 24,109 were excluded because of a previous cancer diagnosis; 3848 were excluded because of conversion to an open procedure; and 4 were excluded because of missing vital status or time to last follow-up. Patients were excluded because of conversion to an open procedure from the traditional laparoscopy group more often than the robotic-assisted surgery group (conversion rate 6.7% vs. 1.6%). The final analytic sample included 127,342 individuals, with 74.5% undergoing robotic-assisted surgery ( n = 94,814) and 25.5% undergoing traditional laparoscopic surgery ( n = 32,528). The median duration of follow-up for those known to be alive was 69.7 months. The demographic and clinical details for the patients in this cohort are summarized in Tables 3 and 4 . The average age at diagnosis was 61.6 (standard deviation [SD] = 10.8) years. Most patients were White (86.5%) and lived in metro areas (81.5%). The most common type of insurance was private insurance (53.3%), followed by Medicare (36.8%). Patients were treated at a variety of facility types, with the most common types including Academic/Research Programs, including NCI Comprehensive Cancer Centers (39.4%) and Comprehensive Community Cancer Programs (34.1%). The number of patients reported in the NCDB increased over time during the study period, with 9589 patients diagnosed in 2010 steadily increasing to 20,161 patients diagnosed in 2017. Patients receiving robotic-assisted surgery were more likely to have lymph node assessment performed (72.8% vs. 56.6%, p < 0.0001), and there was a small increase in the rate of lymph node assessment over the study period in both groups (68.3% in 2010 vs. 74.6% in 2017). All demographic and clinical characteristics were statistically significantly different between robotic-assisted and traditional laparoscopic approaches (all p < 0.0001), but none appear clinically meaningfully different beyond lymph node assessment. Table 3. Summary of patient demographics. ALL N = 127,342 Traditional Laparoscopy N = 32,528 Robotic N = 94,814 Variable Mean (SD) Mean (SD) Mean (SD) Age 61.6 (10.8) 61.4 (11.4) 61.7 (10.6) N (%) N (%) N (%) Race American Indian/Alaskan Native 455 (0.4) 117 (0.4) 338 (0.4) Asian 3928 (3.1) 1252 (3.9) 2676 (2.8) Black 9603 (7.5) 2710 (8.3) 6893 (7.3) Hawaiian or Pacific Islander 508 (0.4) 138 (0.4) 370 (0.4) Other 1388 (1.1) 355 (1.1) 1033 (1.1) White 110,167 (86.5) 27,595 (84.8) 82,572 (87.1) Unknown 1293 (1.0) 361 (1.1) 932 (1.0) Ethnicity Non-Spanish, Non-Hispanic 116,577 (91.6) 29,214 (89.8) 87,363 (92.1) Spanish/Hispanic origin 7598 (6.0) 2468 (7.6) 5130 (5.4) Unknown 3167 (2.5) 846 (2.6) 2321 (2.5) Insurance status Not insured 3314 (2.6) 1145 (3.5) 2169 (2.3) Private insurance/managed care 67,868 (53.3) 17,091 (52.5) 50,777 (53.6) Medicaid 6570 (5.2) 1906 (5.9) 4664 (4.9) Medicare 46,833 (36.8) 11,664 (35.9) 35,169 (37.1) Other government 1556 (1.2) 350 (1.1) 1206 (1.3) Unknown 1201 (0.9) 372 (1.1) 829 (0.9) Median income, based on zip code, 2012 <$38,000 16,130 (12.7) 3976 (12.2) 12,154 (12.8) $38,000–$47,999 24,423 (19.2) 5864 (18.0) 18,559 (19.6) $48,000–$62,999 30,424 (23.9) 7353 (22.6) 23,071 (24.3) $63,000+ 40,140 (31.5) 10,998 (33.8) 29,142 (30.7) Unknown 16,225 (12.7) 4337 (13.3) 11,888 (12.5) No HS degree, based on zip code, 2012 21.0%+ 17,125 (13.5) 4835 (14.9) 12,290 (13.0) 13.0%–20.9% 27,242 (21.4) 6950 (21.4) 20,292 (21.4) 7.0%–12.9% 37,492 (29.4) 8966 (27.6) 28,526 (30.1) <7.0% 29,299 (23.0) 7454 (22.9) 21,845 (23.0) Unknown 16,184 (12.7) 4323 (13.3) 11,861 (12.5) Urban/rural Metro 103,741 (81.5) 27,165 (83.5) 76,576 (80.8) Urban 16,762 (13.2) 3682 (11.3) 13,080 (13.8) Rural 2032 (1.6) 525 (1.6) 1507 (1.6) N/A 4807 (3.8) 1156 (3.6) 3651 (3.9) Open in a new tab HS high school. Table 4. Summary of patient diagnosis and treatment characteristics. ALL N = 127,342 Traditional Laparoscopy N = 32,528 Robotic N = 94,814 Variable N (%) N (%) N (%) Charlson-Deyo score 0 94,112 (73.9) 24,391 (75.0) 69,721 (73.5) 1 25,966 (20.4) 6320 (19.4) 19,646 (20.7) 2 5237 (4.1) 1298 (4.0) 3939 (4.2) 3+ 2027 (1.6) 519 (1.6) 1508 (1.6) Facility Type Community Cancer Program 2380 (1.9) 1155 (3.6) 1225 (1.3) Comprehensive Community Cancer Program 43,442 (34.1) 11,404 (35.1) 32,038 (33.8) Academic/Research Program (including NCI comprehensive cancer centers) 50,165 (39.4) 11,984 (36.8) 38,181 (40.3) Integrated Network Cancer Program 27,223 (21.4) 6692 (20.6) 20,531 (21.7) N/A 4132 (3.2) 1293 (4.0) 2839 (3.0) Facility location New England 8159 (6.4) 2932 (9.0) 5227 (5.5) Middle Atlantic 20,159 (15.8) 5136 (15.8) 15,023 (15.8) South Atlantic 25,030 (19.7) 7190 (22.1) 17,840 (18.8) East North Central 21,006 (16.5) 3972 (12.2) 17,034 (18.0) East South Central 7780 (6.1) 1236 (3.8) 6544 (6.9) West North Central 11,079 (8.7) 2626 (8.1) 8453 (8.9) West South Central 8636 (6.8) 2207 (6.8) 6429 (6.8) Mountain 5393 (4.2) 1551 (4.8) 3842 (4.1) Pacific 15,968 (12.5) 4385 (13.5) 11,583 (12.2) Not available 4132 (3.2) 1293 (4.0) 2839 (3.0) Primary Site C540 – Malignant neoplasm of isthmus uteri 100 (0.1) 31 (0.1) 69 (0.1) C541 – Malignant neoplasm of endometrium 122,721 (96.4) 31,323 (96.3) 91,398 (96.4) C542 – Malignant neoplasm of myometrium 112 (0.1) 34 (0.1) 78 (0.1) C543 – Malignant neoplasm of fundus uteri 1212 (1.0) 373 (1.2) 839 (0.9) C548 – Malignant neoplasm of overlapping sites of corpus uteri 214 (0.2) 51 (0.2) 163 (0.2) C549 – Malignant neoplasm of corpus uteri, unspecified 2379 (1.9) 531 (1.6) 1848 (2.0) C559 – Malignant neoplasm of uterus, part unspecified 604 (0.5) 185 (0.6) 419 (0.4) Grade 1 56,319 (44.2) 15,261 (46.9) 41,058 (43.3) 2 27,762 (21.8) 6756 (20.8) 21,006 (22.2) 3 12,869 (10.1) 3140 (9.7) 9729 (10.3) Unknown 30,392 (23.9) 7371 (22.7) 23,021 (24.3) Assessment of regional lymph nodes No 39,734 (31.2) 14,049 (43.2) 25,685 (27.1) Yes 87,476 (68.7) 18,422 (56.6) 69,054 (72.8) Unknown 132 (0.1) 57 (0.2) 75 (0.1) Radiation No 102,837 (80.8) 26,417 (81.2) 76,420 (80.6) Yes 22,167 (17.4) 5349 (16.4) 16,818 (17.7) Unknown 2338 (1.8) 762 (2.3) 1576 (1.7) Chemotherapy No 117,300 (92.1) 30,002 (92.2) 87,298 (92.1) Yes 9066 (7.1) 2197 (6.8) 6869 (7.2) Unknown 976 (0.8) 329 (1.0) 647 (0.7) Open in a new tab There were no differences in OS by surgical approach at 1 year (98.7% for traditional laparoscopy vs. 98.9% for robotic-assisted surgery), 3 years (95.1% vs. 95.4%), 5 years (91.4% vs. 91.7%), or 10 years (81.5% vs. 81.7%, Fig. 1 ). There were also no differences in OS after adjustment for demographic and clinical factors (HR = 1.00, 95% CI: 0.96–1.04). Given the difference in conversion to open surgery between groups, the analysis was repeated with the inclusion of those that had conversion to open surgery with no change in the results (adjusted HR 1.00, 95% CI 0.96–1.04). Fig. 1. Open in a new tab Overall survival by surgery type. Kaplan Meier plot for overall survival by surgery type (traditional laparoscopy vs robotic-assisted surgery). Statistical comparison by log-rank test. 4. Discussion These data confirm that OS in patients with stage I endometrial cancer is high, with >80% of patients alive at 10 years after diagnosis in both groups. Both traditional laparoscopy and robotic-assisted surgery appear safe for women with stage I disease, with no clinically meaningful or statistically significant differences in OS between the groups. These findings remained consistent after correcting for available known risk factors and after including those who had conversion to open surgery. While reassuring, these findings do not preclude a potential impact of route-of-surgery decisions on endometrial cancer outcomes. There is one small prospective, randomized study that addresses this question [ 15 ], and most existing retrospective cohort studies are from single institutions and have a relatively short duration of follow up. Our group recently reported a single institution review of over 1000 patients with stage I endometrial cancer treated either with traditional laparoscopy or robotic-assisted surgery who were followed for a minimum of 5 years; in our series, robotic-assisted surgery compared with traditional laparoscopy was associated with shorter time to recurrence and poorer recurrence-free survival (RFS), disease-specific survival (DSS), and OS [ 11 ]. Notably, over half of recurrences occurred >2 years after surgery, and more than 25% of recurrences occurred >5 years after surgery [ 11 ]. Lim and colleagues performed a similar single-institution retrospective cohort study (1728 patients with clinical stage I disease, of which approximately 11% were upstaged following surgery) but found no significant difference in OS, PFS, and disease recurrence in early stage endometrial cancer between the use of robotic-assisted surgery and traditional laparoscopy after a median follow-up of 55.7 and 52.9 months respectively [ 13 ]. Notably, they observed a 10 month shorter median time to recurrence for patients treated with robotic-assisted surgery (18.5 versus 28 months), which was similar to that observed by Argenta et al. (16.3 versus 28.7 months), but did not translate into a detriment to observed RFS or OS [ 11 , 13 ]. In an overlapping follow-up study from the same institution, Dagher et al. reported on 901 patients with high-grade, clinical stage I disease (of which 28% were upstaged following surgery), finding no difference in RFS or OS by route of surgery, but again a significant reduction in median time to first recurrence (13.5 versus 19 months, p = 0.02) favoring the traditional laparoscopy cohort in this higher-risk population [ 16 ]. Fu and colleagues performed a meta-analysis to compare the long-term survival outcomes of robotic-assisted and traditional laparoscopic surgery for endometrial cancer [ 8 ]. They included 12 retrospective cohort studies, most of which included all stages of endometrial cancer. They found no difference in OS (HR: 0.962, 95% CI: 0.922–1.004), RFS (HR: 1.096, 95% CI: 0.947–1.296), or DSS (HR: 1.489, 95% CI: 0.713–3.107) between robotic-assisted surgery and traditional laparoscopic surgery in the entire population [ 8 ]. However, in early-stage endometrial cancer, they observed robotic-assisted surgery was associated with significantly poorer RFS (HR: 1.378, 95% CI: 1.102–1.724) with no difference in OS (HR: 1.081, 95% CI: 0.900–1.298) compared to traditional laparoscopy [ 8 ]. It should be noted that the median length of follow-up for patients treated with robotic-assisted surgery, among the 10 studies that reported median follow-up, is 40.5 months, which would be predicted to miss a significant proportion of recurrences and deaths; only 2 studies had a median follow-up of greater than 5 years. While the current study was unable to assess time to recurrence or RFS, our findings regarding OS agree with the meta-analysis findings. One of the main limitations to prior studies has been the relatively short duration of follow-up. The study with the longest duration of follow up is the recent single institution study by our group, with a median follow-up of 104 months in the traditional laparoscopy group and 76 months in the robotic-assisted surgery group [ 11 ]. This study suggested that given the relatively long recurrence-free interval and rate of OS in patients with stage I endometrial cancer, disparate outcomes between surgical modalities may not be identified with the short duration of follow-up in most published studies to date. While the duration of follow up in the present study is not as long as our prior study [ 11 ], the median duration of follow up was relatively long at 69.7 months. Despite similar aims, there are important differences between these studies that may account for disparate results [ 11 , 13 , 16 ]. In particular, the present study, Lim et al. and Dagher et al. were performed later, after robotic platforms were broadly available, and had approximately 75% of patients receiving robotic surgery. In Argenta et al.’s study, approximately 50% of patients underwent robotic surgery, and the use of robotic surgery steadily increased throughout the study period. While Argenta et al. explored the possibility of a “learning curve” bias in their analysis, it is possible that this may have contributed to the difference in outcomes seen between studies. While all studies were focused on stage I disease, Argenta et al. and the current study only included patients with stage I disease, while Lim et al. and Dagher et al. included all patients with suspected uterine confined disease, but ultimately about 12% and 28% of patients respectively had higher stage disease. This unsurprisingly resulted in a near doubling and quadrupling of the use of adjuvant treatment in Lim and Dagher, respectively. Lymph node assessment also varied between studies, as approximately 2/3 of included patients in our study and Argenta et al. had lymph node evaluation, perhaps leading to a relative understaging, while more than 90% of patients in Lim et al.’s study had lymph node assessment. In addition, sentinel lymph node dissection was performed in the vast majority of patients in Lim et al., while this was rare in Argenta et al.’s study. Data regarding type of lymph node assessment was not available for the current study. Argenta et al.’s results also had higher OS particularly in the traditional laparoscopy group (approximately 85–90% at 10 years), while OS in the robotic-assisted group was around 80%, similar to the OS reported in all groups in the other two studies. While these differences may be explained by the longer duration of follow-up in Argenta et al.’s study, they may also be due to selection bias. A comparison of these studies is summarized in Table 1 [ 11 , 13 , 16 ]. A strength of the present study is its large, national cohort. One other study has been published with such a large cohort, which also utilized the NCDB to investigate outcomes associated with surgical approach in endometrial cancer [ 17 ]. This study included patients with endometrial cancer who underwent hysterectomy via any surgical approach from 2010 to 2015. They found that robotic-assisted surgery was associated with a slight improvement in OS compared to traditional laparoscopy (adjusted HR 1.05, 95% CI 1.00–1.09). However, when restricted to patients with stage I disease, they found no difference in OS consistent with our study (HR 1.01, 95% CI 0.95–1.06). Interestingly, they found patients with stage II-IV disease were more likely to be treated with traditional laparoscopy than robotic-assisted surgery, and there was a difference in outcomes between the two surgical approaches only in stage III disease, where improved survival was seen with robotic-assisted surgery [ 17 ]. Ultimately, prospective data is needed to further identify and isolate the impact of surgical approach on oncologic outcomes. One randomized controlled trial has been performed to assess this question [ 15 ]. In this trial, patients with low-grade endometrial cancer regardless of stage were randomized to traditional laparoscopic or robotic-assisted surgery. They observed an OS benefit favoring robotic-assisted surgery (HR 0.39, 95% CI 0.15–0.99) with 5-year OS of 91.8% vs. 93.7% and 10-year OS of 75.5% vs. 85.4% for traditional laparoscopy and robotic-assisted surgery, respectively. They did not observe any differences in PFS between groups. While the study benefited from its long duration of follow up (11.2 years for traditional laparoscopy, 11.9 years for robotic-assisted surgery), it is significantly limited by its small sample size with fewer than 50 patients in each group and imprecise HR estimates. Therefore, the observed OS differences should be interpreted with caution. Overall, these findings suggest that a larger, prospective trial with a similar long duration of follow-up is warranted. While this study benefits from its national large sample size and long duration of follow up, there are important limitations that must be considered. First, this study population is not population-based; the NCDB only includes data from hospitals accredited by Commission on Cancer, which tend to be larger and more urban, and therefore there is a potential for selection bias which may limit generalizability. While the NCDB includes data on most key clinical variables, there are more detailed data which are lacking such as the type of lymph node assessment performed or detailed pathologic findings such as presence of lymphovascular space invasion, degree of myometrial invasion, or molecular classification. We used the use of adjuvant therapy as a proxy for pathologic risk stratification, which was included in the adjusted model and did not impact the results. There is also a lack of rationale for why a given surgical approach was chosen, and key factors that could influence this decision including body mass index and performance status were not available. Further, data regarding other oncologic outcomes such as progression and recurrence are unavailable. Finally, while this study had a relatively long duration of follow up, it is possible the duration of follow up was not long enough to demonstrate small differences in OS given the high OS rates in this population. In conclusion, our data demonstrate excellent survival outcomes for patients with stage I endometrial cancer with no differences in OS observed between those treated with traditional laparoscopy or robotic-assisted surgery over the study period. Despite this encouraging finding, multiple authors, including a recent meta-analysis, suggest that patients with stage I disease who undergo robotic-assisted surgery may experience faster time to recurrence and possibly worse RFS, which could not be assessed in the current study. Fortunately, in most cases these findings do not appear to translate into a clear detriment to OS in the short term, but recent data suggests that recurrences and deaths from endometrial cancer continue well beyond the typical study windows, suggesting that we may not be able to detect the full extent of a route-of-surgery decision with current data sets. Large, prospective studies with long duration of follow-up should be undertaken to further isolate and identify the impact of surgical approach on outcomes in this patient population. HIGHLIGHTS. More patients had robotic-assisted surgery (74.5%) than laparoscopy (25.5%). Survival outcomes are excellent with MIS for stage I endometrial cancer. No overall survival difference was observed by MIS approach. Acknowledgements We acknowledge the Clinical Quality, Outcomes, Discovery, and Evaluation Core of the Center for Learning Health System Sciences for their help obtaining the data for this manuscript. Funding sources & disclosures This research was supported in part by the National Institutes of Health (P30CA77598, UM1TR004405). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology employed, or the conclusions drawn from these data by the investigators. Footnotes Declaration of competing interest None. CRediT authorship contribution statement Sarah J. Boyle: Writing – original draft, Conceptualization. Allison Dona: Writing – review & editing, Methodology. Rachel I. 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