# Robotic Surgical Outcomes in Endometrial Cancer: Does Class III Obesity Matter?

## TL;DR

Robotic surgery is safe for endometrial cancer patients with severe obesity, but it takes longer and has lower success in lymph node mapping.

## Contribution

Demonstrates robotic surgery's safety in Class III obese endometrial cancer patients with specific outcomes data.

## Key findings

- Robotic surgery had no increased complications in Class III obese patients compared to lower BMI groups.
- Class III obese patients had longer operative times and lower rates of successful lymph node mapping.
- Perioperative outcomes like blood loss and hospital stay were similar across BMI groups.

## Abstract

Obesity is a major risk factor for endometrial cancer (EC). Severe (Class III) obesity—defined as a body mass index (BMI) of 40 kg/m2 or higher—increases both the chance of developing EC and makes surgery more challenging. Robotic surgery is a minimally invasive technique that may help overcome these challenges, but data in patients with Class III obesity remain limited. In this study, we analyzed 109 patients with early-stage EC who underwent robotic hysterectomy with bilateral salpingo-oophorectomy and sentinel lymph node staging, and compared perioperative outcomes across the BMI groups (Group A (≥40 kg/m2), Group B (30–39 kg/m2), and Group C (<30 kg/m2)). We found that robotic surgery was surgically safe and feasible even in Class III obese patients, with no increase in intraoperative or postoperative complications compared to normal weight patients. However, Class III obese patients experienced longer operative times and lower rates of bilateral sentinel lymph node mapping compared to the other groups.

Background/Objective: Women with Class III obesity (BMI ≥ 40 kg/m2) have a lifetime risk of endometrial cancer (EC) as high as 10–15%. However, evidence focused specifically on Class III obese patients remains limited. This study evaluated the surgical feasibility and safety of robotic surgery in Class III obese women with EC. Methods: A single-center retrospective study was conducted at the ESGO-accredited University Hospital of Parma (Italy) from October 2021 to February 2025. All women had apparent early-stage EC and underwent robotic hysterectomy with bilateral salpingo-oophorectomy and sentinel lymph node (SLN) mapping with Indocyanine Green. Patients were categorized into three BMI groups: Group A (BMI ≥ 40 kg/m2), Group B (BMI 30–39 kg/m2), and Group C (BMI < 30 kg/m2). Perioperative variables—including operative time, estimated blood loss, conversion to laparotomy, intra- and postoperative complications, hospital and Intensive Care Unit (ICU) stay, and SLN mapping failure—were compared across groups. Results: A total of 109 women were included: 26 (23.9%) in Group A, 45 (41.3%) in Group B, and 38 (34.9%) in Group C. Class III obesity was not associated with higher intraoperative (p = 0.390) or postoperative (p = 0.805) complication rates. Conversion to laparotomy (p = 0.720), estimated blood loss (p = 0.123), ICU stay (p = 0.156), and hospital stay (p = 0.491) were superimposable across groups. Operative time was significantly longer in Group A (p = 0.003) compared to the other groups. Successful bilateral SLN mapping differed significantly across groups (p = 0.026), being lower in Group A (73.1%) compared to Group B (95.6%) and Group C (81.6%). Conclusions: Robotic surgery is safe and feasible in Class III obese EC patients, with perioperative morbidity comparable to that of lower BMI groups. Nevertheless, longer operative times and a lower rate of successful bilateral SLN mapping highlight the need for tailored strategies and further research to optimize nodal staging in severely obese women.