Lymph node assessment at the time of robotic hysterectomy for endometrial intraepithelial neoplasia: A cost-effectiveness analysis

Objective: We sought to determine the cost-effectiveness (CE) of lymph node dissection (LND) at the time of hysterectomy for endometrial intraepithelial neoplasia (EIN).

Methods: A decision analytic model was created to evaluate the strategies of routine full LND, sentinel lymph node dissection (SNLD), SNLD without advancing to full LND in the event of non-mapping, and full LND based on Mayo Criteria, versus no LND. Patients in the no LND group and those in the SLND group without advancement to full LND in the event of non-mapping who were found to have EC on final pathology and suspicious post-operative imaging underwent full LND. Model inputs were derived from the literature. Outcomes included cost, quality adjusted life years (QALYs), lymphedema, and 12-month post-operative complications. Univariate and probabilistic sensitivity analyses (PSA) were performed.

Results: In a theoretical cohort of 1000 women, no LND was the dominate strategy with 960 QALYs and cost $21.94 M. This strategy resulted in 29 peri-operative complications and 11 cases of lymphedema. PSA indicated that LND based on frozen pathology is not CE compared to no LND. When comparing lymph node assessment strategies, SLND without escalation to full LND was the dominate strategy.

Conclusions: Compared to no LND, no strategy of LND was CE. However, if SLND was performed, escalation to full LND in the event of non-mapping resulted in worse CE. With this in mind, it is reasonable to consider either forgoing LND altogether or performing SLND without advancing to full LND to improve costs and reduce complications.