Transperitoneal laparoscopic pelvic and paraaortic lymphadenectomy in gynecologic cancers

Improvements and challenges in intraperitoneal laparoscopic para-aortic lymphadenectomy: The novel "tent-pitching" antegrade approach and vascular anatomical variations in the para-aortic region

INTRODUCTION

This study introduces and compares a new intraperitoneal laparoscopic para-aortic lymphadenectomy method to reach the level of the renal vein, the "tent-pitching" antegrade approach with the retrograde approach in gynecological malignancy surgeries in terms of success rate, complication incidence, and the number of lymph nodes removed. It focuses on the feasibility, safety, and effectiveness. Meanwhile, this article reports on the vascular anatomical variations discovered in the para-aortic region to enhance surgical safety.

MATERIAL AND METHODS

This was a retrospective cohort study including patients undergone laparoscopic para-aortic lymphadenectomy at a single center from January 2020 to December 2023 for high-risk endometrial and early-stage ovarian cancer. Patient charts were reviewed for mode of operation, perioperative complications, operative details, and histopathology. The patients were divided into anterograde group and retrograde group according to the operation mode. The two groups were further compared based on the success rate of lymph node clearance at the renal vein level, perioperative complications, and the number of removed lymph nodes. Quantitative data were analyzed using the t-test, non-normally distributed data using the rank-sum test, and categorical data using Fisher's exact test and the chi-square test, with statistical significance defined as P < 0.05.

RESULTS

Among 173 patients, the antegrade group showed higher surgery success (97.5% vs 68.82%), more lymph nodes removed (median 14 vs 7), and less median blood loss. The operation time was shorter in the antegrade group. Postoperative complications like lymphocele and venous thrombosis were lower in the antegrade group. Vascular abnormalities were found in 28.9% of patients, with accessory lumbar vein routing anomaly and accessory renal arteries being most common.

CONCLUSIONS

The antegrade approach is feasible, safe, and effective, improving surgical exposure, reducing difficulty without additional instruments or puncture sites, and minimizing organ damage risk. It is effective in achieving better access to the renal vein and removing more para-aortic lymph nodes than the retrograde method. Recognizing and carefully managing the diverse vascular abnormalities in the para-aortic area, including variations in renal arteries, veins, and the inferior vena cava, is essential to reduce intraoperative bleeding and the likelihood of converting to open surgery.

Comparison of Robotic-Assisted vs. Conventional Laparoscopy for Para-aortic Lymphadenectomy in Gynecological Malignancies: A Systematic Review and Meta-Analysis

Background

Robotic-assisted surgery is one of the novel minimally invasive surgical techniques for the treatment of gynecological malignancies. The aim of this systematic review and meta-analysis was to compare the outcomes of robot-assisted vs. conventional laparoscopy for para-aortic lymphadenectomy (PAL) in patients with gynecological malignancies.

Methods

An electronic search in PubMed, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar databases was performed for articles, published up to 01^st November 2021. Outcomes including operating time (OT), total blood loss (TBL), length of stay (LOS), and complication rate (CR) in robot-assisted vs. conventional laparoscopy were investigated.

Results

A total of nine studies (7 non-RCTs and 2 RCTs) involving 914 participants were included. Of them, 332 patients underwent robotic laparoscopy (robotic group) and 582-conventional laparoscopy (conventional laparoscopy group). A significant decrease in TBL (MD = -149.1; 95% CI: -218.4 to -79.91) [ml] was observed in the robotic group as compared to the conventional laparoscopy group. However, no significant difference was noted for OT, CR, and LOS in the overall findings. Further subgroup analysis showed that the robotic group had a lower OT in mixed histological populations and studies reporting on the extraperitoneal approach. The lower chance of TBL was observed in mixed histological populations and studies involving extraperitoneal approach, Caucasian population, and non-RCTs design.

Conclusions

Robotic laparoscopy has a significant advantage over the conventional laparoscopy approach for PAL in gynecological malignancies. Further prospective observational studies embedded with a large sample size are needed to validate our findings.

Prognostic Value of Lymph Node Characteristics in Patients with Cervical Cancer Treated with Radical Hysterectomy

Objective

This study evaluated the prognostic value of various lymph node (LN) characteristics, including the lymph node ratio (LNR), in patients with cervical cancer treated with radical hysterectomy.

Methods

In this retrospective study, 260 patients with cervical cancer who had undergone radical hysterectomy with pelvic or paraaortic lymphadenectomies were included. LN characteristics related to several LN statuses included total LN counts, LN metastasis, total positive LN counts, LNR, and levels of lymphadenectomy. LNR was defined as the number of metastatic LNs divided by the total number of LNs harvested. Univariate and multivariate analyses for disease-free survival (DFS) and overall survival (OS) were performed using the clinicopathological and LN characteristics.

Results

Based on receiver-operating characteristics curve analysis, the cut-off value of LNR was 0.0625. Multivariate analysis revealed that high LNR was significantly related to tumor recurrence (hazard ratio [HR], 5.182; 95% confidence interval [CI], 2.424–11.075; p < 0.0001). After adjusting for clinicopathological factors, LNR was also independent prognostic factor for predicting tumor recurrence (HR, 5.930; 95% CI, 2.114–16.634; p = 0.0007). However, total retrieved LN counts and level of lymphadenectomy were not associated with survival outcomes.

Conclusion

LNR may be a prognostic biomarker for predicting disease recurrence in cervical cancer treated with radical hysterectomy.

Laparoscopic para-aortic lymphadenectomy: Technique and surgical outcomes

OBJECTIVE

Pelvic and para-aortic lymph node dissection is an important part of staging surgery. Aim of this study is to evaluate perioperative outcomes of patients, who underwent laparoscopic para-aortic lymphadenectomy for gynecological cancer in a single center over a period of 7 years, based on body mass index (BMI), and to present the surgical technique in steps.

METHODS

Data of patients who underwent para-aortic lymphadenectomy at gynecological oncology department of a tertiary center in between March 2013 and July 2020 were analyzed retrospectively. Patients were evaluated in two groups according to their BMI (< 30 kg/m² as non-obese and ≥ 30 kg/m² as obese groups). Surgical technique is described in steps. Perioperative outcomes of the two groups were evaluated.

RESULTS

A total of 230 patients were included in the study. BMI was ≥30 at 58.46 % of the patients. Peri-operative features were not significantly affected by the patient's BMI with the presented surgical technique, however, collected para-aortic lymph node numbers were higher in the group with BMI < 30, though sufficient number of lymph nodes were achieved in both groups.

CONCLUSION

Although some technical difficulties may be encountered, laparoscopic para-aortic lymphadenectomy is feasable in gynecologic oncological surgery independent of BMI. However, surgical experience is important.

Systemic Laparoscopic Para-Aortic Lymphadenectomy to the Left Renal Vein

Background

No large-scale clinical study has been done to show the standard surgical boundary and efficacy of laparoscopic para-aortic lymphadenectomy (LPAL).

Objectives

Therfore, this study aimed to evaluate the feasibility, efficacy, and standard surgical boundary of LPAL performed up to the left renal vein level in gynecological malignancies.

Methods

Medical records of 333 patients were retrospectively reviewed. All cases had gynecologic malignancies and had an operation including LPAL by a single surgical team between November 2003 and May 2018.

Results

Three hundred twenty-six patients underwent LPAL as part of their staging, restaging, or debulking surgery. Seven patients with isolated para-aortic lymph node recurrence underwent a repeat LPAL. The median age and body mass index were 54 years (range, 28-81 years) and 26.0 kg/m² (range, 20.3-37.2 kg/m²), respectively. The median operating time was 60 minutes (range, 24-135 minutes), and the median number of harvested para-aortic lymph nodes was 12 (range, 6-49). There were 11 cases of complications: 5 of major vessel injuries (3 inferior vena cava, 1 aorta, and 1 common iliac vein), 2 lymphocysts, 2 cases of chylous ascites, a cisterna chyli rupture, and 1 case of ureteric injury. There were 2 conversions to laparotomy: 1 left common iliac vein laceration that needed to be repaired and removal of an enlarged para-aortic lymph node completely.

Conclusion

It is feasible and efficient to perform LPAL to the left renal vein level for women with gynecologic malignancies by well-trained gynecologic oncology surgeons according to our suggested standard surgical boundary.

Distribution of iliac veins posterior to the common iliac artery bifurcation related to pelvic lymphadenectomy: A digital in vivo anatomical study of 442 Chinese females

OBJECTIVES

To investigate the distribution of iliac veins posterior to common iliac artery bifurcation (CIAB) for pelvic lymphadenectomy.

METHODS

After IRB approval was obtained, computer tomography angiography data of 442 female pelvises were acquired. After vascular three-dimensional (3D) reconstructions, the structural types, frequencies and diameters of iliac veins immediately posterior to CIAB were investigated and measured. To quantify iliac vein courses, linear distances and their distances on sagittal, coronal and vertical axes from CIAB to external/internal iliac veins confluence (EIIVC) were geometrically measured.

RESULTS

There were five structural types of iliac veins distribution immediately posterior to CIAB: common iliac vein (CIV, 13.8%), no occurrence of great vein (N, 71.27%, 0), EIIVC (1.58%) and external iliac vein (EIV, 13.35%) on the left side, while confluence of common iliac veins (CCIV, 8.82%), CIV (77.38%), N (1.58%, 0), EIIVC (6.11%), and EIV (6.11%) on right. The venous diameters immediately posterior to CIAB in "CCIV", "CIV" and "EIIVC" were significantly larger than that in "EIV" (P<0.05). Their linear distances and their distances on each axis from CIAB to external/internal iliac veins confluence (EIIVC) from CIAB to EIIVC were obtained.

CONCLUSIONS

In this study, we presented new distribution of iliac veins posterior to CIAB, including structural types, frequencies, venous diameters immediately posterior to CIAB, and their quantified courses from CIAB to EIIVC. It could help surgeons reduce the risk of vascular injury, hemorrhage or transfusion in pelvic lymphadenectomy.

The role of laparoscopy in the surgical treatment of endometrial cancer

Introduction

Endometrial carcinoma is one of the most common neoplasms in gynecological oncology and the most common genital cancer in women in developed countries. The 5-year overall survival rate depends on the FIGO stage. For patients with stage I endometrial cancer it is estimated as 80%. Traditionally, the main treatment of endometrial cancer consists of total abdominal hysterectomy with bilateral salpingo-oophorectomy and, in some histological or clinical stages, with additional pelvic lymphadenectomy. The main surgical approach so far for women with endometrial cancer has been laparotomy. However, in the last decades there have been many reports stating that the survival rate in such cases is similar after laparoscopy and laparotomy. Some researchers claim that laparoscopy is as effective as laparotomy, and it might be much more precise than laparotomy thanks to its special optic system.

Aim

To establish the method of choice for treatment of stage I endometrial cancer.

Material and methods

Comparing the preliminary results from data collected during surgical procedures performed at the First Department of Obstetrics and Gynecology of the Medical Centre of Postgraduate Education in Warsaw and the Department of Obstetrics and Gynecology of the Rural Hospital in Garwolin.

Results

Laparoscopy is as effective as laparotomy, and it might be much more precise than laparotomy.

Conclusions

Taking into consideration all the above arguments, if an experienced endoscopic surgeon and proper laparoscopic equipment are available, laparoscopy might become the method of choice for treatment of stage I endometrial cancer.

Feasibility of laparoscopic extraperitoneal pelvic lymphadenectomy in gynecologic malignancies

OBJECTIVE

The aim of this study is to evaluate the feasibility of laparoscopic extraperitoneal pelvic lymphadenectomy (LEPL) in gynecologic malignancies.

METHODS

Twenty-nine women with cervical, ovarian or endometrial cancer underwent laparoscopic extraperitoneal pelvic lymphadenectomy between July 2008 and December 2010. The operating time, nodal yield, blood loss and complications were recorded.

RESULTS

The number of patients with cervical, ovarian and endometrial carcinoma was 14, 3 and 12, respectively. The median age of patients was 48.9±12.6 years. The median body mass index was 25.6±4.8. Conversion to the transperitoneal laparoscopic approach was necessary in 6 patients for peritoneal tears causing CO(2) gas leakage. Among the remaining 23 patients, the median operating time for laparoscopic extraperitoneal pelvic lymphadenectomy was 69 min (range 50-126 min), and the median estimated blood loss was 20 ml (range 5-105 ml). The median total number of resected nodes was 26 (range 14-42), and complications related to the procedure were rare.

CONCLUSIONS

Laparoscopic extraperitoneal pelvic lymphadenectomy is a feasible and safe procedure. It can be used in gynecologic malignancies.

Robotic surgery for cervical cancer

The development of robotic technology has facilitated the application of minimally invasive techniques for the treatment and evaluation of patients with early, advanced, and recurrent cervical cancer. The application of robotic technology for selected patients with cervical cancer and the data available in the literature are addressed in the present review paper. The robotic radical hysterectomy technique developed at the Mayo Clinic Arizona is presented with data comparing 27 patients who underwent the robotic procedure with 2 matched groups of patients treated by laparoscopic (N = 31), and laparotomic radical hysterectomy (N = 35). A few other studies confirmed the feasibility and safety of robotic radical hysterectomy and comparisons to either to the laparoscopic or open approach were discussed. Based on data from the literature, minimally invasive techniques including laparoscopy and robotics are preferable to laparotomy for patients requiring radical hysterectomy, with some advantages noted for robotics over laparoscopy. A prospective randomised trial is currently being performed under the auspices of the American Association of Gyneoclogic Laparoscopists comparing minimally invasive radical hysterectomy (laparoscopy or robotics) with laparotomy. For early cervical cancer radical parametrectomy and fertility preserving trachelectomy have been performed using robotic technology and been shown to be feasible, safe, and easier to perform when compared to the laparoscopic approach. Similar benefits have been noted in the treatment of advanced and recurrent cervical cancer where complex procedures such as extraperitoneal paraortic lymphadenectomy and pelvic exenteration have been required.

CONCLUSION

Robotic technology better facilitates the surgical approach as compared to laparoscopy for technically challenging operations performed to treat primary, early or advanced, and recurrent cervical cancer. Although patient advantages are similar or slightly improved with robotics, there are multiple advantages for surgeons.