Extraperitoneal Robotic-Assisted Para-Aortic Lymphadenectomy in Gynecologic Cancer Staging: Current Evidence

The role of minimally invasive surgery in gynaecological cancer: an overview of current trends

Background

The capabilities of minimally invasive surgery, either as conventional laparoscopy, or as robotic surgery, have increased to an extent that it enables complex operations in the field of gynaecological oncology.

Objective

To document the role of minimally invasive gynaecological surgery in cancer.

Materials and methods

A review of the literature that shaped international guidelines and clinical practice.

Main outcome measures

Current guidelines of major international scientific associations and trends in accepted clinical practice.

Results

In recent years, evidence on oncologic outcome has limited the role of minimally invasive techniques in cervical cancer, while the treatment of early endometrial cancer with laparoscopy and robotic surgery has become the international standard. In ovarian cancer, the role of minimally invasive surgery is still limited. Current evidence on perioperative morbidity underlines the necessity to implicate minimally invasive techniques whenever possible.

Conclusion

The optimal surgical route for the treatment of gynaecological cancer remains in many cases controversial. The role of minimally invasive surgery remains increasing in the course of time.

What is new?

This comprehensive review offers an entire perspective on the current role of minimally invasive surgery in gynaecological cancer therapy.

Robot-assisted Extraperitoneal Para-aortic Lymphadenectomy Is Associated with Fewer Surgical Complications: A Post Hoc Analysis of the STELLA-2 Randomized Trial

STUDY OBJECTIVE

To evaluate if extraperitoneal para-aortic lymphadenectomy (PALND) using a robot-assisted approach was associated with fewer complications than all other approaches (conventional laparoscopic transperitoneal or extraperitoneal and robot-assisted transperitoneal) without compromising lymph node yield, operative time, or length of stay.

DESIGN

Post hoc analysis of the prospective randomized open-label multicenter trial (STELLA-2).

SETTING

Three academic referral hospitals.

PATIENTS

Two hundred and three eligible patients from the STELLA-2 trial were included.

INTERVENTIONS

The patients were randomized to extraperitoneal or transperitoneal PALND using a minimally invasive approach (either laparoscopic or robot-assisted) for surgical staging of endometrial or ovarian cancer. The minimally invasive approaches were not subjected to randomization.

MEASUREMENTS AND MAIN RESULTS

The primary end point was evaluated through a composite variable that included at least 1 of the following events: blood loss ≥500 mL during PALND, any intraoperative complication related to PALND, severe postoperative complication (Clavien-Dindo ≥grade IIIA), impossibility of completing the procedure, or conversion to laparotomy. Of the 203 patients analyzed, 68 were assigned to the extraperitoneal laparoscopic group (X-L), 62 to the transperitoneal laparoscopic group (T-L), 35 to the extraperitoneal robotic group (X-R), and 38 to the transperitoneal robotic group (T-R). A reduced trend in complications was observed in the extraperitoneal robot-assisted arm when considering the primary end point (X-L: 25.0%, T-L: 24.2%, X-R: 5.7%, T-R: 28.9%; p = .073). In a multivariable analysis, age (odds ratio [OR] 1.05; 95% confidence interval [CI], 1.00-1.09), body mass index (OR 1.09; 95% CI, 1.03-1.16), and waist-to-hip ratio (OR 1.66; 95% CI, 1.12-2.47) were found to independently increase the risk of PALND complications, whereas the extraperitoneal robotic approach (OR 0.13; 95% CI, 0.02-0.64) was an independent protective factor for complication occurrence.

CONCLUSION

Robot-assisted extraperitoneal PALND is associated with fewer surgical complications, without compromising lymph node retrieval, operative time, or length of stay. Robot-enhanced 3D visualization, surgeon ergonomics, or hemostatic precision could explain our results.

Docking for robotic extraperitoneal para-aortic lymphadenectomy with Da Vinci Xi surgical system

Regarding extraperitoneal para-aortic lymphadenectomy, installation is key when performed with the assistance of the Da Vinci Xi robotic system. We developed a step-by-step guide, from patient installation to placement of the trocars to patient cart docking, to perform in the efficient and safest installation possible this procedure. The operation does not differ from standard laparoscopic extraperitoneal lymphadenectomy. The benefits of robotic surgery in this indication are comparable to those of the standard laparoscopic approach. Those benefits imply a precise knowledge of the management and installation of the da Vinci Xi robotic system.

Introducing nerve-sparing approach during minimally invasive radical hysterectomy for locally-advanced cervical cancer: A multi-institutional experience

OBJECTIVE

To evaluate the impact of nerve-sparing (NS) approach on outcomes of patients undergoing minimally invasive radical hysterectomy (MRH) for locally advanced stage cervical cancer (LACC).

METHODS

Data of consecutive patients undergoing minimally invasive surgery for LACC were retrospectively retrieved in a multi-institutional setting from 2009 to 2016. All patients included had minimally invasive class III radical hysterectomy (MRH or NS-MRH). Propensity matching algorithm was used to decrease possible allocation bias when comparing outcomes between groups.

RESULTS

Overall, 83 patients were included. The prevalence of patients undergoing NS approach increased aver the study period (from 7% in the year 2009-2010 to 97% in the year 2015-2016; p-for-trend < 0.001). NS-MRH and MRH were performed in 47 (57%) and 36 (43%) patients, respectively. After the application the propensity-matching algorithm, we compared 35 patients' pair (total 70 patients). Postoperative complications rate was similar between groups. Patients undergoing NS-LRH experienced shorter hospital stay than patients undergoing LRH (3.6 vs. 5.0 days). 60-day pelvic floor dysfunction rates, including voiding, fecal and sexual alterations, were lower in the NS group in comparison to control group (p = 0.02). Five-year disease-free (p = 0.77) and overall (p = 0.36) survivals were similar comparing NS-MRH with MRH.

CONCLUSIONS

The implementation of NS approach in the setting of LACC improves patients' outcomes, minimizing pelvic dysfunction rates. NS approach has not detrimental effects on survival outcomes.

Impact of Surgical Route in Influencing the Risk of Lymphatic Complications After Ovarian Cancer Staging

Lymphatic complications are a common occurrence after staging surgery for early-stage ovarian cancer (eEOC). We investigated whether the introduction of minimally invasive surgery influences the risk of developing lymphoceles and lymphorrhea in patients undergoing staging for eEOC. For this purpose, data of consecutive patients affected by eEOC undergoing staging surgery between January 1980 and January 2016 were retrospectively reviewed, and a systematic review and meta-analysis was performed. This systematic review was registered in the International Prospective Register of Systematic Review. Among 341 patients included in the present study, 47 severe postoperative complications occurred (13.7%), including 40 lymphatic complications: 31 symptomatic lymphoceles (9%) and 9 cases of lymphorrhea (2.6%), respectively. Laparoscopic staging correlated with a lower risk of developing any severe lymphatic complications in comparison with open surgery (p = .02). In particular, the laparoscopic approach and para-aortic node involvement were associated with a trend toward lower lymphoceles (odds ratio, .13; 95% confidence interval, .07-2.20; p = .05) and a trend toward higher risk of lymphorrhea developing (odds ratio, 4.02; 95% confidence interval, .93-17.3; p = .06), respectively. In conclusion, the implementation of a minimally invasive approach might result in a slight reduction of lymphatic complications after eEOC staging.