Improving Double Docking for Robot-assisted Para-aortic Lymphadenectomy in Endometrial Cancer Staging: Technique and Surgical Outcomes

Efficacy of Single- and Dual-Docking Robotic Surgery of Paraaortic and Pelvic Lymphadenectomy in High-Risk Endometrial Cancer

(1) The surgical method of choice for the treatment of endometrial cancer is minimally invasive surgery. In cases of high-risk endometrial cancer, completed paraaortic and pelvic lymphadenectomy are indicated. The aim of this study was to analyze the types of docking during robotic surgery assisted with the da Vinci X system while performing paraaortic and pelvic lymphadenectomy. (2) Methods: A total of 25 patients with high-risk endometrial cancer, with a mean age of 60.07 ± 10.67 (range 34.69-83.23) years, and with a mean body mass index (BMI) of 28.4 ± 5.62 (range 18-41.5) kg/m2, were included in this study. The analyzed population was divided into groups that underwent single or dual docking during surgery. (3) Results: No statistical significance was observed between single and dual docking during paraaortic and pelvic lymphadenectomy and between the type of docking and the duration of the operation. However, there was a statistically significant correlation between the duration of the operation and previous surgery (p < 0.005). The number of removed lymph nodes was statistically associated with BMI (p < 0.005): 15.87 ± 6.83 and 24.5 ± 8.7 for paraaortic and pelvic lymph nodes, respectively, in cases of single docking, and 18.05 ± 7.92 and 24.88 ± 11.75 for paraaortic and pelvic lymph nodes, respectively, in cases of dual docking. (4) Conclusions: The robot-assisted approach is a good surgical method for lymphadenectomy for obese patients, and, despite the type of docking, there are no differences in the quality of surgery.

A modified technique to perform para-aortic lymphadenectomy up to the renal vein

OBJECTIVE

To investigate the safety and feasibility of our modified technique to perform lymph node excision up to the renal vein in cases of gynecological cancer.

MATERIALS AND METHODS

87 patients with endometrial or ovarian neoplasms underwent laparoscopic para-aortic lymphadenectomy (LPAL) up to the left renal vein were enrolled prospectively. During surgery, the surgeon was positioned to the right side of the patient and an additional trocar was introduced into the upper right abdomen. The laparoscopic video screen was placed to the side of the patient's head. Three-fan retractor forceps were used to hold up the duodenum and small bowel. The rest of the procedure was the same as conventional LPAL.

RESULTS

The median operating time for LPAL was 72 min (range: 40-115 min) and the median estimated blood loss was 45 ml (range: 15-1000 mL). There were two cases of intra-operative vascular injury. The median number of retrieved para-aortic lymph nodes (PALNs) was 18 (range: 10-37). Of the 87 patients, 11 patients had positive PALNs. None of the cases required laparotomy.

CONCLUSION

Our findings demonstrate that our modified LPAL technique is feasible, reproducible, can achieve good exposure and reduces surgical difficulty.

Robotic-Assisted Infrarenal Para-aortic Lymphadenectomy in Gynecological Cancers: Technique and Surgical Outcomes

OBJECTIVE

Mini-invasive surgery has essentially replaced open laparotomy in surgery for endometrial and cervical carcinoma. Of the procedures needed for a complete staging, especially para-aortic lymphadenectomy (PALND) is challenging to perform. The present study was undertaken to investigate the technical and surgical outcomes of robotic-assisted PALND for gynecological cancers in the setting of a tertiary university hospital in Finland.

METHODS

This was a retrospective chart review of 283 robotic-assisted para-aortic lymphadenectomies using the single-docking transperitoneal technique performed at the Department of Obstetrics and Gynecology of Tampere University Hospital, in 2009-2016. The primary outcome measure was the extent of the operation in terms of the height, that is, how often the level cranial to the inferior mesenteric artery (IMA) was achieved. The secondary outcome measures included operation time and surgical outcome.

RESULTS

The majority of operations (n = 239 [84.4%]) were performed for endometrial carcinoma. The most common operation type was robotic-assisted hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy and PALND, which took a median of 3:38 hours or 218 minutes (range, 140-341 minutes) to perform. The high PALND (above the level of IMA) succeeded in 235 operations (83%). In the total cohort, the median number of para-aortic lymph nodes removed was 12 (range, 0-38), with a learning curve approximately more than 40 operations. Para-aortic lymph node metastases were found in 43 patients (15.2%). Seven conversions to laparotomy (2.5%) were done. The conversion and intraoperative complication rates were 2.5% and 3.5%, respectively, and postoperative complications was 18%, according to the classification of Clavien-Dindo. The median length of the postoperative hospital stay was 2 days (range, 1-8 days).

CONCLUSIONS

Using the transperitoneal technique for PALND, the area between IMA and the renal veins can be reached in more than 80% of the operations, with a very low or 2.5% conversion rate.

Early feasibility surveillance of gynecologic robotic-assisted surgeries in Japan

AIM

To evaluate the clinical relevance of robotic-assisted surgeries (RAS) for gynecologic malignancies in a Japanese multi-institutional cohort.

METHODS

A retrospective review of perioperative outcomes of 357 gynecologic RAS procedures was conducted in 24 hospitals accredited to perform RAS by the Japanese Society of Obstetrics and Gynecology (JSOG) over a 4-year period, January 2014 to December 2017.

RESULTS

More than 25 (high), 10-24 (middle) and less than 10 cases (low) were enrolled from 3, 8 and 13 hospitals, respectively. A total of 247 patients underwent RAS for malignant indications. Radical hysterectomy (RH) was conducted for 200 patients, while para-aortic node excision (PAN) for 47 patients. RAS with RH or PAN was more feasible in high-volume centers with significantly shorter operation time and lesser blood loss than that in middle-volume centers. The total rate of perioperative injury and complications in RAS with PAN reached 33.3% in high-volume centers, which was almost equal to those in middle-volume centers (35.5%) but much higher than RAS without PAN (8.5%).

CONCLUSION

Perioperative surveillance demonstrated high feasibility of gynecologic RAS procedures conducted in JSOG accredited hospitals for these 4 years. It is mandatory for RAS conducting hospitals to have careful attitudes to realize their learning curves in conducting advanced procedures.

The role of robotic aortic lymphadenectomy in gynecological cancer: surgical and oncological outcome in a single institution experience

BACKGROUND AND OBJECTIVE

This study aims to investigate the surgical outcomes observed in robotic transperitoneal aortic lymphadenectomy (AL) in gynecological cancer patients.

METHODS

Retrospective data were collected and analyzed on 71 patients undergoing robotic surgical procedures for gynecological cancers, including transperitoneal AL, between December 2014 and February 2018 at the Catholic University of the Sacred Heart, Rome, Italy.

RESULTS

Median age of the sample population was 50 years (range, 26-76 years). The median operative time was 210 minutes (range, 75-480 minutes), the median estimated blood loss was 50 ml (range, 20-300 ml). The number of para-aortic nodes removed was 12 (range, 7-43). In the whole series, 13 patients (18.3%) had at least one metastatic node. Overall, 10 patients (14.1%) experienced any grade early postoperative complications. Three patients experienced more than one complication. Three intraoperative complications occurred with two cases of vascular injury. Conversion to laparotomy was necessary for one patient (1.4%).

CONCLUSIONS

The present study shows the safety and adequacy of robotic transperitoneal AL as surgical staging step for gynecological cancers in terms of perioperative and postoperative outcomes.

Iliaco-enteric fistula after robot-assisted comprehensive surgical staging of endometrial cancer: a case report

Fistula formation between bowel and blood-vessel is a very rare complication after intraabdominal surgery. We report a case of iliaco-enteric fistula following robot-assisted surgical staging of endometrial cancer. A 71-year-old woman subjected to comprehensive endometrial cancer staging presented with hematochezia 35 days postoperatively. A retroperitoneal right-sided abscess and an iliaco-enteric fistula was confirmed upon imaging. The patient received endovascular repair of the aneurysm in her right common iliac artery and the segments of the small bowel containing the fistula were resected via laparotomy. If a patient presents with new onset postoperative hematochezia after pelvic and/or paraaortic lymphadenectomy, fistulation between bowel and the major abdominal blood vessels should be part of the differential diagnoses.