Robotic transperitoneal infra-renal aortic lymphadenectomy in early-stage endometrial cancer

Identifying safe diagnostic algorithms for sentinel lymph node mapping in high-risk endometrial cancer: The SENTIREC-endo study

INTRODUCTION

It is unclear if sentinel node (SLN) mapping can replace pelvic- (PLD) and paraaortic lymphadenectomy (PALD) for high-risk endometrial cancer (EC). A diagnostically safe surgical algorithm, taking failed mapping cases into account, is not defined. We aimed to investigate the diagnostic accuracy of SLN mapping algorithms in women with exclusively high-risk EC.

METHODS

We undertook a prospective national diagnostic cohort study of SLN mapping in women with high-risk EC from March 2017 to January 2023. The power calculation was based on the negative predictive value (NPV). Women underwent SLN mapping, PLD and PALD besides removal of suspicious and any FDG/PET-positive lymph nodes. Accuracy analyses were performed for five algorithms.

RESULTS

170/216 included women underwent SLN mapping, PLD and PALD and were included in accuracy analyses. 42/170 (24.7%) had nodal metastasis. The algorithm SLN and PLD in case of failed mapping, demonstrated a sensitivity of 86% (95% CI 74-100) and an NPV of 96% (95% CI 91-100). The sensitivity increased to 93% (95% CI 83-100) and the NPV to 98% (95% CI 94-100) if PLD was combined with removal of any PET-positive lymph nodes. Equivalent results were obtained if PLD and PALD were performed in non-mapping cases; sensitivity 93% (95% CI 83-100) and NPV 98% (95% CI 95-100).

CONCLUSION

SLN-mapping is a safe staging procedure in women with high-risk EC if strictly adhering to a surgical algorithm including removal of any PET-positive lymph nodes independent of location and PLD or PLD and PALD in case of failed mapping.

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.

Comparison of Different Lymph Node Staging Schemes for Predicting Survival Outcomes in Node-Positive Endometrioid Endometrial Cancer Patients

Objective: To compare the prognostic predictive performance of six lymph node (LN) staging schemes: American Joint Committee on Cancer (AJCC) N stage, number of retrieved lymph nodes (NRLN), number of positive lymph nodes (NPLN), number of negative lymph nodes (NNLN), lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) among node-positive endometrioid endometrial cancer (EEC) patients. Methods: A total of 3,533 patients diagnosed with node-positive EEC between 2010 and 2016 from the Surveillance, Epidemiology, and End Results (SEER) database were retrospectively analyzed. We applied X-tile software to identify the optimal cutoff value for different staging schemes. Univariate and multivariate Cox regression models were used to assess the relationships between different LN schemes and survival outcomes [disease-specific survival (DSS) and overall survival (OS)]. Moreover, Akaike information criterion (AIC) and Harrell concordance index (C-index) were used to evaluate the predictive performance of each scheme in both continuous and categorical patterns. Results: N stage (N1/N2) was not an independent prognostic factor for node-positive EEC patients based on multivariate analysis (DSS: p = 0.235; OS: p = 0.145). Multivariate model incorporating LNR demonstrated the most superior goodness of fit regardless of continuous or categorical pattern. Regarding discrimination power of the models, LNR outperformed other models in categorical pattern (OS: C-index = 0.735; DSS: C-index = 0.737); however, LODDS obtained the highest C-index in continuous pattern (OS: 0.736; DSS: 0.739). Conclusions: N stage (N1/N2) was unable to differentiate the prognosis for node-positive EEC patients in our study. However, LNR and LODDS schemes seemed to have a better predictive performance for these patients than other number-based LN schemes whether in DSS or OS, which revealed that LNR and LODDS should be more helpful in prognosis assessment for node-positive EEC patients than AJCC N stage.

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.

The prognostic significance of aortic lymph node metastasis in endometrial cancer: Potential implications for selective aortic lymph node assessment

OBJECTIVES

To evaluate the prognostic impact of aortic vs. pelvic lymph node (LN) metastasis among women with endometrial cancer (EC).

METHODS

Using data from the SEER 18 Registries we identified 3650 women with LN positive (stage IIIC) EC. We used Kaplan-Meier curves and log-rank tests to compare mortality between women with stage IIIC1 and IIIC2 disease. We used Cox proportional hazards regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between stage III sub-stage (IIIC1 vs. IIIC2) and survival.

RESULTS

Endometrioid tumors were more common among women with stage IIIC1 than IIIC2 tumors (62.5% vs. 54.3%) while, non-endometrioid histologies were more common among stage IIIC2. In the multivariable model, stage IIIC2 was associated with higher all-cause (HR = 1.44, 95% CI = 1.22-1.69) and EC-specific mortality (HR = 1.49, 95% CI = 1.25-1.77) compared with IIIC1. Women with non-endometrioid EC had poor survival, in particular, women with carcinosarcomas had higher EC-specific mortality compared to women with endometrioid EC (HR = 3.32, 95% CI = 2.71-4.07). When stratifying women according to substage, older age and non-endometrioid histology were associated with higher EC-specific mortality. Compared to women with a pelvic-only LN dissection, women with pelvic and aortic dissections had lower all-cause (HR = 0.74, 95% CI = 0.63-0.88) and EC-specific (HR = 0.79, 95% CI = 0.66-0.95) mortality.

CONCLUSION

Women with aortic LN positive EC are more likely to die from their disease. Older women and non-endometrioid histologies are more likely to have aortic LN involvement. Compared to women with a pelvic-only LN dissection, women with pelvic and aortic dissections had lower EC mortality.

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.

Robotic lower pelvic port placement for optimal upper paraaortic lymph node dissection

Objective

Upper paraaortic lymph node dissection (UPALD) to the infrarenal level is one of the most challenging robotic procedures. Because robotic system has the limitation in robotic arm mobility. This surgical video introduces a novel robotic approach, lower pelvic port placement (LP3), to perform optimally and simultaneously both UPALD and pelvic procedures in gynecologic cancer patients using da Vinci Xi system.

Methods

The patient presented with high-grade endometrial cancer. She underwent robotic surgical staging operation. For the setup of the LP3, a line was drown between both anterior superior iliac spines. At 3 cm below this line, another line was drown and four robotic ports were placed on this line.

Results

After paraaortic lymph node dissection (PALD) was completed, the boom of robotic system was rotated 180° to retarget for the pelvic lateral displacement. Robotic ports were placed and docked again. The operation was completed robotically without any complication.

Conclusion

The LP3 was feasible for performing simultaneously optimal PALD as well as procedures in pelvic cavity in gynecologic cancer patients. The advantage of LP3 technique is the robotic port placement that affords for multi-quadrant surgery, abdominal and pelvic dissection. The LP3 is facilitated by utilizing advanced technology of Xi system, including the patient clearance function, the rotating boom, and ‘port hopping’ that allows using every ports for a camera. The LP3 will enable surgeons to extend the surgical indication of robotic surgical system in the gynecologic oncologic field.

Sentinel lymph node mapping and staging in endometrial cancer: A Society of Gynecologic Oncology literature review with consensus recommendations

The emphasis in contemporary medical oncology has been "precision" or "personalized" medicine, terms that imply a strategy to improve efficacy through targeted therapies. Similar attempts at precision are occurring in surgical oncology. Sentinel lymph node (SLN) mapping has recently been introduced into the surgical staging of endometrial cancer with the goal to reduce morbidity associated with comprehensive lymphadenectomy, yet obtain prognostic information from lymph node status. The Society of Gynecologic Oncology's (SGO) Clinical Practice Committee and SLN Working Group reviewed the current literature for preparation of this document. Literature-based recommendations for the inclusion of SLN assessment in the treatment of patients with endometrial cancer are presented. This article examines.

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

We reviewed the current evidence on the safety, effectiveness, and applicability of extraperitoneal robotic-assisted para-aortic lymphadenectomy (ExtRA-PAL) as the staging procedure of gynecologic malignancies. PubMed (MEDLINE), Scopus, Web of Science databases, and ClinicalTrials.gov were searched for original studies reporting outcomes of ExtRA-PAL. Quality of the included studies and their level of recommendation were assessed using the Grading of Recommendations, Assessment, Development, and Evaluation and the American College of Obstetricians and Gynecologists guidelines, respectively. Overall, 62 studies were identified; after a process of evidence acquisition 5 original investigations were available for this review that included 98 patients undergoing ExtRA-PAL. The main surgical indication was staging for cervical cancer (n = 71, 72%). The mean (SD) number of para-aortic node yielded was 15.4 (±4.7) nodes. Blood transfusion and intraoperative complication rates were 2% and 6%, respectively. ExtRA-PAL was completed in 88 patients (90%). Six (6%) and 4 (4%) patients had conversion to other minimally invasive procedures and open surgery, respectively. Success rate was 99% among patients undergoing ExtRA-PAL without concomitant procedures. Overall, mean (SD) length of hospital stay was 2.8 (±0.5) days. Twenty-four patients (24%) developed postoperative events. According to the Clavien-Dindo grading system, grades IIIa and IIIb morbidity rates were 12% and 2%, respectively. No grades IV and V morbidity occurred. ExtRA-PAL is associated with a high success rate and a relative low morbidity rate. However, because of the limited data on this issue, further studies are warranted to assess the long-term effectiveness of this procedure.

Robotic retroperitoneal lymph node dissection in gynaecological neoplasms: comparison of extraperitoneal and transperitoneal lymphadenectomy

OBJECTIVE

The main aim of our study is to review the till now available literature data on the role of robotic retroperitoneal lymph node dissection in gynaecological cancers by comparing the extraperitoneal versus the transperitoneal approach.

METHODS

A thorough and systematic search was performed in electronic databases of PubMed and Scopus.

RESULTS

The extraperitoneal approach is described in 148 patients. The age of the patients ranged from 26 to 78 years. The indications included cervical, endometrial and ovarian carcinoma in 113, 22 and 12 patients, respectively. The operative time ranged between 45 and 410 min. The number of dissected lymph nodes ranged from 3 to 25, while only 13 of them were found to be positive. The mean estimated blood loss during the operation was 77 ml (range <50-200 ml). Seven cases were converted to open. The duration of hospital stay ranged from 2 to 14 days. The transperitoneal approach is described in 898 patients. The age of the patients ranged from 15 to 89 years. Cervical, endometrial and ovarian carcinomas were the principal neoplasias present in 248, 449 and 164 patients, respectively. The operative time ranged from 19 to 633 min. The number of dissected lymph nodes ranged from 1 to 54, while the total number of patients with positive lymph nodes dissected was 56 patients. The estimated blood loss during the operation varied between 20 and 1800 ml. Only 9 out of 898 patients were converted to open. The duration of hospital stay ranged from 1 to 40 days.

CONCLUSION

A reliable definition of the "kind" of lymphadenectomy used in each study is the first step in order to reach safe conclusions. The lack of comparative studies, especially the randomized ones, cannot help us draw any safe conclusion regarding both the clinical outcomes and the possibility of any superiority of these different approaches (extraperitoneal and transperitoneal).