Feasibility of hand-assisted laparoscopic sentinel node biopsy in open endometrial cancer surgery

Indocyanine green in gynecologic surgery: Where do we stand? A literature review and meta-analysis

The main objective of this study was to review and perform a meta-analysis of current literature on the use of indocyanine green for sentinel lymph node detection in pelvic gynecologic cancer. We included all studies focusing on indications and procedures associated with the use of ICG in gynecologic surgery and available on the Medline and Pubmed database. For the meta-analysis, random effect models were used for estimation of the 95 % detection rate and 95 % confidence interval, and stratified analyses by cancer type, concentration and localization of injection were performed. A total of 147 articles were included, of which 91 were studied in a meta-analysis. Results concerning detection rate by indocyanine green injection site were found to be 95.1 % and 97.3 % respectively for intracervical injection in 2 or 4 quadrants, and 77.0 % and 94.8 % for hysteroscopic and intradermal injection respectively. Results concerning detection rate by cancer type were 95.8 %, 95.2 %, 94.7 % and 95.7 % respectively for cervical, endometrial, vulvar and endometrial/cervical cancers. Finally, the results concerning detection rate by indocyanine green concentration were 91.2 %, 95.7 %, 96.7 % and 97.7 % for concentrations of <1.25 mg/ml, 1.25 mg/ml, 2.5 mg/ml and 5 mg/ml respectively. In conclusion, indocyanine green is shown to allow highlighting of sentinel lymph nodes with good reliability with an overall indocyanine green detection rate of 95.5 %. Our literature review revealed that indocyanine green feasibility has also been demonstrated in several surgical contexts, notably for reconstructive surgery and detection of endometriosis.

Prophylactic ligation of uterine arteries at its origin in laparoscopic surgical staging for endometrial cancer

AIM

The aim of this study was to compare the surgical outcomes between patients who were staged laparoscopically for early-stage endometrioid-type endometrial cancer (EC) between those who underwent prophylactic ligation of uterine arteries (UAs) prior to pelvic lymphadenectomy and the patients who were operated with standard procedure.

METHODS

This retrospective study was conducted in women diagnosed with early-stage and low/intermediate-risk endometrioid-type EC. The control group included patients who underwent standard laparoscopic pelvic lymphadenectomy and the study group concerned patients who underwent prophylactic ligation of UA prior to pelvic lymphadenectomy. The prophylactic ligation of UA procedure was performed at a point just proximal to its origin.

RESULTS

The mean lymph node count dissected in the study group was higher in terms of statistical significance (17.5 ± 2.2 vs. 19.8 ± 3.6, p = 0.003 and p ˂ 0.05). The rate of the patients who had a positive pelvic lymph node detected did not differ between groups (7.4% vs. 16.7%, p = 0.258 and p ˂ 0.05). The operation time (OT) of the patients in the study group did not differ between groups (p = 0.546 and p ˂ 0.05). Hemoglobin drop (-0.5 ± 0.7) and hematocrite drop (-0.8 ± 0.9) values in the study group were found to be lower in the study group (p = 0.000, p = 0.000, and p ˂ 0.05).

CONCLUSIONS

Performing prophylactic ligation of UA at its origin prevents unwanted bleeding and facilitates the laparoscopic pelvic lymphadenectomy procedure.

Paucity of data evaluating patient centred outcomes following sentinel lymph node dissection in endometrial cancer: A systematic review

•

SLND has potentially favourable patient-centred outcomes over systematic LND.

•

High-quality evidence comparing SLND with other methods of staging is lacking.

•

SLND was associated with shorter operating times and lower estimated blood loss.

•

Intraoperative and postoperative complications were not conclusively different.

Sentinel lymph node dissection (SLND) is presently used by the majority of gynaecologic oncologists for surgical staging of endometrial cancer. SLND assimilated into routine surgical practice because it increases precision of surgical staging and may reduce morbidity compared to a full, systematic LND. Previous research focussed on the accuracy of SLND. Patient centred outcomes have never been conclusively demonstrated. The objective of this systematic review was to evaluate patient centred outcomes of SLND for endometrial cancer patients. Literature published in the last five years (January 2015 to April 2020) was retrieved from PubMed, EMBASE, and Cochrane library, across five domains: (1) perioperative outcomes; (2) adjuvant treatment; (3) patient-reported outcomes (PROs); (4) lymphedema, and (5) cost. Covidence software ascertained a standardised and monitored review process. We identified 21 eligible studies. Included studies were highly heterogeneous, with widely varying outcome measures and reporting. SLND was associated with shorter operating times and lower estimated blood loss compared to systematic LND, but intra-operative and post-operative complications were not conclusively different. There was either no impact, or a trend towards less adjuvant treatment used in patients with SLND compared to systematic LND. SLND had lower prevalence rates of lymphedema compared to systematic LND, although this was shown only in three retrospective studies. Costs of surgical staging were lowest for no node sampling, followed by SLND, then LND. PROs were unable to be compared because of a lack of studies. The quality of evidence on patient-centred outcomes associated with SLND for surgical staging of endometrial cancer is poor, particularly in PROs, lymphedema and cost. The available studies were vulnerable to bias and confounding.

Registration of Systematic Review: PROSPERO (CRD42020180339)

Immunohistochemical Markers in Endometrial Cancer

In 2018, 382,069 new cases of uterine cancer were registered worldwide and 89,929 deaths from this cancer were reported [...].

Utility of Intraoperative Fluorescence Imaging in Gynecologic Surgery: Systematic Review and Consensus Statement

BACKGROUND

This study aimed to review the current knowledge on the utility of intraoperative fluorescence imaging in gynecologic surgery and to give evidence-based recommendations to improve the quality of care for women who undergo gynecologic surgery.

METHODS

A computer-based systematic review of the MEDLINE, CENTRAL, Pubmed, EMBASE, and SciSearch databases as well as institutional guidelines was performed. The time limit was set at 2000-2019. For the literature search, PRISMA guidelines were followed. A modified-Delphi method was performed in three rounds by a panel of experts to reach a consensus of conclusions and recommendations.

RESULTS

Indocyanine green (ICG) is used primarily in gynecology for sentinel node-mapping. In endometrial and cervical cancer, ICG is a feasible, safe, time-efficient, and reliable method for lymphatic mapping, with better bilateral detection rates. Experience in vulvar cancer is more limited, with ICG used together with Tc-99 m as a dual tracer and alone in video endoscopic inguinal lymphadenectomy. In early ovarian cancer, results are still preliminary but promising. Indocyanine green fluorescence imaging also is used for ureteral assessment, allowing intraoperative ureteral visualization, to reduce the risk of ureteral injury during gynecologic surgery.

CONCLUSIONS

For most gynecologic cancers, ICG fluorescence imaging is considered the tracer of choice for lymphatic mapping. The use of this new technology expands to a better ureteral assessment.