Lymphedema, serious adverse events, and imaging 1 year after comprehensive staging for endometrial cancer: results from the RASHEC trial

Robot-assisted pelvic and renal surgery compared with laparoscopic or open surgery: Literature review of cost-effectiveness and clinical outcomes

BACKGROUND AND AIM

The purpose of this study was to evaluate clinical experiences and cost-effectiveness by comparing robot-assisted surgery with laparoscopic- or open surgery for pelvic and renal operations.

METHODS

A narrative review was carried out.

RESULTS

When using robotic-assisted surgery, oncological and functional results are similar to after laparoscopic or open surgery. One exception may be a shorter survival in cancer of the cervix uteri. In addition, postoperative complications after robotic-assisted surgery are similar, bleeding and transfusion needs are less, and the hospital stay is shorter but the preparation of the operating theater before and after surgery and the operation times are longer. Finally, robot-assisted surgery has, in several studies, been reported to be not cost-effective primarily due to high investment costs. However, more recent studies provide improved cost-effectiveness estimates due to more effective preparation of the operating theater before surgery, improved surgeon experience, and decreased investment costs.

CONCLUSIONS

Complications and functional and oncological outcomes after robot-assisted surgery are similar to open surgery and laparoscopic surgery. The cost-effectiveness of robot-assisted surgery is likely to equal or surpass the alternatives.

Lymphadenectomy, obesity and open surgery are associated with surgical complications in endometrial cancer

OBJECTIVE

To investigate surgical complications related to the staging procedure for endometrial cancer (EC) and to explore complication associations towards patient characteristics and survival.

METHODS

A population-based cohort study of women diagnosed with EC where primary surgery was performed at a tertiary centre between 2012 and 2016. The Swedish Quality Registry for Gynecological Cancer was used for identification, medical records reviewed and surgical outcomes, including complications according to Clavien-Dindo (CD), and comorbidity (Charlson's index) registered. Uni- and multivariable logistic regression analyses were performed with complications as outcome and multivariable Cox regression analysis with overall survival (OS) as endpoint.

RESULTS

In total 549 women were identified where 108 (19.7%) had CD grade II-V complications. In the multivariable regression analysis; surgical technique, BMI and lymph node dissection, but not comorbidity or age, were found to be risk factors for complications CD grade II-V, with OR of 0.32 (95%CI:0.18-0.56) for minimalinvasive surgery (MIS) compared to open, OR 2.18 (95%CI:1.37-3.49) for BMI ≥30 and OR 2.63 (95%CI:1.32-5.31) for pelvic and paraaortic lymphnode dissection. In Cox regression analysis, a significant lower OS was found within the first 1.5 years for the cohort of complications (CD II-V) compared to no complications.

CONCLUSION

Surgical staging with lymphadenectomy was found a risk factor for complications together with high BMI in EC. Using MIS was significantly associated with less complications. Overall survival was found to be negatively affected within the first years after complications. Our results may be taken into consideration when performing updated treatment guidelines including surgical staging.

Risk factors for lymphatic complications following lymphadenectomy in patients with endometrial cancer

OBJECTIVE

Lymph node (LN) metastasis is among the important prognostic factors for survival in endometrial cancer (EC). This study aimed to evaluate the occurrence of lymphatic complications following lymphadenectomy in patients with EC.

MATERIALS AND METHODS

EC patients were retrospectively evaluated. Lower extremity lymphedema (LEL) and pelvic lymphocele (PL) were evaluated according to the International Society of Lymphology guidelines and the National Cancer Institute Common Terminology Criteria for Adverse Events, respectively.

RESULTS

A total of 289 patients were enrolled. Surgery was performed via laparotomy and laparoscopy in 200 (69.2%) and 89 (30.8%) patients, respectively. LEL and PL occurred in 43 (14.9%) and 33 (11.4%) patients, respectively. In multivariate logistic regression analysis, circumflex iliac node (CIN) removal (odds ratio [OR]: 3.22; 95% CI: 1.43-7.98; P = 0.004) was an independent risk factor for LEL, while the surgical approach (OR: 4.46; 95% CI: 1.13-29.9; P = 0.004) was an independent risk factor for PL.

CONCLUSION

CIN dissection was a significant risk factor for LEL, while laparotomy was an independent risk factor for PL compared to laparoscopy in EC patients. This suggests that laparoscopic surgery combined with sentinel lymph node navigation surgery will prevent lymphatic complications in low-risk EC patients.

Surgical outcomes of conventional laparoscopic and robotic-assisted hysterectomy

INTRODUCTION

The aim of the present study was to compare surgical outcomes of total laparoscopic hysterectomy with those of the robotic approach using the da Vinci Xi system.

METHODS

Patients who underwent hysterectomy with da Vinci Xi for early endometrial cancer or benign indications from 2018 to 2019 were selected. The control group consisted of patients who underwent conventional laparoscopy.

RESULTS

A total of 300 patients were included in the study. The mean duration of surgery differed significantly (p = 0.025) between those who underwent laparoscopy (125.01 ± 76.168) and robotic-assisted surgery (142.96 ± 82.657 min). Blood loss, median hospital stay, intraoperative and postoperative complications were similar in both groups. No statistical difference was observed in the subgroups with a body mass index of more than 30 kg/m² or more than 40 kg/m² concerning the duration of surgery or the surgical outcome.

CONCLUSION

The da Vinci Xi did not improve surgical outcomes in patients who underwent hysterectomy by trained laparoscopists and takes more time than conventional laparoscopy when performed in patients of normal weight.

Lymphedema secondary to melanoma treatments: diagnosis, evaluation, and treatments

Approximately 300,000 new cases of melanoma are annually diagnosed in the world. Advanced stage melanomas require sentinel lymph node biopsy (SLNB), sometimes lymph node dissections (LND). The development rate of lower extremity lymphedema ranges from 7.6% to 35.1% after inguinal SLNB, and from 48.8% to 82.5% after inguinal LND. Development rate of upper extremity lymphedema ranges from 4.4% to 14.6% after axillary LND. Lymphedema management has constantly improved but effective evaluation and surgical management such as supermicrosurgical lymphaticovenular anastomosis (LVA) are becoming common as minimally invasive lymphatic surgery. Diagnosis and new classification using indocyanine green lymphography allowing pre-clinical secondary lymphedema stage management are improving effectiveness of supermicrosurgical LVA and vascularized lymph node transfer. Lymphatic transfer with lymph-interpositional-flap can restore lymph flow after large oncologic excision even without performing lymphatic anastomosis. Since lymphatic reconstructive surgery may affect local to systemic dissemination of remnant tumor cells, careful consideration is required to evaluate indication of surgical treatments.

Incidence of lymphedema in the lower limbs and lymphocyst formation within one year of surgery for endometrial cancer: A prospective longitudinal multicenter study

OBJECTIVE

The study aimed to determine the incidence of lower limb lymphedema (LLL) after surgery for endometrial cancer (EC) by means of three methods, and to determine the incidence of lymphocysts after one year.

METHODS

A prospective longitudinal multicenter study was conducted in 14 hospitals in Sweden. Two-hundred-and-thirty-five women with EC were included; 116 underwent surgery that included lymphadenectomy (+LA) and 119 were without lymphadenectomy (-LA). Lymphedema was assessed objectively on four occasions; preoperatively, at 4-6 weeks, six months and one year postoperatively using systematic measurement of leg circumferences, enabling calculation of leg volumes, and a clinical grading of LLL, and subjectively by the patient's perception of lymphedema measured by a lymphedema-specific quality-of-life instrument. Lymphocyst was evaluated by vaginal ultrasonography.

RESULTS

After one year the incidence of LLL after increase in leg volume adjusted for body mass index was 15.8% in +LA women and 3.4% in -LA women. The corresponding figures for clinical grading were 24.1% and 11.8%, and for patient-reported perceived LLL 10.7% and 5.1%. The agreement between the modalities revealed fair to moderate correlation between patient-reported LLL and clinical grading, but poor agreement between volume increase and patient-reported LLL or clinical grading. Lymphocysts were found in 4.3% after one year.

CONCLUSIONS

Although the incidence of LLL and lymphocysts after surgery for EC including LA seemed to be relatively high the study demonstrated significant variations in incidence depending on the measurement modality. This emphasizes the need for a 'gold standard' of measurement of LLL in clinical practice and research.

Robotic Surgery in Gynecology

The robotic-assisted laparoscopic surgical approach has improved complex gynecologic surgeries. It has the advantages of excellent visualization through the high-resolution 3-dimensional view, a wrist-like motion of the robotic arms and improved ergonomics. Similar to conventional laparoscopic surgeries, it is associated with a decrease in long-term surgical morbidity, early recovery and return to work, and improved esthetics. We discuss preoperative planning, surgical techniques, and some of the latest clinical results of robotic-assisted laparoscopic gynecologic surgery.