Robotic-assisted transperitoneal aortic lymphadenectomy as part of staging procedure for gynaecological malignancies: single institution experience

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.

Role of robotic surgery in ovarian malignancy

As part of minimally invasive surgery, robotic-assisted approach is becoming increasingly popular in gynecologic oncology. It has been shown to be effective and feasible for staging and treating endometrial and cervical cancer, but its role in the context of primary and recurrent ovarian cancers is presently debated. Scanty data are available in the literature, and the level of evidence supporting its use in ovarian cancer is quite low. However, from a retrospective case-control series, robotic surgery seems to be safe and feasible for early-stage ovarian cancer. Its use in treating patients with advanced-stage or relapsed ovarian cancer is still highly controversial, suggesting the choice of robotic approach in a highly selected population.

Laparoscopic technique of para-aortic lymph node dissection: A comparison of the different approaches to trans- versus extraperitoneal para-aortic lymphadenectomy

Since Dr Dargent first reported endoscopic surgery using retroperitoneal pelvicoscopy to perform pelvic lymph node sampling in 1987, many literature reviews on the safety and feasibility of laparoscopic staging surgery of gynecologic malignancies have been published. However, the procedure of laparoscopic lymphadenectomy is more difficult to perform due to the limited surgical space and associated technical problems. Especially in the para-aortic lymphadenectomy procedure, there are many barriers to overcome in the surgical field, learning curve, and technique. We present a review of lymphadenectomy, especially para-aortic lymphadenectomy.

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).

Robotic surgery for ovarian cancers: individualization of the surgical approach to select ovarian cancer patients

BACKGROUND

While well-accepted treatment for endometrial and cervical cancers, the role of robotic surgery in the management of primary and recurrent ovarian cancers remains an area of active study and debate.

METHODS

Narrative review of the pertinent literature on the use of robotics in the treatment of ovarian cancers.

RESULTS

The available evidence may indicate the feasibility of robotics for primary and secondary debulking of ovarian cancers. The use of robotics can be considered for the surgical treatment of patients requiring primary tumour excision, alone or with one additional major procedure, and patients with isolated recurrences. However, most of the publications are underpowered, retrospective, fail to provide sufficient data on long-term oncological outcomes and are published by highly skilled minimally invasive surgeons.

CONCLUSIONS

Robot-assisted surgery may provide a tool to individualize the surgical approach to select ovarian cancer patients. Copyright © 2015 John Wiley & Sons, Ltd.

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

OBJECTIVES

To assess the clinical performance of robotic-assisted infra-renal aortic lymphadenectomy (IRL) using a single center-docked approach for patients with endometrial cancer.

METHODS

Robotic-assisted hysterectomy with pelvic and aortic lymphadenectomy was performed in 97 clinical stage I endometrial cancer (EC) patients with the intent to remove infra-renal aortic lymph nodes. Peri-operative data was contemporaneously accessioned and a retrospective database analysis was performed to examine clinical outcomes.

RESULTS

IRL versus infra-mesenteric artery (IMA) dissections were accomplished in 88 (90.7%) and nine (9.3%) cases, respectively. There were no laparotomy conversions. Histology included 20.6% G1, 41.2% G2, and 38.1% G3 (endometrioid and Type II histologies). Forty-four (45.4%) cases had >50% depth-of-invasion and 43 (44.3%) cases had lymphovascular space invasion. Lymph node metastases were detected in 39 (40.2%) cases [37 (38.1%) pelvic, 16 (16.5%) pelvic+aortic, two (2.1%) isolated aortic lymph nodes]. Aortic metastasis was identified in 16/37 (43.2%) pelvic node positive cases, and 6/34 (17.7%) IRL cases with positive pelvic nodes had infra-renal metastasis, yet normal aortic nodes below the IMA. Harvested aortic lymph nodes for IRL exceeded IMA cases (15.9±6.3 vs. 8.9±4.6; p<0.01). Mean BMI for IMA cases exceeded IRL cases (37.4±3.3 vs. 31.4±7.1kg/m(2); p<0.001). Twenty-five (81%) patients with BMI >35kg/m(2) underwent successful IRL (range 36-47kg/m(2)) compared to 95% of cases <35kg/m(2) (p=0.03).

CONCLUSIONS

IRL was accomplished in 95% of EC patients with BMI <35kg/m(2) and 81% with BMI >35kg/m(2) using a single center-docked approach. A strict 35kg/m(2) BMI cut-off for avoiding IRL is therefore not advised.