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Bayer A, Heinze T, Alkatout I, Osmonov D, Stelzner S, Wedel T. Embryological Development and Topographic Anatomy of Pelvic Compartments-Surgical Relevance for Pelvic Lymphonodectomy. J Clin Med 2021; 10:jcm10040708. [PMID: 33670197 PMCID: PMC7916954 DOI: 10.3390/jcm10040708] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 01/03/2023] Open
Abstract
Background: The oncological outcome of surgery for the treatment of pelvic malignancies can be improved by performing pelvic lymphonodectomy. However, the extent and regions of lymph node harvest are debated and require profound knowledge of anatomy in order to avoid collateral damage. Methods: The embryological development and topographic anatomy of pelvic compartments in relation to pelvic lymphonodectomy for rectal, uterine, and prostate cancer are reviewed. Based on pre-dissected anatomical specimens, lymph node regions and drainage routes of the posterior and urogenital pelvic compartments are described in both genders. Anatomical landmarks are highlighted to identify structures at risk of injury during pelvic lymphonodectomy. Results: The ontogenesis of urogenital and anorectal compartments and their lymphatic supply are key factors for adequate lymphonodectomy, and have led to compartment-based surgical resection strategies. However, pelvic lymphonodectomy bears the risk of injury to somatic and autonomic nerves, vessels, and organs, depending on the regions and extent of surgery. Conclusion: Embryologically defined, compartment-based resection of pelvic malignancies and their lymphatic drainage routes are based on clearly delineated anatomical landmarks, which permit template-oriented pelvic lymphonodectomy. Comprehensive knowledge of pelvic anatomy, the exchange of surgical concepts between specialties, and minimally invasive techniques will optimize pelvic lymphonodectomy and reduce complications.
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Affiliation(s)
- Andreas Bayer
- Kurt Semm Center for Minimally Invasive and Robotic Surgery, Center of Clinical Anatomy, Institute of Anatomy, Kiel University, 24098 Kiel, Germany; (A.B.); (T.H.)
| | - Tillmann Heinze
- Kurt Semm Center for Minimally Invasive and Robotic Surgery, Center of Clinical Anatomy, Institute of Anatomy, Kiel University, 24098 Kiel, Germany; (A.B.); (T.H.)
| | - Ibrahim Alkatout
- Kurt Semm Center for Minimally Invasive and Robotic Surgery, Department of Obstetrics and Gynecology, Campus Kiel, University Hospital Schleswig Holstein, 24105 Kiel, Germany
- Correspondence: (I.A.); (T.W.); Tel.: +49-431-500-21450 (I.A.); +49-431-880-2489 (T.W.)
| | - Daniar Osmonov
- Kurt Semm Center for Minimally Invasive and Robotic Surgery, Department of Urology, Campus Kiel, University Hospital Schleswig Holstein, 24105 Kiel, Germany;
| | - Sigmar Stelzner
- Department of General Surgery, Hospital Dresden-Friedrichstadt, 01067 Dresden, Germany;
| | - Thilo Wedel
- Kurt Semm Center for Minimally Invasive and Robotic Surgery, Center of Clinical Anatomy, Institute of Anatomy, Kiel University, 24098 Kiel, Germany; (A.B.); (T.H.)
- Correspondence: (I.A.); (T.W.); Tel.: +49-431-500-21450 (I.A.); +49-431-880-2489 (T.W.)
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Raspagliesi F, Bogani G. Radical surgery for cervical cancer. Lancet Oncol 2019; 20:1198-1199. [PMID: 31383546 DOI: 10.1016/s1470-2045(19)30409-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 06/06/2019] [Accepted: 06/07/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Francesco Raspagliesi
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan 20133, Italy.
| | - Giorgio Bogani
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan 20133, Italy
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Alkatout İ, Holthaus B. Congress report of the 23 rd AGE annual meeting from 26 th - 28 th April 2018 in Hamburg. J Turk Ger Gynecol Assoc 2018; 19:176-181. [PMID: 29983405 PMCID: PMC6085521 DOI: 10.4274/jtgga.2018.0076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The Study Group of Gynecological Endoscopy (AGE) has a growing number of members each year. This is an acknowledgment as well as a challenge for the study group. The challenges were faced in the form of exemplary cooperative work by the core members of AGE, the Velen Study Group for Ambulant Surgery (VAAO), the Foundation of Endometriosis Research (SEF), the Study Group of Urogynecology and Plastic Pelvic Floor Reconstruction (AGUB), the Study Group for Robotic-assisted Surgery in Gynecology (ARCGyn), and the Study Group of Gynecological Oncology (AGO). More than 1500 AGE members have been able to create significant effects preemptively by designing a Congress program that was prepared interactively. The program of live surgery was designed in the course of two days on the basis of an online inquiry. The first transmission of laparoscopy on a body donor and anatomic demonstrations on formalin-fixed specimens were especially significant in this context. Sessions of general gynecology, including myoma therapy, endometriosis and infertility treatment, and gynecologic oncology and urogynecology covered the entire spectrum of minimally invasive surgical techniques. Individual topics were addressed in specific courses. The Congress was preceded by an optional certified basic course (MIC I) of the AGE. Far more than 500 congress attendees from all German-speaking countries were spirited away to a paramedical steep face, which was ascended together with a renowned German extreme climber. The keynote lecture was especially impressive and held by the pioneer and founder of the neuropelveology. The world’s leading expert in this field described the responsibilities of our specialty in a visionary manner and motivated all of the listeners strongly in regard of their actions and efforts.
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Affiliation(s)
- İbrahim Alkatout
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Bernd Holthaus
- Clinic of Obstetrics and Gynecology, St. Elisabeth Hospital, Damme, Germany
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Kimmig R, Ind T. Minimally invasive surgery for cervical cancer: consequences for treatment after LACC Study. J Gynecol Oncol 2018; 29:e75. [PMID: 29770634 PMCID: PMC5981116 DOI: 10.3802/jgo.2018.29.e75] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/02/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Rainer Kimmig
- Department of Obstetrics and Gynaecology, West German Cancer Center, University Hospital of Essen, Essen, Germany.
| | - Thomas Ind
- Department of Gynaecological Oncology, Royal Marsden Hospital, London, UK.,St. George's University of London, London, UK
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Self-Reported Long-Term Autonomic Function After Laparoscopic Total Mesometrial Resection for Early-Stage Cervical Cancer: A Multicentric Study. Int J Gynecol Cancer 2017; 27:1501-1507. [PMID: 28708791 DOI: 10.1097/igc.0000000000001045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES This multicentric retrospective study investigates the early and long-term self-reported urinary, bowel, and sexual dysfunctions in early-stage cervical cancer patients who submitted to laparoscopic total mesometrial resection (L-TMMR), total laparoscopic radical hysterectomy, vaginal-assisted laparoscopic radical hysterectomy, and laparoscopic-assisted radical vaginal hysterectomy. METHODS Cervical cancer patients, FIGO (International Federation of Gynecology and Obstetrics) stage IA2-IB1/IIA1 who submitted to nerve-sparing radical hysterectomy were recruited. Pelvic functions were assessed within 30 days (early outcome) and 12 months after surgery (long-term outcome). RESULTS Two hundred thirteen subjects receiving nerve-sparing radical hysterectomy were enrolled. Laparoscopic total mesometrial resection was performed in 46 patients (21.6%), total laparoscopic radical hysterectomy in 65 patients (30.5%), vaginal-assisted laparoscopic radical hysterectomy in 54 patients (25.4%), and laparoscopic-assisted radical vaginal hysterectomy in 48 women (22.5%). Operative time was significantly lower in the L-TMMR group (240 minutes; range, 120-670 minutes; P = 0.001). The overall perioperative complication rate was 11.3%, with no statistically significant differences among the 4 groups. Stress incontinence and sensation of bladder incomplete emptying were detected, respectively, in 54 patients (25.6%) and 65 patients (30.7%) with a significantly lower prevalence among those in the L-TMMR group, which resulted, respectively, in 11.1% (P = 0.022) and 13.3% (P = 0.036). The prevalence rates of constipation, sensation of incomplete bowel emptying, and effort during evacuation were significantly higher among those in the L-TMMR group, resulting in, respectively, 37% (P = 0.001), 42.3% (P = 0.012), and 50% (P = 0.039). One hundred forty-nine patients (70%) were sexually active. Fifty-eight women (38.9%) reported low enjoyment, 83 women (55.7%) medium enjoyment, and 8 women (5.4%) reported high enjoyment, without statistically significant differences among the 4 groups. CONCLUSIONS Laparoscopic total mesometrial resection is associated with improved long-term urinary autonomic functions and worse gastrointestinal autonomic outcome. Further larger prospective trials are needed to evaluate both the oncological and functional outcomes in order to establish the most appropriate surgical approach for early-stage cervical cancer patients.
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Picerno T, Sloan NL, Escobar P, Ramirez PT. Bowel injury in robotic gynecologic surgery: risk factors and management options. A systematic review. Am J Obstet Gynecol 2017; 216:10-26. [PMID: 27640938 DOI: 10.1016/j.ajog.2016.08.040] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/22/2016] [Accepted: 08/31/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to analyze the published literature on bowel injuries in patients undergoing gynecologic robotic surgery with the aim to determine its incidence, predisposing factors, and treatment options. DATA SOURCES Studies included in this analysis were identified by searching PubMed Central, OVID Medline, EMBASE, Cochrane, and ClinicalTrials.gov databases. References for all studies were also reviewed. Time frame for data analysis spanned from November 2001 through December 2014. STUDY ELIGIBILITY CRITERIA All English-language studies reporting the incidence of bowel injury or complications during robotic gynecologic surgery were included. Studies with data duplication, not in English, case reports, or studies that did not explicitly define bowel injury incidence were excluded. STUDY APPRAISAL AND SYNTHESIS METHODS The Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies were used to complete the systematic review with the exception of scoring study quality and a single primary reviewer. RESULTS In all, 370 full-text articles were reviewed and 144 met the inclusion criteria. There were 84 bowel injuries recorded in 13,444 patients for an incidence of 1 in 160 (0.62%; 95% confidence interval, 0.50-0.76%). There were no significant differences in incidence of bowel injury by procedure type. The anatomic location of injury, etiology, and management were rarely reported. Of the bowel injuries, 87% were recognized intraoperatively and the majority (58%) managed via a minimally invasive approach. Of 13,444 patients, 3 (0.02%) (95% confidence interval, 0.01-0.07%) died in the immediate postoperative period and no deaths were a result of a bowel injury. CONCLUSION The overall incidence of bowel injury in robotic-assisted gynecologic surgery is 1 in 160. When the location of bowel injuries were specified, they most commonly occurred in the colon and rectum and most were managed via a minimally invasive approach.
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Alkatout I, Mettler L, Maass N, Ackermann J. Robotic surgery in gynecology. J Turk Ger Gynecol Assoc 2016; 17:224-232. [PMID: 27990092 DOI: 10.5152/jtgga.2016.16187] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/27/2016] [Indexed: 01/24/2023] Open
Abstract
Robotic surgery is the most dynamic development in the sector of minimally invasive operations currently. It should not be viewed as an alternative to laparoscopy, but as the next step in a process of technological evolution. The advancement of robotic surgery, in terms of the introduction of the Da Vinci Xi, permits the variable use of optical devices in all four trocars. Due to the new geometry of the "patient cart," an operation can be performed in all spatial directions without re-docking. Longer instruments and the markedly narrower mechanical elements of the "patient cart" provide greater flexibility as well as access similar to those of traditional laparoscopy. Currently, robotic surgery is used for a variety of indications in the treatment of benign gynecological diseases as well as malignant ones. Interdisciplinary cooperation and cooperation over large geographical distances have been rendered possible by telemedicine, and will ensure comprehensive patient care in the future by highly specialized surgery teams. In addition, the second operation console and the operation simulator constitute a new dimension in advanced surgical training. The disadvantages of robotic surgery remain the high costs of acquisition and maintenance as well as the laborious training of medical personnel before they are confident with using the technology.
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Affiliation(s)
- Ibrahim Alkatout
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Liselotte Mettler
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Nicolai Maass
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Johannes Ackermann
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Robotically assisted peritoneal mesometrial resection (PMMR) in endometrial cancer supported by ICG labeling of the compartmental lymphatic system. Gynecol Oncol Rep 2016; 16:24. [PMID: 27331131 PMCID: PMC4899481 DOI: 10.1016/j.gore.2016.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 03/14/2016] [Accepted: 03/15/2016] [Indexed: 12/18/2022] Open
Abstract
Peritoneal mesometrial resection is a compartment based radical hysterectomy in endometrial cancer ICG staining of the lymph-vessel system facilitates identification of compartment borders Fluorescence based HD-video documentation supports education in surgery of endometrial cancer
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Robotic Compartment-Based Radical Surgery in Early-Stage Cervical Cancer. Case Rep Surg 2016; 2016:4616343. [PMID: 27195167 PMCID: PMC4852353 DOI: 10.1155/2016/4616343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 03/26/2016] [Accepted: 04/03/2016] [Indexed: 11/18/2022] Open
Abstract
A radical hysterectomy with pelvic lymphadenectomy is the recommended treatment option in patients with early-stage cervical cancer. Although various classifications were developed in order to define the resection margins of this operation, no clear standardization could be achieved both in the nomenclature and in the extent of the surgery. Total mesometrial resection (TMMR) is a novel procedure which aims to remove all components of the compartment formed by Müllerian duct in which female reproductive organs develop. TMMR differs from the conventional radical hysterectomy techniques in that its surgical philosophy, terminology, and partly resection borders are different. In this paper, a TMMR with therapeutic pelvic lymphadenectomy operation that we performed for the first time with robot-assisted laparoscopic (robotic) approach in an early-stage cervical cancer patient was presented. This procedure has already been described in open surgery by Michael Höckel and translated to the robotic surgery by Rainer Kimmig. Our report is the second paper, to our knowledge, to present the initial experience regarding robotic TMMR in the English literature.
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Kimmig R, Aktas B, Buderath P, Rusch P, Heubner M. Intraoperative navigation in robotically assisted compartmental surgery of uterine cancer by visualisation of embryologically derived lymphatic networks with indocyanine-green (ICG). J Surg Oncol 2016; 113:554-9. [PMID: 26792025 PMCID: PMC6221053 DOI: 10.1002/jso.24174] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/06/2016] [Indexed: 01/27/2023]
Abstract
Background and Objectives To evaluate feasibility of intraoperative visualization of embryologically defined organ compartments and their drainage by ICG in uterine cancer. Methods Total of 2.5 mg of ICG have been injected into cervix or corpus in uterine cancer patients immediately prior to surgery. Green fluorescence was intermittently detected during robotically assisted laparoscopic surgery (Firefly System®, Intuitve Surgical Inc.). Total of 36 patients with uterine cancer without macroscopically suspicious nodes were evaluated with respect to their compartmental lymphatic network, collecting lymphatic vessels, and the connection to the postponed lymph basins. Results Müllerian (sub) compartment and transport of lymph fluid along the lymphatic collectors and connecting vessels to the postponed lymph basins could be visualized invariably in all patients. Cervix drained along the ligamentous and caudal part of vascular mesometria, whereas midcorporal and fundal drainage occurred along the upper part of vascular mesometria and along the mesonephric pathway along the ovarian vessels. Conclusions Visualization of lymphatic network and downstream flow of lymphatic fluid to the postponed lymph basins by ICG is feasible; it can be used to navigate along compartment boarders for education, intraoperative orientation, and quality control. It seems to confirm the compartmental order of pelvic organ systems and postponed lymph basins. J. Surg. Oncol. 2016;113:554–559. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Rainer Kimmig
- Department of Gynecology and Obstetrics, West-German Tumor Center, University of Duisburg-Essen, Essen, Germany
| | - Bahriye Aktas
- Department of Gynecology and Obstetrics, West-German Tumor Center, University of Duisburg-Essen, Essen, Germany
| | - Paul Buderath
- Department of Gynecology and Obstetrics, West-German Tumor Center, University of Duisburg-Essen, Essen, Germany
| | - Peter Rusch
- Department of Gynecology and Obstetrics, West-German Tumor Center, University of Duisburg-Essen, Essen, Germany
| | - Martin Heubner
- Department of Gynecology and Obstetrics, West-German Tumor Center, University of Duisburg-Essen, Essen, Germany
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Höckel M. Long-Term Experience with (Laterally) Extended Endopelvic Resection (LEER) in Relapsed Pelvic Malignancies. Curr Oncol Rep 2015; 17:435. [DOI: 10.1007/s11912-014-0435-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Müller S, Grønning LE, Nilsen FS, Mygland V, Patel HRH. Robotic and minimal access surgery: technology and surgical outcomes of radical prostatectomy for prostate cancer. Expert Rev Anticancer Ther 2014; 14:1317-21. [PMID: 25266367 DOI: 10.1586/14737140.2014.965689] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since the 1990s, minimal access surgery has been utilized in urology. In the past 15 years, robotic surgery has evolved and become a natural part of minimal access surgery. The dissemination has been fast and the opportunity of prospective trials has been missed. Nevertheless, robotic surgery has obvious benefits for the surgeon and patient. Even though the scientific evidence is not strong, robotic surgery is here to stay. However, there are lessons to learn from the implementation of the da Vinci system with regards to patient safety and prospective evaluation of the new technology. The future of surgery will include technologies derived from robotic surgery.
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Affiliation(s)
- Stig Müller
- Department of Urology, Akershus University Hospital, Sykehusveien 23, Lørenskog 1478, Norway
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Kimmig R, Aktas B, Buderath P, Wimberger P, Iannaccone A, Heubner M. Definition of compartment-based radical surgery in uterine cancer: modified radical hysterectomy in intermediate/high-risk endometrial cancer using peritoneal mesometrial resection (PMMR) by M Höckel translated to robotic surgery. World J Surg Oncol 2013; 11:198. [PMID: 23947937 PMCID: PMC3751733 DOI: 10.1186/1477-7819-11-198] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 08/01/2013] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The technique of compartment-based radical hysterectomy was originally described by M Höckel as total mesometrial resection (TMMR) for standard treatment of stage I and II cervical cancer. However, with regard to the ontogenetically-defined compartments of tumor development (Müllerian) and lymph drainage (Müllerian and mesonephric), compartments at risk may also be defined consistently in endometrial cancer. This is the first report in the literature on the compartment-based surgical approach to endometrial cancer. Peritoneal mesometrial resection (PMMR) with therapeutic lymphadenectomy (tLNE) as an ontogenetic, compartment-based oncologic surgery could be beneficial for patients in terms of surgical radicalness as well as complication rates; it can be standardized for compartment-confined tumors. Supported by M Höckel, PMMR was translated to robotic surgery (rPMMR) and described step-by-step in comparison to robotic TMMR (rTMMR). METHODS Patients (n = 42) were treated by rPMMR (n = 39) or extrafascial simple hysterectomy (n = 3) with/without bilateral pelvic and/or periaortic robotic therapeutic lymphadenectomy (rtLNE) for stage I to III endometrial cancer, according to International Federation of Gynecology and Obstetrics (FIGO) classification. Tumors were classified as intermediate/high-risk in 22 out of 40 patients (55%) and low-risk in 18 out of 40 patients (45%), and two patients showed other uterine malignancies. In 11 patients, no adjuvant external radiotherapy was performed, but chemotherapy was applied. RESULTS No transition to open surgery was necessary. There were no intraoperative complications. The postoperative complication rate was 12% with venous thromboses, (n = 2), infected pelvic lymph cyst (n = 1), transient aphasia (n = 1) and transient dysfunction of micturition (n = 1). The mean difference in perioperative hemoglobin concentrations was 2.4 g/dL (± 1.2 g/dL) and one patient (2.4%) required transfusion. During follow-up (median 17 months), one patient experienced distant recurrence and one patient distant/regional recurrence of endometrial cancer (4.8%), but none developed isolated locoregional recurrence. There were two deaths from endometrial cancer during the observation period (4.8%). CONCLUSIONS We conclude that rPMMR and rtLNE are feasible and safe with regard to perioperative morbidity, thus, it seems promising for the treatment of intermediate/high-risk endometrial cancer in terms of surgical radicalness and complication rates. This could be particularly beneficial for morbidly obese and seriously ill patients.
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