Feasibility of sentinel lymph node fluorescence detection during robotic laparoendoscopic single-site surgery in early endometrial cancer: a prospective case series

Sentinel lymph node biopsy at robotic-assisted hysterectomy for atypical hyperplasia and endometrial cancer

Lymph node (LN) evaluation in endometrial cancer is controversial. Sentinel lymph node biopsy (SLNB) allows for an accurate nodal assessment while minimising the risks of a full pelvic lymph node dissection (PLND). The aims of this study are to examine the characteristics and peri-operative outcomes of women with atypical hyperplasia (AH) or endometrial cancer undergoing robotic-assisted hysterectomy (RAH) ± SLNB or PLND; to examine the utilisation, feasibility and role of SLNB and compare their peri-operative outcomes. Retrospective cohort study from December 2018 to February 2021 of women who underwent RAH ± LN assessment for endometrial cancer or AH. 115 women underwent RAH. 59% had SLNB, 29% had no LN assessment, and 12% had PLND. The final diagnosis was mostly early stage low-grade disease; Stage 1A-50%, Grade 1 endometrioid adenocarcinoma (EAC)-56%. The detection rate was 90%. There was a statistically significant trend towards performing SLNB over time (P value 0.004). There was a statistically shorter length of stay, less estimated blood loss, and shorter surgical duration in the SLNB cohort, compared to the no LN assessment cohort (P values 0.02, 0.01, and 0.03, respectively). There was statistically significant less estimated blood loss and surgical duration in the SLNB compared to the PLND cohort (P values 0.03 and 0.001, respectively). SLNB at RAH was utilised and feasible. It was safe with a low complication rate and had advantages compared to PLND cohort. SLNB should be considered in suitable selected women undergoing surgery for endometrial cancer or AH.

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

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

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

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

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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)

Ultra-minimally invasive approaches for endometrial cancer treatment: review of the literature

INTRODUCTION

We conducted a systematic review to evaluate the outcomes and role of ultra-minimally invasive surgical approaches for treatment of women diagnosed with endometrial cancer. Although, there is no agreed definition of the term "ultraminimal," we considered the hysteroscopic surgery, single-port surgery, mini/microlaparoscopy and percutaneous laparoscopy as surgical approaches that would best fit this description.

EVIDENCE ACQUISITION

The current systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines. We performed a literature search using MEDLINE (PubMed), EMBASE and Cochrane Library databases for English-language studies published before August 1, 2020. We used the following keywords including "endometrial cancer," "endometrial malignancy," "fertility-sparing or preserving," "hysteroscopy," "hysteroscopic resection," "dilatation and curettage," "ultra-minimally invasive surgery," "progestin therapy," "hormone therapy," "single port," "single-site," "minilaparoscopy," "microlaparoscopy," "percutaneous" and "3 mm laparoscopy."

EVIDENCE SYNTHESIS

A total of 21 studies, reporting on 229 patients were included. 219 (95.6%) of the patients were premenopausal. Among premenopausal women, complete disease response was reported in 186 (84.9%) patients. The complete response rate was 77.1% in patients who underwent focal or extensive endometrial resection, 90.9% in patients who had the two-step approach and 88.9% in the group of patients treated with the three-step technique. Among 98 women who wished and attempted to conceive, 65 (66.3%) women became pregnant. Recurrent disease was diagnosed in 26 of 219 (11.9%) patients. No surgical complications were reported. In 10 postmenopausal patients that underwent hysteroscopic resection, no recurrences were detected after 5 years of follow-up. We identified 11 studies that reported on the use single-port laparoscopic surgery and included a total of 447 patients. The rate of intraoperative and postoperative complications was 2.6% and 5.2%, respectively. The majority of the studies did not report on the duration of follow-up or oncological outcomes. Ten studies, including 296 patients, investigated the role of single-port robotic-assisted laparoscopy. The overall rate of intraoperative and postoperative complications was 1.0% and 7.1%, respectively. Two studies, including 38 patients, reported on the role of minilaparoscopy. None of these cases required conversion to laparotomy. Data on overall survival in the cohort of patients that underwent minilaparoscopy were not reported. We found only one publication reporting on the use of percutaneous laparoscopy. This prospective study included 30 patients. No complication was reported, and with a median follow-up time of 14 months (range 12-36) no recurrences were diagnosed.

CONCLUSIONS

Several ultra-minimally invasive surgical techniques have been developed and implemented in selected patients with endometrial cancer. The results of this review support the feasibility and perioperative safety of these approaches, while long-term outcomes are not adequately studied. However, further work is required in standardization of the techniques, in determining the learning curve of the operator and establishing their oncological safety.

Evaluation of quality of life, body image and surgical outcomes of robotic total laparoscopic hysterectomy and sentinel lymph node mapping in low-risk endometrial cancer patients - A Robotic Gyne Club study

INTRODUCTION

The aims of the study were to evaluate quality of life, cosmetic results and surgical outcomes of robotic single-site and robotic multiport total laparoscopic hysterectomy with sentinel lymph node mapping in women treated for low-risk endometrial cancer.

MATERIAL AND METHODS

The study is a prospective, multicenter, case-control study conducted at Ospedale Santa Chiara in Trento and Novara and Pavia University Hospitals. Seventy-six consecutive patients with a biopsy-confirmed diagnosis of low-risk endometrial cancer or atypical endometrial hyperplasia who between January 2017 and January 2019 had undergone robotic total laparoscopic hysterectomy and sentinel lymph node mapping were included. Data on surgical outcomes, quality of life and cosmetic results were prospectively collected and analyzed based on the surgical approach with robotic single-site vs robotic multiport assistance. Patients' clinical characteristics, intra-operative parameters, sentinel lymph node mapping results and postoperative findings were prospectively recorded. Clinical follow up was performed 4 weeks and 6 and 12 months after surgery. Fifty-one patients underwent a robotic multiport procedure and 25 patients a robotic single-site surgery.

RESULTS

There was one significant difference between the two groups in terms of patient characteristics: mean body mass index (BMI) in the multiport group was 29 kg/m² vs 24.8 kg/m² in the single-site group (P value <.001). After univariate and multivariate analysis on intraoperative and postoperative findings, a shorter surgical time was observed in the single-site cohort than in the multiport group (148.7 vs 158.2 minutes, P value .0182). BMI also had a significant effect on surgical time (P = .022). No differences were seen in terms of sentinel lymph node detection: the bilateral detection rate was 96.1% for multiport (66.7% bilateral, 29.4% monolateral) and 96% for single-site (76% bilateral, 20% monolateral) procedures. No differences between the two approaches were identified with regard to postoperative complications, pain, cosmetic results or quality of life comparisons.

CONCLUSIONS

For the treatment of low-risk endometrial cancer and atypical endometrial hyperplasia with total hysterectomy and sentinel lymph node mapping, the robotic single-port approach is comparable to the multiport procedure in terms of intraoperative and postoperative findings, and has an advantage in terms of shorter surgical times. Further studies are required to identify possible differences in quality of life and cosmetic results.