Median Number Of Para-aortic Nodes Research Articles

Dual docking robotic surgical staging for high risk endometrial cancer

ObjectiveThe standard of care for patients with high intermediate and high risk endometrial cancer is surgical staging including total hysterectomy with bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomy. Over the past decade, laparoscopic or robot-assisted minimally invasive surgery has showed many benefits in the management of endometrial cancer. Few studies have specifically assessed the use of minimally invasive surgery for staging of high risk endometrial cancer. The objective of this study was to evaluate the feasibility, the morbidity and oncologic outcomes of dual docking robot-assisted surgical staging of high risk endometrial cancer. MethodsWe conducted a retrospective observational study from January 2014 to March 2016 in patients with high risk endometrial cancer who underwent dual docking robotic hysterectomy with pelvic and paraaortic lymphadenectomy (± omentectomy). Patients' demographics, operative time, conversion rate, intra and postoperative complications, pathologic results, length of stay and survival were analyzed. ResultsTwenty patients met the inclusion criteria. Staging surgical procedure was performed robotically with a dual docking in 18 patients. Two patients were converted to laparotomy (1 for bladder extension, 1 for exposure reasons) and no patient had a laparoconversion for complication (conversion rate 10%). One patient was post operatively re-operated within 30 days because of port hernia. In one case, paraaortic lymphadenectomy was not performed because of hemorrhage risk. When the procedure was performed with robot-assisted surgery, the median number of paraaortic nodes was 19.5 (3–45). The median operative time was 240 min (180–300). Eighty-five percent (17/20) of patients were discharged at day 4 or before. The median time to start adjuvant treatments, when indicated, was 5.5 weeks. With a median follow up of 8 months (1–18 months), no tumor recurrence was reported. ConclusionRobotic surgical staging with dual docking in women with high risk endometrial cancer seems to be feasible with few complications. More studies are required to assess the safety of robotic surgery and its impact on survival.

Robotic infrarenal paraaortic and pelvic nodal staging for endometrial cancer: feasibility and lymphatic complications.

This study was designed to evaluate the feasibility and lymphatic complications of robotic pelvic and infrarenal paraaortic lymphadenectomy in endometrial cancer patients. All patients diagnosed with high risk endometrial cancer during the study period were identified (n = 212). Clinical prospective data, with reassessment of lymphatic complications, was analysed for all cases (n = 140) planned for a complete robotic nodal staging. The outcome measures were: success rate of infrarenal paraaortic lymphadenectomy, the rate of lymphatic complications and factors associated with nodal yield. Of the 212 women, an open or restricted robotic procedure was performed in 57 women (27%) and no operation in 15 (7%), the latter due to disseminated disease or comorbidity. In 140 women (66%) in whom staging was intended, the lymphadenectomy included the infrarenal area in 70%, was restricted to the inframesenteric area in 21% and aborted or incomplete in 9%. The median number of paraaortic nodes was 10 (range 2-39). An unsuccessful staging was associated with high BMI and the surgeon's inexperience. At 1 year, three patients (2%) had developed a grade two lower limb lymphedema. Eleven women (8%) demonstrated pelvic lymphocysts; seven (64%) resolved spontaneously. Only one paraaortic lymphocyst was found; this required drainage. No cases of chylous ascites occurred. An infrarenal robotic paraaortic lymphadenectomy is feasible in 70% of high risk endometrial cancer cases when intended (88% in non-obese patients operated by experienced surgeons), but is restricted in obese patients and by surgeon's inexperience.

A comparison of extraperitoneal versus transperitoneal laparoscopic or robotic para-aortic lymphadenectomy for staging of endometrial carcinoma

ObjectiveThe optimal surgical approach for complete lymphadenectomy in patients with endometrial cancer is controversial. The objective of our study was to compare the surgical outcomes of extraperitoneal laparoscopic, transperitoneal laparoscopic, and robotic transperitoneal para-aortic lymphadenectomy in endometrial cancer staging. MethodsA retrospective review was performed on patients who underwent extraperitoneal or transperitoneal para-aortic lymphadenectomy for endometrial cancer staging from January 2007 to November 2012. Three patient groups were compared: extraperitoneal laparoscopic para-aortic lymphadenectomy, robotic hysterectomy and pelvic lymphadenectomy (“extraperitoneal group”; N=34); laparoscopic hysterectomy and transperitoneal pelvic and para-aortic lymphadenectomy (“transperitoneal laparoscopic group”; N=108); and robotic hysterectomy and transperitoneal pelvic and para-aortic lymphadenectomy (“transperitoneal robotic group”; N=52). Fisher's exact test and Kruskal–Wallis test were used for statistical analysis, and statistical significance was defined as P<0.05. ResultsThe median number of para-aortic lymph nodes obtained was higher in the extraperitoneal group than in the transperitoneal laparoscopic and robotic groups (10, 5, and 4.5 nodes, respectively; P<0.001). BMI was higher in the extraperitoneal group (median, 35.1kg/m2) than in the transperitoneal groups but did not differ between the transperitoneal laparoscopic group (median, 28.4kg/m2) and the transperitoneal robotic group (median, 30.2kg/m2). Among patients with a BMI <35kg/m2, the median number of para-aortic nodes harvested was higher in the extraperitoneal group than in the transperitoneal laparoscopic and robotic groups (9, 4, and 5 nodes, respectively; P<0.01). The same pattern was observed among patients with a BMI ≥35kg/m2 (10, 6, and 3 nodes, respectively), but only the extraperitoneal group and the transperitoneal robotic group were significantly different (P=0.001). There was no significant difference in median estimated blood loss between the extraperitoneal group and either the transperitoneal laparoscopic group (100 vs. 112.5mL; P=0.06) or the transperitoneal robotic group (100 vs. 67.5mL; P=0.23). The median operative time was longer in the extraperitoneal group (339.5min; range, 242–453min) than in the transperitoneal laparoscopic group (286min; range, 101–480min) and the transperitoneal robotic group (297.5min, range 182–633min) (P<0.01). ConclusionExtraperitoneal laparoscopic para-aortic lymphadenectomy resulted in a higher number of para-aortic lymph nodes removed than transperitoneal laparoscopic or robotic lymphadenectomy. The extraperitoneal approach should be considered for endometrial cancer staging.

Single-Port Laparoscopic Extraperitoneal Para-aortic Lymphadenectomy

The aim of this study was to evaluate the feasibility and the safety of single-port extraperitoneal laparoscopic para-aortic lymphadenectomy for patients with gynecologic cancer. From July 2012 to January 2013, a total of 7 patients with gynecologic cancer underwent a laparoscopic pelvic and para-aortic lymphadenectomy with a single-port device. An extraperitoneal approach was performed for para-aortic lymphadenectomy using only one 2.5-cm incision on the left side. In 6 patients, additionally, hysterectomy and pelvic lymphadenectomy with conventional laparoscopy were performed to complete the treatment. Aortic dissection was complete in all cases without complications. The median age of the patients was 63 years (range, 48-78 years), and the median patient body mass index was 31 kg/m(2) (range, 19-38 kg/m(2)). The median number of para-aortic nodes was 17 (range, 10-25); the median operative time was 204 minutes (range, 120-300 minutes). The median hospital stay was 4 days (range, 3-6 days). No patient encountered postoperative complications. This study demonstrates the feasibility of single-port laparoscopic extraperitoneal para-aortic lymphadenectomy.

Comparison of Single-Port Laparoscopy, Standard Laparoscopy, and Robotic Surgery in Patients with Endometrial Cancer

The aim of this study was to evaluate single-port laparoscopy (SPL) for the surgical treatment of presumed early-stage endometrial cancer and to compare surgical outcomes to laparoscopy and robotics. A multi-institutional, matched retrospective cohort study was performed. All patients with clinical stage I or occult stage II endometrial cancer who underwent SPL hysterectomy, bilateral salpingo-oophorectomy +/- lymphadenectomy from April 2009 to September 2010 were identified. Outcomes were compared with patients matched by age, body mass index (BMI), tumor histology, and grade, who underwent laparoscopy or robotic surgery. Data was analyzed using Kruskal-Wallis 1-way analysis of variance and chi-square test for frequency data. A P value of <.05 was considered significant. A total of 90 matched patients (30 SPL, 30 LSC, and 30 robotic) were included in the study. There were no significant differences in median operating time or estimated blood loss between the 3 groups. The median number of pelvic lymph nodes obtained was significantly higher in the robotic (17.0 [8-36] and SPL group (16.0 [11-21]) compared with the laparoscopy group (13.0 [3-18]) P = .04. However, there was no significant difference in the median number of para-aortic nodes obtained between the 3 groups. There was no significant difference between the groups in length of hospital stay, comorbid conditions, complication rates, or operative times. Our findings suggest SPL surgery for endometrial carcinoma is feasible with similar operating times, hospital length of stay, complication rates, and estimated blood loss when compared with laparoscopy and robotics.