In the last decade, laparoscopy as well as robotics have been increasingly applied with success to patients with gynaecological malignancies, including endometrial cancer [
In this paper we describe our experience using a retrograde and retroperitoneal hysterectomy for minimally invasive comprehensive surgical staging of the endometrial cancer. In our opinion the retrograde and retroperitoneal approach allows to get optimal and constant protection of the ureter, faster control of unexpected intraoperative hemorrhages and better modulation of radicality.To this end we have adopted a combination of the retroperitoneal laparoscopic approach as originally described by Köhler et al. [
From January 2002 to December 2011, all patients with diagnosis of endometrial cancer were treated by the same team of gynecologic oncologists operators at two departmental hospitals: Turin and La Spezia. The analysis was based on the data of 95 patients. Data regarding patient characteristics and intraoperative details were elicited from an oncologic database developed for retrospective review. The patient characteristics retrieved were age, body mass index, concomitant diseases, previous surgeries, stage of disease according to the 2009 International Federation of Gynecology and Obstetrics [
Patients were positioned in a dorsal lithotomy with legs apart and semiflexed, and the arms tucked at the sides. The surgical table was kept in a low position and the monitor between the patient’s legs, facing the two surgeons to facilitate an ergonomic working position. A simplified equipment of no disposable instruments was used including a scissor, two grasping forceps, a washing-aspiration cannulae, and a 3 mm bipolar coagulation forceps. Ligasure (ValleyLab, Boulder, CO, USA) was used only for radical hysterectomies. Never the uterine manipulator was utilized.
A gasless access to the peritoneum was obtained by grasping the skin at the umbilicus with 2 Backhaus forceps and strongly elevating it while a 2 cm depth and 1 cm long incision was blindly made inside the umbilicus at its deepest part. A 10 mm trocar was then gently inserted throughout the incision to hold the laparoscope with the camera. When indicated by the surgical history of the patient, a Veress needle was first inserted into the peritoneal cavity at the left upper abdominal quadrant (Palmer site) to obtain intraperitoneal gas distension. At this point, patient was put in Trendelenburg position and three 5 mm trocars placed in the lower abdomen under direct vision. Two of these trocars were placed laterally to the epigastric vessels at the level of the superior iliac spine while the third one was centrally sovrapubic.
An incision was made where the broad ligament overlies the psoas muscle thus allowing to enter into the pararectal space. The peritoneum was opened parallel to the infundibulopelvic ligament above the crossing with the external iliac artery and along the umbilical artery (which can be tracked upwards along the abdominal wall). An avascularized space of areolar tissue was developed by dissection between a medial leaflet of the broad ligament and the external and internal iliac vessel, taking care to dislocate the ureter on the medial leaflet and avoiding dissection laterally to the internal iliac artery. Following the course of the ureter by one side and the internal iliac artery by the other, the crossing of the uterine artery was encountered (generally 1-2 cm further back the origin of the superior bladder artery). The uterine artery was bipolarly coagulated over 1-2 cm distance. Often the uterine veins were grasped and coagulated altogether.
When necessary a pelvic lymphadenectomy was performed either as first surgical step or following surgical staging. In any case it was performed bilaterally from the level of the aortic bifurcation along the external iliac vessels to the circumflex iliac vein. Internal iliac lymph nodes are then removed. The obturator lymph nodes were removed taking care to identify the obturator nerve. Para-aortic lymphadenectomy was not routinely performed unless suspicious pelvic lymph nodes or deep endometrial invasion or serous papillary or other abnormal histological types were present. Lymph nodes were removed altogether in one single endobag from the vagina at the end of the operation. The round ligament was only partially divided and the anterior leaf of the broad ligament utilized to prepare the paravesical space. A blunt dissection toward the pelvic floor between the superior bladder artery and the cervix was created on both sides. The vesicouterine peritoneal fold was left aside and retrograde dissection initiated from the sides of cervix. Cervical and vaginal uterine vessels were eventually identified, isolated, and coagulated. At the end of this time the transection of the round ligament was completed by dividing all the anterior leaf down to the vesicouterine peritoneal fold. This was finally mobilized from connections to the lower uterine segment. The infundibulopelvic ligaments were identified as high as possible out of the pelvis. While being grasped and elevated, an incision was bluntly made 1 cm beneath the ligament on the underlying peritoneum. This allowed to push away the ureter before coagulation. These ligaments were coagulated with bipolar over a 2 cm distance and were divided.
Afterwards, the posterior margin of the peritoneum was superficially incised towards the posterior vaginal apex and rectovaginal septum. By creating the avascular space the medial portion of the sacrouterine ligament could be safely drawn away from the isthmic portion of the ureter. The apical part of the rectovaginal septum was then opened. During this step parametrial tissue containing the vascular pedicles was coagulated and variably dissected as a function of the radicality required. A third operator was then enrolled to expose, by means of ring forceps, the anterior vaginal vault which was therefore incised and opened by the first operator. A vaginal tampon was then used to stop gas loss and maintain the pneumoperitoneum. While the second operator was grasping the anterior margin of the vagina, the first operator executed the retrograde incision of the vagina (circular culdotomy). This was facilitated by pulling up the cervix and dissecting the vaginal mucosa at variable distance from the portio as indicated by need of radicality. During this final step the sacrouterine ligaments were coagulated and transected. The retrograde direction of the culdotomy proceeded parallel and 2-3 cm above the course of the ureter. The vagina was then sutured laparoscopically by using 14 cm 0 Quill SRS suture (Angiotech, Vancouver, BC, Canada). Closure started at one angle of the vaginal cuff and prosecuted in a running fashion with a final stich securing one uterosacral ligament to the other. Finally, the pelvis was washed and hemostasis assured.
The results are summarized in Tables
Patients characteristics.
Patient’s profile | |
---|---|
Number of cases | 95 |
Age (years) mean (range) | 63.46 (43–84) |
BMI mean (range) | 29.64 (20–46) |
Other pathologies | |
Hypertension | 60 |
Diabetes | 13 |
Thyroid | 9 |
Other | 13 |
Total (%) | 95 (100%) |
Previous surgeries | 51 |
Histology | |
Endometrioid | 67 |
Adenosquamous | 8 |
Serous-papillary | 6 |
Villous-glandular | 5 |
Undifferentiated | 5 |
Mucinous | 2 |
Carcinosquamous | 1 |
Clear cell | 1 |
Grading | |
G1 | 33 |
G2 | 43 |
G3 | 19 |
Myometrial invasion | |
No invasion | 6 |
<50% | 50 |
>50% | 39 |
FIGO Staging | |
IA | 51 |
IB | 26 |
II | 3 |
IIIA | 5 |
IIIC1 | 7 |
IIIC2 | 3 |
Positive washing cytology | 12 (6/12 myom.invasion < 50%) |
Perioperative data.
Number of cases | |
---|---|
Hysterectomy + bilat. annessiectomy | 95 |
|
74 |
|
21 |
Operative time (min) | 129.47 (60–240) |
EBL (mL)* | 125.15 (100–300) |
Pelvic lymphadenectomy | 65 |
Mean number of pelvic lymph removed | 10.25 (1–28) |
Para-aortic lymphadenectomy and omentectomy | 13 |
Mean number of hospitalization days | 3.5 (2–5) |
Intraoperative complications (2 blood transfusions, 3 ureteral injuries) | 5.2% (5/95) |
Postoperative complications (fistula, lymphocyst, ascess, renal dilatation, hematoma) | 5.2% (5/95) |
Adjuvant therapy, followup, and survival.
Number of cases | |
---|---|
Adjuvant radiotherapy | 20 |
Adjuvant chemotherapy | 9 |
No adjuvant therapy | 66 |
Mean followup (months) | 49.09 (4–140) |
Lost | 6 |
NED* | 75 |
ED° | 1 |
Deaths | 13 |
Recurrences | 13 (12 deaths + 1 ED) |
|
4 |
|
6 |
|
3 |
Disease-free interval (months) | 15 (7–34) |
*NED: no evidence of disease.
°ED: evidence of disease.
In this study we have reported about the method applied at our department for total laparoscopic hysterectomy in case of endometrial cancer. As shown in Table
In conclusion, we confirm adequacy and cost effectiveness of laparoscopy for surgical staging and treatment of endometrial cancer. Specifically, our method of retrograde and retroperitoneal hysterectomy is particularly indicated and valuable in that it avoids the use of uterine manipulator and allows easy modulation of radicality. This last consideration is important since patients suitable for surgical treatment of endometrial cancer represent a quite heterogeneous population.