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

Abstract

BackgroundThe 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).MethodsPatients (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.ResultsNo 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%).ConclusionsWe 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.

Intraoperative navigation in robotically assisted compartmental surgery of uterine cancer by visualisation of embryologically derived lymphatic networks with indocyanine‐green (ICG)

“…Patients (n = 36) with either endometrial or cervical cancer were treated by radical hysterectomy and therapeutic +/− pelvic/paraaortic lymphadenectomy either as total mesometrial or peritoneal mesometrial resection (TMMR or PMMR ). The procedures were performed by robotically assisted laparoscopy using the “da Vinci” SI or Xi System of Intuitive Surgical Inc® (Sunnyvale, CA) and using infrared laser excitation and fluorescence detection with the Firefly‐System®.…”

“…Patients (n ¼ 36) with either endometrial or cervical cancer were treated by radical hysterectomy and therapeutic þ/À pelvic/paraaortic lymphadenectomy either as total mesometrial or peritoneal mesometrial resection (TMMR or PMMR [13][14][15]). The procedures were performed by robotically assisted laparoscopy using the "da Vinci" SI or Xi Conflicts of interest: Rainer Kimmig received honoraria/travel reimbursement from Intuitive Surgical Inc. for presentations, proctoring with respect to robotic surgery in Europe.…”

ICG-gestützte Navigation bei der Chirurgie uteriner Malignome

“…Zervixkarzinompatientinnen (n = 36) wurden mit einer radikalen Hysterektomie und therapeutischen ± pelvinen/paraaortalen Lymphonodektomie behandelt, entweder als totale mesometriale oder als peritoneale mesometriale Resektion (TMMR oder PMMR; [14][15][16] Zervixkarzinompatientinnen (n = 20, mittleres Alter 44 Jahre, FIGO-Stadium Ib-IIb) erhielten eine TMMR mit therapeutischer Lymphonodektomie [14,15]. Alle Resektionen waren bestätigt R0 (mittlere Lymphknotenzahl n = 57).…”

“…Alle Resektionen waren bestätigt R0 (mittlere Lymphknotenzahl n = 57). Endometriumkarzinompatientinnen (n = 16, mittleres Alter 61 Jahre, FIGO-Stadium I-III) erhielten eine PMMR mit oder ohne pelvine/paraaortale Lymphonodektomie abhängig vom Tumorstadium [14,16,17]. Alle Resektionen waren bestätigt R0 (mittlere Lymphknotenzahl n = 56).…”

“…Die Übertragung dieses Konzepts auf das Endometriumkarzinom resultierte in der peritonealen mesometrialen Resektion (PMMR) kombiniert mit der therapeutischen pelvinen und paraaortalen Lymphadenektomie (tLNE) nach M. Höckel [14,16].…”