Efficacy of vaginal natural orifice transluminal endoscopic sentinel lymph node biopsy for endometrial cancer: a prospective multicenter cohort study

Abstract

Introduction: Natural orifice transluminal endoscopic surgery (NOTES) is performed increasingly often despite the lack of high-quality evidence confirming its safety, especially for malignant diseases. The aim of this prospective study is to verify that vaginal NOTES (vNOTES) can be performed safely and effectively in early endometrial cancer staging surgery. Materials and Methods: This prospective study was conducted in two tertiary hospitals in southern China from January 2021 to May 2022. A total of 120 patients with stage I endometrial cancer were included. vNOTES or multiport laparoscopic staging surgery was selected according to each patient’s wishes. The primary outcome was the sentinel lymph node detection rate, analyzed by a noninferiority test. The secondary outcomes were perioperative outcomes. Results: Among the 120 patients enrolled, 57 underwent vNOTES, and 63 underwent multiport laparoscopy. The patient-specific detection rates of sentinel lymph nodes were 94.73 and 96.82% in the vNOTES and laparoscopy groups, respectively. Additionally, the bilateral detection rates were 82.46 and 84.13%, and the side-specific detection rates were 88.60 and 90.48% in these two groups, respectively. All three detection rates in the vNOTES group were noninferior to those of laparoscopy group at a noninferiority cutoff of –15%. The median operation times of the vNOTES and laparoscopy groups were 132.35 and 138.73 min (P=0.362), and the median estimated blood loss were 75 and 50 ml (P=0.096), respectively. No intraoperative complications occurred in either group. The pain scores on the Numerical Rating Scale at both 12 h and 24 h after operation were significantly lower in the vNOTES group (P<0.001) and the median postoperative hospital stay was significantly shorter in the vNOTES group (P=0.001). Conclusion: This study illustrates the potential applicability of vNOTES in gynecological malignancy surgery by demonstrating its safety and effectiveness in endometrial cancer staging. However, its long-term survival outcomes require further exploration.

Sentinel Lymph Node Mapping by Retroperitoneal vNOTES for Uterus-Confined Malignancies: A Standardized 10-Step Approach

“…This vNOTES technique has several potential advantages over laparoscopic approaches, such as sentinel dissection without Trendelenburg positioning; a caudal to cranial LNs inspection following the natural lymphatic distribution upwards, which could improve the identification of true SLNs and not secondary or higher nodes situated on the sentinel pathway; better access to LNs situated under the external iliac vein; and a less invasive approach avoiding transabdominal incisions with reduced risks of adhesion formation potentially responsible for the severe side effects associated with postoperative radiotherapy in the case of cervical cancer with LN involvement [ 1 , 36 ]. In addition, vNOTES approaches could reduce operative times, present reduced postoperative pain, and decrease hospital stays [ 37 , 38 , 39 ].…”

Sentinel Lymph Node Mapping by Retroperitoneal vNOTES for Uterus-Confined Malignancies: A Standardized 10-Step Approach

“…This vNOTES technique has several potential advantages over the laparoscopic approaches, such as sentinel dissection without Trendelenburg positioning, a caudal to cranial LNs inspection following the natural lymphatic distribution upwards, which could improve the identification of true SLNs and not secondary or higher nodes situated on the sentinel pathway, better access to LNs situated under the external iliac vein, and a less invasive approach avoiding transabdominal incisions with reduced risks of adhesions formation potentially responsible of severe side effects associated with postoperative radiotherapy in the case of cervical cancer with LNs involvement [2,26]. In addition, vNOTES approaches could reduce operative times, present reduced postoperative pain, and shorter hospital stays [27][28][29].…”