Retroperitoneal Sentinel Lymph Node Biopsy by Vaginally Assisted Natural Orifices Endoscopic Transluminal Endoscopic Surgery in Early Stage Endometrial Cancer: Description of Technique and Surgeon’s Perspectives after the First Experience

Abstract

Endometrial cancer is the most commonly diagnosed gynecological malignancy. Feasibility and safety of laparoscopy are no longer to be demonstrated in patients with uterine-confined endometrial carcinoma. Vaginally assisted natural orifices endoscopic transluminal endoscopic surgery (vNOTES) is a new endoscopic approach over the past decade with significant evidence in benign pathology. Publications exploring VNOTES surgery in gynecological cancer were published first in 2014. We hereby report our first experience with vNOTES surgery in endometrial cancer. A 64-year-old patient presented with postmenopausal bleeding. Endometrial biopsy identified a G1 endometrioid adenocarcinoma. MRI suspected deep invasion of myometrium with no abnormal lymph node. She underwent a total hysterectomy with bilateral adnexectomy and retroperitoneal pelvic sentinel node biopsy by vNOTES. The final histopathology confirmed G1 endometrial adenocarcinoma FIGO II (proximal focal invasion of cervical stroma and superficial invasion of myometrium). The patient was discharged 2 days postoperatively with no complications. vNOTES offers a closer approach and a better view of afferent lymphatics and probably the best chances to identify the true sentinel node. This approach presents several advantages compared to abdominal laparoscopy such as faster postoperative recovery, reduced pain, decreased postoperative wound infections, and no abdominal trocar port complications. The future research should focus on oncological safety, accuracy, and reliability of this technique, and an international registry should help to gather rapidly these informations.

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

“…We proposed a standardized 10-step approach for SLN mapping by retroperitoneal vNOTES for patients with early-stage endometrial and cervical cancer. Since Baekelandt first described this technique in 2019 [ 12 ], only a few articles have been published on this topic, including case reports, small single-center case series, and proposals for technique modifications [ 14 , 15 , 16 , 17 , 18 , 19 , 22 ]. Following the IDEAL (Idea Development Exploration Assessment Long-term follow-up) framework, we can consider that research regarding this technique is in Stage 2a (Development), and its standardized description appeared necessary before moving to Stage 2b (Exploration), allowing for a greater surgical homogeneity required to conduct larger multi-center studies.…”

“…The retroperitoneal vNOTES approach appears to be the most promising, providing easy visualization of lymphatic afferent vessels and pelvic lymph nodes (LNs), early LN assessment, and a coherent mapping methodology following the lymphatic flow from caudal to cranial [ 14 ]. Although this technique appears to be a possible revolutionary tool to stage endometrial and cervical cancer, only a few publications have reported it [ 12 , 14 , 15 , 16 , 17 , 18 , 19 ].…”

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

“…We proposed a standardized 10-step approach for SLN mapping by retroperitoneal vNOTES for patients with early-stage endometrial and cervical cancer. Since Baekelandt first described this technique in 2019 [6], only a few articles have been published on this topic, including case reports, small single-center case series, and proposals for technique modifications [8][9][10][11][12][13]16]. Following the IDEAL (Idea Development Exploration Assessment Long-term follow-up) framework, we can consider that research regarding this technique is at stage 2a (Development), and its standardized description appeared necessary before moving to stage 2b (Exploration), allowing a greater surgical homogeneity required to conduct larger multi-center studies.…”

“…The retroperitoneal vNOTES approach appears the most promising, providing easy visualization of lymphatic afferent vessels and pelvic lymph nodes (LNs), early LNs assessment, and a coherent mapping methodology following the lymphatic flow from caudal to cranial [8]. Although this technique appears to be a possible revolutionary tool to stage endometrial and cervical cancer, only a few publications have reported it [6,[8][9][10][11][12][13].…”

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

“…However, leakage may also occur when the lymphatic vessels are cutoff to create a retroperitoneal space, and substantial damage can occur when the lateral bladder space is opened. The relevant studies at present are case reports or small sample size retrospective studies 7 , 9 , 23 ; therefore, the retroperitoneal approach needs further evaluation.…”