Robot-assisted Extraperitoneal Para-aortic Lymphadenectomy Is Associated with Fewer Surgical Complications: A Post Hoc Analysis of the STELLA-2 Randomized Trial

Abstract

Study Objective: To evaluate if extraperitoneal para-aortic lymphadenectomy (PALND) using a robot-assisted approach was associated with fewer complications than all other approaches (conventional laparoscopic transperitoneal or extraperitoneal and robot-assisted transperitoneal) without compromising lymph node yield, operative time, or length of stay. Design: Post hoc analysis of the prospective randomized open-label multicenter trial (STELLA-2). Setting: Three academic referral hospitals. Patients: Two hundred and three eligible patients from the STELLA-2 trial were included. Interventions: The patients were randomized to extraperitoneal or transperitoneal PALND using a minimally invasive approach (either laparoscopic or robot-assisted) for surgical staging of endometrial or ovarian cancer. The minimally invasive approaches were not subjected to randomization. Measurements and Main Results: The primary end point was evaluated through a composite variable that included at least 1 of the following events: blood loss ≥500 mL during PALND, any intraoperative complication related to PALND, severe postoperative complication (Clavien-Dindo ≥grade IIIA), impossibility of completing the procedure, or conversion to laparotomy. Of the 203 patients analyzed, 68 were assigned to the extraperitoneal laparoscopic group (X-L), 62 to the transperitoneal laparoscopic group (T-L), 35 to the extraperitoneal robotic group (X-R), and 38 to the transperitoneal robotic group (T-R).

Surgical Outcomes of Transperitoneal Para-Aortic Lymphadenectomy Compared With Extraperitoneal Approach in Gynecologic Cancers: A Systematic Review and Meta-Analysis

“…When we pooled the results from the seven studies, the EP group demonstrated less PALND operative time compared to TP (WMD −10.46 min, 95% CI −19.04, −1.88; p = 0.02) (20,21,24,25,27,28,30). However, the sensitivity analysis showed no significant differences with the removal of two studies (23,26) (p = 0.16, p = 0.10).…”

“…According to the literature search and the inclusion criteria, we included 2,354 patients in 13 studies (3 RCTs and 10 non-RCTs) for meta-analysis (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32). The 10 non-RCTs were all the retrospective comparisons (Figure 1).…”

“…However, the preoperative characteristics were comparable in other studies, with similar age, BMI, surgical history observed in each of the included studies. The patients in the two studies were divided into four groups, depending on their treatment type: TP laparoscopy, EP laparoscopy, TP robotic laparoscopy, and robot-assisted EP laparoscopy (20,22).…”

Gynecologic Robotic Surgery: Intraoperative Complication and Conversion Rates

“…Interestingly, most of them concerned vascular injuries during lymphadenectomy that were managed by suturing, coagulation or surgical clip placement. Same statement was published in a large prospective randomized trial [6]. Bebia et al concluded that robotic assisted lymphadenectomy is associated with fewer complications compared to laparoscopic, due to better visualization, surgeon's ergonomy and hemostatic precision [6].…”

“…Same statement was published in a large prospective randomized trial [6]. Bebia et al concluded that robotic assisted lymphadenectomy is associated with fewer complications compared to laparoscopic, due to better visualization, surgeon's ergonomy and hemostatic precision [6]. Based on their findings, do the authors have a similar experience?…”