BERKELEY, CA (UroToday.com) - There are few published descriptions of robotic retroperitoneal aortocava lymphadenectomy. Magrina et al.,[1] made a technical description in 2 cadavers and 1 live cervical cancer; Vergote[2] reported 5 cases of cervical cancer in which lymphadenectomy was performed up to the inferior mesenteric artery; and Narducci[3] described 6 cases of non seminomatous and gynecological cancer, with dissection up to the renal vein. Several articles describe the advantages of this technique, both in gynecologic and urologic procedures. These include reduced adhesion formation,[4] especially important in patients requiring radiotherapy.[5]
The objective of this article[6] was to describe our initial experience with this procedure. Robotic retroperitoneal aortocava lymphadenectomy transforms aortic lymphadenectomy into a relatively simple procedure, in comparison to the more common transperitoneal access. It is a technique easily reproduced by experienced surgeons and especially advantageous in patients who are obese or who do not tolerate the Trendelenburg position.
We presented 13 cases of gynecological cancer, with lymphadenectomy up to the renal vein. All procedures were performed by a single surgeon with experience in laparoscopic lymphadenectomy (though previous robotic experience was limited to 4 noncomplex procedures and directly moved to robotics). This could have adversely affected our results.
Our study presents several deficiencies. Though data were prospectively collected, our database was not designed specifically to describe this technique. Most of the surgeries included other oncological procedures, and we did not record the time it took to perform the lymphadenectomy. In the cases in which it was the only procedure performed, surgical time was 150-180 minutes. This is significantly longer than classic laparoscopy, which, in our experience, takes 120-150 min. This could be related to the learning curve, as well as robot setup time.
We have not been able to compare our results with robotic transperitoneal access or classic laparoscopic access. Our perception is that robotic access does not offer any great advantages, but we don´t have evidence of this. In December 2013 Pakrish published a comparative study:[7] classic extraperitoneal access vs classic and robotic transperitoneal access, with results in favor of the extraperitoneal route.
Immediately after the publication of our article, Gynecology Oncology published an excellent study by a Spanish group,[8] describing 17 extraperitoneal robotic cases and comparing them to a previous classic extraperitoneal series by the same group. This is the first article to compare robotic and laparoscopic extraperitoneal access. They report a greater number of lymph nodes obtained robotically, as well as reduced blood loss. They report no differences in surgical time (150 min) or hospital stay (2 days). There were more postoperative complications in the robotic group, though these differences were not significant.
Our group found that robotic access offered greater precision, ergonomy, and improved access to the interaortocava and precava lymph nodes. Disadvantages included greater surgical time, the need for an additional trocar, lack of haptic sensitivity, and the unavailability of advanced sealing devices. We did not perform a cost analysis.
Robotic access, in our opinion, does not offer important advantages over classic access when aortic lymphadenectomy is the only procedure performed. Robotic surgery has significant ergonomic advantages for the surgeon, who must perform long and tiring operations, for up to 5 or 6 hours, and if complex procedures are also indicated, robotic surgery can be very useful and improve outcomes.
References:
- Magrina JF, Kho R, Montero RP, Magtibay PM, Pawlina W. Robotic extraperitoneal aortic lymphadenectomy: Development of a technique. Gynecol Oncol 2009, Apr;113(1):32-5.
- Vergote I, Pouseele B, Van Gorp T, Vanacker B, Leunen K, Cadron I, et al. Robotic retroperitoneal lower para-aortic lymphadenectomy in cervical carcinoma: First report on the technique used in 5 patients. Acta Obstet Gynecol Scand 2008;87(7):783-7.
- Narducci F, Lambaudie E, Houvenaeghel G, Collinet P, Leblanc E. Early experience of robotic-assisted laparoscopy for extraperitoneal para-aortic lymphadenectomy up to the left renal vein. Gynecol Oncol 2009, May 16.
- Occelli B, Narducci F, Lanvin D, Querleu D, Coste E, Castelain B, et al. De novo adhesions with extraperitoneal endosurgical para-aortic lymphadenectomy versus transperitoneal laparoscopic para-aortic lymphadenectomy: A randomized experimental study. Am J Obstet Gynecol 2000, Sep;183(3):529-33.
- Stanic S, Mayadev JS. Tolerance of the small bowel to therapeutic irradiation: A focus on late toxicity in patients receiving para-aortic nodal irradiation for gynecologic malignancies. Int J Gynecol Cancer 2013, May;23(4):592-7.
- Gorostidi M, Larreategui J, Bernal T, Goiri C, Arrue M, Navarrina P, Lekuona A. Robotic retroperitoneal para-aortic lymphadenectomy at donostia university hospital. J Minim Invasive Gynecol 2013, Oct 22.
- Pakish J, Soliman PT, Frumovitz M, Westin SN, Schmeler KM, Reis RD, et al. A comparison of extraperitoneal versus transperitoneal laparoscopic or robotic para-aortic lymphadenectomy for staging of endometrial carcinoma. Gynecol Oncol 2013, Dec 20.
- Díaz-Feijoo B, Gil-Ibáñez B, Pérez-Benavente A, Martínez-Gómez X, Colás E, Sánchez-Iglesias JL, et al. Comparison of robotic-assisted vs conventional laparoscopy for extraperitoneal paraaortic lymphadenectomy. Gynecol Oncol 2013, Nov 11.
Written by:
Mikel Gorostidi, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Robotics and Minimally Invasive Surgery
Hospital Universitario Donostia
Basque Country, Spain
Robotic retroperitoneal para-aortic lymphadenectomy at Donostia University Hospital - Abstract
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