Robotic Surgery Can Effectively Treat High-Risk EC After Prior Hysterectomy

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Robotic peritoneal mesometrial resection (PMMR) can be a safe and effective option for women with endometrial cancer (EC) who have already undergone a hysterectomy and later discovered high-risk factors. While the procedure carries a slightly higher risk of complications compared with PMMR performed in patients who have not had a prior hysterectomy, the long-term benefits appear promising.

With a median follow-up of 31.7 months, the recurrence rate among the 32 patients with intermediate/high-risk EC treated with PMMR targeted compartmental lymphadenectomy (TCL) or systematic pelvic and paraaortic lymphadenectomy (LNE) following prior hysterectomy included in the study was 12.5% (4/32) without any isolated locoregional recurrences, despite limited use of adjuvant radiotherapy (21.9%).

While complication rates were present (6.3% intraoperative and 18.8% postoperative), these results warrant further investigation into this approach for managing cancer recurrence after initial treatment.

“Our data indicate the general feasibility of the procedure with an intraoperative complication rate of 6.3%. This rate is substantially higher than those we reported for benign robotic hysterectomy as well as primary PMMR [plus] TCL, perhaps reflecting the increased complexity of the procedure following prior hysterectomy,” wrote study authors in findings published in Archives of Gynecology and Obstetrics.

PMMR plus TCL is a promising strategy for patients with high-risk EC. This approach shows potential for effectively managing higher-risk cases diagnosed after initial surgery, offering localized control and sparing extensive lymph node dissection. This study sought to evaluate feasibility and safety of a completing PMMR with TCL among patients with EC after prior hysterectomy.

A total of 32 patients with intermediate-/high-risk EC treated with PMMR and TCL or systematic pelvic and periaortic LNE following prior hysterectomy were enrolled through and deemed eligible by a retrospective systematic search for the ICD-code C.54 from 2010-2021. Patients were surgically treated and filtered for their risk classification according to classic histopathological criteria. Those with intermediate/high-risk EC were included in the analysis.

Further, only patients who received PMMR, including either systematic pelvic with or without periaortic LNE or TCL following prior simple hysterectomy were included.

Fifteen of the 32 patients had received systematic pelvic with or without periaortic LNE. Seventeen patients were treated by PMMR and TCL. The mean age among those enrolled in the study was 60.8 years (range, 48-80; 7.4) and the mean body mass index (BMI) was 32.4 kg/m2 (range, 17-45; 8.4). No relevant differences were seen between the systematic LNE and TCL groups.

In the whole cohort, the mean length of stay was 8.8 days (range, 4-30; 5.0). Length of stay was significantly longer in the LNE group at 11.5 days compared with 6.4 days in the TCL group, with a mean difference of 5.1 days (95% CI, 2.1-8.1). The mean skin-to-skin time mirrored the length of stay difference, with LNE averaging 236 minutes vs 187 minutes for TCL. Further and as expected, surgical duration was longer in the LNE group (291 minutes) vs the TCL group (187 minutes) due to the increased complexity of the procedure.

Among those enrolled, 1 ml of ICG solution at a dose of 1.66 mg/ml was injected into the mesometrium on each side of the vaginal stump. With periaortic TCL, 1 ml of the same ICG solution was injected into the infundibulopelvic ligament on each side through the abdominal wall under laparoscopic control.

Findings showed that the TCL group reached a 100% sentinel node detection rate, with pelvic nodes identified at the iliac bifurcation and obturator fossa, and periaortic nodes located at the mouth of the ovarian veins in the interaortocaval region. The mean postoperative hemoglobin decrease was 2.7 g/dl after systematic LNE vs 2.1 g/dl with TCL. This suggests potentially less blood loss with the targeted approach.

Overall, few complications arose during surgery (6.3%), and were mostly observed in the LNE group (13.3%). Both were manageable blood vessel issues and didn't require switching to open surgery. After surgery, 18.8% of patients experienced complications, with 4 needing additional surgery, including vaginal cuff issues, bleeding, bowel perforation, and excessive fluid drainage. These complications were similar in both groups.

A total of 68.8% (n = 22) of patients had FIGO stage I disease, and 15.6% (n = 5) had FIGO stage II and III disease. Four patients had positive lymph nodes (12.5%), and all of these patients received systematic pelvic and paraaortic LNE. On average, it took 34.4 days for patients to undergo PMMR after their initial hysterectomy (range, 6-78; 17.6).

The mean follow-up was 31.7 months (range, 0-92; 28.8) among the entire cohort. Of the patients who received systemic LNE, the mean observation time was 45.8 months (range, 0-92; 35.4) vs 19.2 months (range, 0-40; 12.6) in the TCL group.

Notably, 5 women died during the observation period. Four patients were recurring patients, including 1 with a BMI of 41.4 kg/m2 and who had an abdominal wall infection with pelvic abscess formation 3 months following surgery.

“In conclusion, our findings suggest that cancer field surgery via secondary PMMR and LNE in intermediate/high-risk EC following simple hysterectomy is feasible. In addition, it seems to provide equally excellent locoregional control without adjuvant radiotherapy even when performed as a secondary procedure following prior hysterectomy,” wrote study authors.

REFERENCE:

Buderath P, Elgharib M, Kimmig R. Peritoneal mesometrial resection with lymphadenectomy following prior hysterectomy in intermediate/high-risk endometrial cancer: feasibility and safety. Arch Gynecol Obstet. Published online January 13, 2024. doi:10.1007/s00404-023-07275-3