Total laparoscopic radical hysterectomy with pelvic lymphadenectomy for endometrial cancer
C. Vasilescu, Oana Stãnciulea, Monica Popa, Rodica Anghel, V. Herlea, Arleziana FlorescuCazuri clinice, no. 1, 2008
* Department of General Surgery and Liver Transplantation, Fundeni Clinical Institute
* Department of General Surgery and Liver Transplantation
* Department of Radiotherapy, Institue of Oncology Bucharest
* Department of Pathology
* Department of Anaesthesia and Intensive Care Center
* Department of General Surgery and Liver Transplantation
* Department of Radiotherapy, Institue of Oncology Bucharest
* Department of Pathology
* Department of Anaesthesia and Intensive Care Center
Introduction
Radical hysterectomy performed entirely by laparoscopy has been described by Canis et al. (1)and Nezhat et al.(2) This operation was initially time consuming and of questionable radicality. During the past decade some reports, on a limited number of patients, have shown the feasibility of a radical resection by laparoscopic surgery and have documented an equivalent number of pelvic nodes harvested by laparoscopy and open surgery (3). Nevertheless, few long-term data on the morbidity and survival after laparoscopic radical hysterectomy are available. Moreover, the feasibility of laparoscopic radical hysterectomy after preoperative brachytherapy is also a matter of debate (4).
Case report
We present the case of a 56-years-old Caucasian woman with no significant history, with the first postmenopausal bleeding episode in august 2007, associated with hypo-gastric discomfort. A curettage of the endometrium was performed. The result of the biopsy showed endometrial endometroid G3 adenocarcinoma of the uterus. Chest X-ray showed no modifications. A CT scan was performed witch showed a slightly enlarged uterus with no enlarged lymph nodes and no liver metastasis. In November 2007 the patient followed radiotherapy. Brachytherapy was delivered pre-operatively in two fractions for a total dose of 1500 cGy associated with external radiotherapy in 24 fractions for a total dose of 4320 cGy. Preoperatively CBC's demonstrated mild anemia. The patient was informed about the possibility of conversion to open surgery. She accepted the offer of laparos-copic approach after counseling and informed consent was obtained. In January 2008 the patient underwent laparos-copic total radical hysterectomy with pelvic lymphadenec-tomy. The postoperatory course was uneventful. The patient was discharged 3 days after surgery. The histopathological exam revealed a stage I endometriod adenocarcinoma of the uterus (pT1ApN0pMo), negative surgical margins and 12 negative lymph nodes.
Surgical technique
The patient was placed in gynecological position and a Foley urinary catheter ensured the bladder was emptied during the surgery. A uterine manipulator was placed inside the uterus through the vagina allowing a suitable mobilization in order to obtain a better exposure of the pelvic structures.
After a CO2 pneumoperitoneum was created a 10 mm trocar was placed in the subumbilical site to introduce the laparoscope. Two additionally 10 mm trocars were placed in each iliac fossa, lateral to the epigastric artery and another 10 mm trocar was place in line with this two, on the medial line. At the inspection of the peritoneal cavity we detected an uterus slightly increased in size, without other modifications.
The procedure started with division of the round ligaments using Valleylab Ligasure Vessel Sealing System. The peritoneum was incised cranially to the paracolic fossa just above the external iliac vessels until the psoas muscle is visualised. The adnexa was pulled medialy with an atraumatic grasper. The urether is not dissected at this stage. The external iliac vessels were identified and lymph nodes from the anterior and the medial surface were removed until the iliac bifurcation and placed in an Endobag. The procedure continued with the identification of the hipogastric and the umbilical artery which were pulled medially in order to open the obturator fossa and remove the lymphatic tissue superior to the obturator nerve.This disection does nor require coagluation.
The lumbo-ovarian pedicle was disected using Ligasure.
The next step was the opening of the paravesical and pararectal spaces by using blunt dissection; this maneuvre was facillitated by pulling the uterin fundus towards the opposite direction with the uterine manipulator. The parametrium being isolated between the two spaces can be safely devided. At the superior limit of the parametrium the uterin artery is identified and divided at its origin.
Thereafter, by placing the uterin fundus in median and posterior position, the vesico-uterine peritoneal fold was opened by scissors and a bladder dissection from the low uterine segment down to the vagina was performed.During this step, the location of the cleavage plane was crucial in order to avoid bladder injury. Then the ureter is dissected, freed from its attachments to the parametria and decrossed from the uterin artery down to its entry into the bladder. Next the rectovaginal space is opend and the uterosacral ligaments divided; this allows the division of paravaginal attachments. The vagina is sectioned and the specimen is extracted transvaginally. Then the vaginal stump was sutured.
Discussion
Endometrial cancer is the most common gynecological malignancy in western countries.The median age at diagnosis is the sixth decade, although 20-25% of casese will be diagnosed premenopausally (5). Endometrioid adenocarcinoma of the uterus represent around 80% of all endometrial carcinoma. Endometrial cancer affects most women in premenopausal or perimenopausal period and it is associated with low grade endometrial hyperplasia and less aggressive growth patterns. The cancer is more aggressive in 10% of the cases, especially the serous, clear cell and adenosquamous type (6). In premenopausal women, more aggressive forms are found, they are estrogen independent and are associated with an atrophic endometrium.
The diagnosis is suspected in presence of irregular vaginal bleeding or bleeding after menopause. In presence of these symptoms are performed: endometrial biopsy by dilation and curettage with or without a hysteroscopy. The main system used to stage endometrial cancer is called the FIGO (International Federation of Gynecology and Obstetrics) system. Approximate 5-year survival by stage ranges between 91 % in stage I A and 17% in stage IV B.
In management of endometrial cancer there are several points to be discused.
First is to establish if the lymphadenectomy, known to be a prognostic factor has also a terapeutical signifiance. There are studies who recommend rutine pelvic lymphadenectomy in apparently early stage endometrial cancer, based on the fact that in about 10 % of the cases metastasis are found in lymph nodes in pacients with clinical early stage of endometrial cancer (7, 6).
A retrospective study conducted in USA showed a possible therapeutic beneffit of lymphadenectomy proved by increased survival (8). One of the beneffits of rutine lympha-denectomy, beside an accurate staging is the fact that radiotherapy is not rutinely recommended, but only in cases with positive lymph nodes. Homesley and co. reported that lymphadenectomy does not result in increased morbidity (9).
Regarding the adequate number of lymph nodes removed, they are found to be, in large studies between 17-22 lymph nodes per patient (10). The higher the number of recovered lymph nodes the greather the chance of detecting at least one positive node. A limitation to this theory may be the fact that the surgeons do not usually know the number of lymph nodes resected during the operation (5). Most authors recommend rutine pelvic lymphadenectomy in cases with deep myometrial invasion and in cases with high preoperative histopathological grade (11).
The second issue to be discused is the approach. Since was first described in 1989 by Reich (12) laparoscopic hysterectomy rappidly gain acceptance and its indications was extended in gynecolocical malignancies.
Currently there are several laparoscopic procedures performed in endometrial cancer: exploratory laparoscopy in advanced endometrial cancer, laparoscopic lymph nodes sampling, total laparoscopic hysterectomy, total laparoscopic radical hysterectomy, laparoscopic assisted vaginal hysterec-tomy, robbot assisted laparoscopic hysterectomy (13).
Laparoscopic surgery is adapted to lymph node dissection, gives a direct view of the uterus and origin of the uterine arteries and affords the surgeon an adequate, minimally invasive alternative to standadrd open pelvic lymphadenectomy (14). According to Kim (14) succesful laparoscopic radical hysterectomy depends on the training of the surgical team, on the institution volume in the field of oncological laparoscopy and on the quality of the equipment.
Conclusion
Total laparoscopic radical hysterectomy with pelvic lympha-denectomy was not associated with seminificatively increased operative time or blood loss and, in experienced hands, appears to be a feasible alternative to conventional surgical approach in patients with endometrial carcinoma.
Reference List
1. CANIS, M., MAGE, G., WATTIEZ, A., POULY, J.L., MANHES, H., BRUHAT, M.A. - Does endoscopic surgery have a role in radical surgery of cancer of the cervix uteri? J. Gynecol. Obstet. Biol. Reprod., 1990, 19:921.
2. NEZHAT, C.R., BURRELL, M.O., NEZHAT, F.R., BENIGNO, B.B., WELANDER, C.E. - Laparoscopic radical hysterectomy with paraaortic and pelvic node dissection. Am. J. Obstet. Gynecol., 1992, 166:864.
3. ABU-RUSTUM, N.R. - Laparoscopy 2003: oncologic perspective. Clin. Obstet. Gynecol., 2003, 46:61.
4. POMEL, C., ATALLAH, D., LE BOUEDEC, G., ROUZIER, R., MORICE, P., CASTAIGNE, D., DAUPLAT, J. -Laparoscopic radical hysterectomy for invasive cervical cancer: 8-year experience of a pilot study. Gynecol. Oncol., 2003, 91:534.
5. CHAN, J.K., KAPP, D.S. - Role of complete lymphadenec-tomy in endometrioid uterine cancer. Lancet Oncol., 2007, 8:831.
6. MUNDHENKE, C., BAUERSCHLAG, D., FISCHER, D., FRIEDRICH, M., MAASS, N. - Malignant tumors of the uterus. Ther. Umsch., 2007, 64:381.
7. CHAN, J.K., URBAN, R., CHEUNG, M.K., SHIN, J.Y., HUSAIN, A., TENG, N.N., BEREK, J.S., WALKER, J.L., KAPP, D.S., OSANN, K. - Lymphadenectomy in endometrioid uterine cancer staging: how many lymph nodes are enough? A study of 11,443 patients. Cancer, 2007, 109:2454.
8. KILGORE, L.C., PARTRIDGE, E.E., ALVAREZ, R.D., AUSTIN, J.M., SHINGLETON, H.M., NOOJIN, F., III, CONNER, W. - Adenocarcinoma of the endometrium: survival comparisons of patients with and without pelvic node sampling. Gynecol. Oncol., 1995, 56:29.
9. HOMESLEY, H.D., KADAR, N., BARRETT, R.J., LENTZ, S.S. - Selective pelvic and periaortic lymphadenectomy does not increase morbidity in surgical staging of endometrial carcinoma. Am. J. Obstet. Gynecol., 1992, 167:1225.
10. KOHLER, C., KLEMM, P., SCHAU, A., POSSOVER, M., KRAUSE, N., TOZZI, R., SCHNEIDER, A. - Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies. Gynecol. Oncol., 2004, 95:52.
11. HOLUB, Z., BARTOS, P., DORR, A., EIM, J., JABOR, A., KLIMENT, L., JR. - The role of laparoscopic hysterectomy and lymph node dissection in treatment of endometrial cancer. Eur. J. Gynaecol. Oncol., 1999, 20:268.
12. REICH, H. - New techniques in advanced laparoscopic surgery. Baillieres Clin. Obstet. Gynaecol., 1989, 3:655.
13. CHO, Y.H., KIM, D.Y., KIM, J.H., KIM, Y.M., KIM, Y.T., NAM, J.H. - Laparoscopic management of early uterine cancer: 10-year experience in Asan Medical Center. Gynecol. Oncol., 2007, 106:585.
14. KIM, D.H., MOON, J.S. - Laparoscopic radical hysterectomy with pelvic lymphadenectomy for early, invasive cervical carcinoma. J. Am. Assoc. Gynecol. Laparosc., 1998, 5:411.
Radical hysterectomy performed entirely by laparoscopy has been described by Canis et al. (1)and Nezhat et al.(2) This operation was initially time consuming and of questionable radicality. During the past decade some reports, on a limited number of patients, have shown the feasibility of a radical resection by laparoscopic surgery and have documented an equivalent number of pelvic nodes harvested by laparoscopy and open surgery (3). Nevertheless, few long-term data on the morbidity and survival after laparoscopic radical hysterectomy are available. Moreover, the feasibility of laparoscopic radical hysterectomy after preoperative brachytherapy is also a matter of debate (4).
Case report
We present the case of a 56-years-old Caucasian woman with no significant history, with the first postmenopausal bleeding episode in august 2007, associated with hypo-gastric discomfort. A curettage of the endometrium was performed. The result of the biopsy showed endometrial endometroid G3 adenocarcinoma of the uterus. Chest X-ray showed no modifications. A CT scan was performed witch showed a slightly enlarged uterus with no enlarged lymph nodes and no liver metastasis. In November 2007 the patient followed radiotherapy. Brachytherapy was delivered pre-operatively in two fractions for a total dose of 1500 cGy associated with external radiotherapy in 24 fractions for a total dose of 4320 cGy. Preoperatively CBC's demonstrated mild anemia. The patient was informed about the possibility of conversion to open surgery. She accepted the offer of laparos-copic approach after counseling and informed consent was obtained. In January 2008 the patient underwent laparos-copic total radical hysterectomy with pelvic lymphadenec-tomy. The postoperatory course was uneventful. The patient was discharged 3 days after surgery. The histopathological exam revealed a stage I endometriod adenocarcinoma of the uterus (pT1ApN0pMo), negative surgical margins and 12 negative lymph nodes.
Surgical technique
The patient was placed in gynecological position and a Foley urinary catheter ensured the bladder was emptied during the surgery. A uterine manipulator was placed inside the uterus through the vagina allowing a suitable mobilization in order to obtain a better exposure of the pelvic structures.
After a CO2 pneumoperitoneum was created a 10 mm trocar was placed in the subumbilical site to introduce the laparoscope. Two additionally 10 mm trocars were placed in each iliac fossa, lateral to the epigastric artery and another 10 mm trocar was place in line with this two, on the medial line. At the inspection of the peritoneal cavity we detected an uterus slightly increased in size, without other modifications.
The procedure started with division of the round ligaments using Valleylab Ligasure Vessel Sealing System. The peritoneum was incised cranially to the paracolic fossa just above the external iliac vessels until the psoas muscle is visualised. The adnexa was pulled medialy with an atraumatic grasper. The urether is not dissected at this stage. The external iliac vessels were identified and lymph nodes from the anterior and the medial surface were removed until the iliac bifurcation and placed in an Endobag. The procedure continued with the identification of the hipogastric and the umbilical artery which were pulled medially in order to open the obturator fossa and remove the lymphatic tissue superior to the obturator nerve.This disection does nor require coagluation.
The lumbo-ovarian pedicle was disected using Ligasure.
The next step was the opening of the paravesical and pararectal spaces by using blunt dissection; this maneuvre was facillitated by pulling the uterin fundus towards the opposite direction with the uterine manipulator. The parametrium being isolated between the two spaces can be safely devided. At the superior limit of the parametrium the uterin artery is identified and divided at its origin.
Thereafter, by placing the uterin fundus in median and posterior position, the vesico-uterine peritoneal fold was opened by scissors and a bladder dissection from the low uterine segment down to the vagina was performed.During this step, the location of the cleavage plane was crucial in order to avoid bladder injury. Then the ureter is dissected, freed from its attachments to the parametria and decrossed from the uterin artery down to its entry into the bladder. Next the rectovaginal space is opend and the uterosacral ligaments divided; this allows the division of paravaginal attachments. The vagina is sectioned and the specimen is extracted transvaginally. Then the vaginal stump was sutured.
Discussion
Endometrial cancer is the most common gynecological malignancy in western countries.The median age at diagnosis is the sixth decade, although 20-25% of casese will be diagnosed premenopausally (5). Endometrioid adenocarcinoma of the uterus represent around 80% of all endometrial carcinoma. Endometrial cancer affects most women in premenopausal or perimenopausal period and it is associated with low grade endometrial hyperplasia and less aggressive growth patterns. The cancer is more aggressive in 10% of the cases, especially the serous, clear cell and adenosquamous type (6). In premenopausal women, more aggressive forms are found, they are estrogen independent and are associated with an atrophic endometrium.
The diagnosis is suspected in presence of irregular vaginal bleeding or bleeding after menopause. In presence of these symptoms are performed: endometrial biopsy by dilation and curettage with or without a hysteroscopy. The main system used to stage endometrial cancer is called the FIGO (International Federation of Gynecology and Obstetrics) system. Approximate 5-year survival by stage ranges between 91 % in stage I A and 17% in stage IV B.
In management of endometrial cancer there are several points to be discused.
First is to establish if the lymphadenectomy, known to be a prognostic factor has also a terapeutical signifiance. There are studies who recommend rutine pelvic lymphadenectomy in apparently early stage endometrial cancer, based on the fact that in about 10 % of the cases metastasis are found in lymph nodes in pacients with clinical early stage of endometrial cancer (7, 6).
A retrospective study conducted in USA showed a possible therapeutic beneffit of lymphadenectomy proved by increased survival (8). One of the beneffits of rutine lympha-denectomy, beside an accurate staging is the fact that radiotherapy is not rutinely recommended, but only in cases with positive lymph nodes. Homesley and co. reported that lymphadenectomy does not result in increased morbidity (9).
Regarding the adequate number of lymph nodes removed, they are found to be, in large studies between 17-22 lymph nodes per patient (10). The higher the number of recovered lymph nodes the greather the chance of detecting at least one positive node. A limitation to this theory may be the fact that the surgeons do not usually know the number of lymph nodes resected during the operation (5). Most authors recommend rutine pelvic lymphadenectomy in cases with deep myometrial invasion and in cases with high preoperative histopathological grade (11).
The second issue to be discused is the approach. Since was first described in 1989 by Reich (12) laparoscopic hysterectomy rappidly gain acceptance and its indications was extended in gynecolocical malignancies.
Currently there are several laparoscopic procedures performed in endometrial cancer: exploratory laparoscopy in advanced endometrial cancer, laparoscopic lymph nodes sampling, total laparoscopic hysterectomy, total laparoscopic radical hysterectomy, laparoscopic assisted vaginal hysterec-tomy, robbot assisted laparoscopic hysterectomy (13).
Laparoscopic surgery is adapted to lymph node dissection, gives a direct view of the uterus and origin of the uterine arteries and affords the surgeon an adequate, minimally invasive alternative to standadrd open pelvic lymphadenectomy (14). According to Kim (14) succesful laparoscopic radical hysterectomy depends on the training of the surgical team, on the institution volume in the field of oncological laparoscopy and on the quality of the equipment.
Conclusion
Total laparoscopic radical hysterectomy with pelvic lympha-denectomy was not associated with seminificatively increased operative time or blood loss and, in experienced hands, appears to be a feasible alternative to conventional surgical approach in patients with endometrial carcinoma.
Reference List
1. CANIS, M., MAGE, G., WATTIEZ, A., POULY, J.L., MANHES, H., BRUHAT, M.A. - Does endoscopic surgery have a role in radical surgery of cancer of the cervix uteri? J. Gynecol. Obstet. Biol. Reprod., 1990, 19:921.
2. NEZHAT, C.R., BURRELL, M.O., NEZHAT, F.R., BENIGNO, B.B., WELANDER, C.E. - Laparoscopic radical hysterectomy with paraaortic and pelvic node dissection. Am. J. Obstet. Gynecol., 1992, 166:864.
3. ABU-RUSTUM, N.R. - Laparoscopy 2003: oncologic perspective. Clin. Obstet. Gynecol., 2003, 46:61.
4. POMEL, C., ATALLAH, D., LE BOUEDEC, G., ROUZIER, R., MORICE, P., CASTAIGNE, D., DAUPLAT, J. -Laparoscopic radical hysterectomy for invasive cervical cancer: 8-year experience of a pilot study. Gynecol. Oncol., 2003, 91:534.
5. CHAN, J.K., KAPP, D.S. - Role of complete lymphadenec-tomy in endometrioid uterine cancer. Lancet Oncol., 2007, 8:831.
6. MUNDHENKE, C., BAUERSCHLAG, D., FISCHER, D., FRIEDRICH, M., MAASS, N. - Malignant tumors of the uterus. Ther. Umsch., 2007, 64:381.
7. CHAN, J.K., URBAN, R., CHEUNG, M.K., SHIN, J.Y., HUSAIN, A., TENG, N.N., BEREK, J.S., WALKER, J.L., KAPP, D.S., OSANN, K. - Lymphadenectomy in endometrioid uterine cancer staging: how many lymph nodes are enough? A study of 11,443 patients. Cancer, 2007, 109:2454.
8. KILGORE, L.C., PARTRIDGE, E.E., ALVAREZ, R.D., AUSTIN, J.M., SHINGLETON, H.M., NOOJIN, F., III, CONNER, W. - Adenocarcinoma of the endometrium: survival comparisons of patients with and without pelvic node sampling. Gynecol. Oncol., 1995, 56:29.
9. HOMESLEY, H.D., KADAR, N., BARRETT, R.J., LENTZ, S.S. - Selective pelvic and periaortic lymphadenectomy does not increase morbidity in surgical staging of endometrial carcinoma. Am. J. Obstet. Gynecol., 1992, 167:1225.
10. KOHLER, C., KLEMM, P., SCHAU, A., POSSOVER, M., KRAUSE, N., TOZZI, R., SCHNEIDER, A. - Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies. Gynecol. Oncol., 2004, 95:52.
11. HOLUB, Z., BARTOS, P., DORR, A., EIM, J., JABOR, A., KLIMENT, L., JR. - The role of laparoscopic hysterectomy and lymph node dissection in treatment of endometrial cancer. Eur. J. Gynaecol. Oncol., 1999, 20:268.
12. REICH, H. - New techniques in advanced laparoscopic surgery. Baillieres Clin. Obstet. Gynaecol., 1989, 3:655.
13. CHO, Y.H., KIM, D.Y., KIM, J.H., KIM, Y.M., KIM, Y.T., NAM, J.H. - Laparoscopic management of early uterine cancer: 10-year experience in Asan Medical Center. Gynecol. Oncol., 2007, 106:585.
14. KIM, D.H., MOON, J.S. - Laparoscopic radical hysterectomy with pelvic lymphadenectomy for early, invasive cervical carcinoma. J. Am. Assoc. Gynecol. Laparosc., 1998, 5:411.