|Year : 2021 | Volume
| Issue : 1 | Page : 58-60
Robotic radical parametrectomy with pelvic lymphadenectomy: Technique and feasibility
Vandana Jain, Subrata Debnath, Nidhi Gupta, Sudhir Rawal
Department of Uro-Gynae Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
|Date of Submission||04-May-2021|
|Date of Acceptance||01-Jun-2021|
|Date of Web Publication||31-Jul-2021|
Dr. Vandana Jain
Department of Uro-Gynae Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi.
Source of Support: None, Conflict of Interest: None
Cervical cancer can be detected incidentally after simple hysterectomy carried out for benign gynecological conditions or preinvasive cervical lesions. The risk of recurrence is high, and survival is poor in the absence of further treatment in the form of radiation therapy or radical parametrectomy. Though both forms of treatment result in similar survival, surgery has the advantage to stage the disease and guide the need for adjuvant therapy and also avoids the radiation-associated complications. Though traditionally performed by laparotomy, laparoscopic and robotic approaches have been found to be feasible and safe for this complex procedure.
Keywords: Cystotomy, occult invasive cervical cancer, robotic radical parametrectomy
|How to cite this article:|
Jain V, Debnath S, Gupta N, Rawal S. Robotic radical parametrectomy with pelvic lymphadenectomy: Technique and feasibility. J Curr Oncol 2021;4:58-60
| Introduction|| |
Treatment options for patients diagnosed with occult invasive cervical cancer after inadvertent simple hysterectomy include adjuvant radiation therapy or further surgery in the form of radical parametrectomy.
Radical parametrectomy involves removal of bilateral parametrium, upper vaginectomy, and bilateral pelvic ± para-aortic lymphadenectomy, allows the assessment of the real extent of disease, thereby guiding the further adjuvant therapies only when needed, and also avoids radiation-related complications to the bowel, bladder, and vagina.
| Case Report|| |
We are reporting a case of a 57-year-old woman who underwent simple extrafascial hysterectomy at an outside facility one month back in view of abnormal uterine bleeding. The final pathology report suggested a 2×2-cm growth on the cervix, moderately differentiated squamous cell carcinoma, lymphovascular space invasion (LVSI) present, depth of invasion 3 mm of 1.2 cm, and margins free of invasive cancer.
On gynecological examination, the vault was normal and bilateral parametrium was free. A positron emission tomography–magnetic resonance imaging (PET-MRI) scan was done, which ruled out any locoregional or distant metastasis.
The procedure was successfully completed robotically using the Da Vinci Si system. The procedure was performed with the patient in a steep Trendelenburg position and the robot placed between the legs of the patient. A sponge stick was placed in the vagina to aid in dissecting the bladder and rectum from the vaginal vault.
| Docking the Robot|| |
A 12-mm port was placed two fingers above the umbilicus for the camera. Two 8-mm robotic ports were placed 8 cm to the right and 8 cm to the left of the camera port at the level of the umbilicus to accommodate the monopolar scissors and bipolar forceps, respectively. Another 8-mm robotic port was placed 8 cm lateral to the left robotic port for the prograsp forceps. A 5-mm port was placed, 5 cm cranial to both the camera and right robotic port for suction, and another 12-mm assistant port was placed 2 inches above the right anterior superior iliac spine [Figure 1].
| Procedure|| |
After docking the robot, the procedure was completed in the following 10 steps:
- Separating the adhesions between the bladder and the rectum
- Opening the retroperitoneum bilaterally and creating pararectal and paravesical spaces
- Revision of bilateral infundibulopelvic ligaments
- Bilateral pelvic node dissection
- Dissection of the bladder from the vault anteriorly and rectum from the vault posteriorly
- Bilateral ureteric dissection till entry into the bladder
- Coagulating and cutting the uterosacral and cardinal ligaments at the level of sacrum and lateral pelvic wall, respectively
- Opening the vault after taking an adequate length of the vagina
- Delivering the specimen vaginally
- Closure of the vaginal vault.
A small cystotomy occurred intraoperatively, which was repaired robotically at the same time.
Various steps of the procedure are depicted in [Figure 2][Figure 3][Figure 4][Figure 5]. [Figure 6] depicts the final parametrectomy specimen. The duration of surgery was 225 minutes; estimated blood loss was 50 mL, and the patient was discharged on the third postoperative day with a Foley’s catheter, which was removed on postoperative day 15 with a postvoid residual urine of 80 mL.
On final histopathology, there was no residual tumor at the vaginal vault, bilateral parametrium was free, and 14 pelvic nodes were retrieved, which were all free. The patient did not require any adjuvant treatment and is presently disease-free at a follow-up period of 2.5 years.
| Discussion|| |
Simple hysterectomy is a suboptimal treatment for early invasive cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) stage IA2–IB1). In the absence of further treatment, the risk of recurrence is high with a five-year survival of about 50%. The estimated five-year survival is 90% after radical parametrectomy or adjuvant radiation therapy.,
However, due to technical difficulties, a lack of surgical expertise, and a lack of knowledge about the safety and efficacy of the procedure, most of the treating physicians offer radiation therapy/concurrent chemoradiation for invasive cervical cancer diagnosed after simple hysterectomy.
Minimally invasive surgical techniques are developed with an aim to decrease morbidity associated with the procedures without compromising the oncological outcomes. Till date, about 47 cases of robotic radical parametrectomy have been reported for gynecological malignancies.,,,,,,
The mean operative time for robotic radical parametrectomy across various reports ranges from 182 to 365 minutes. The mean blood loss ranges from 100 to 147 mL, and the mean duration of hospital stay ranges from 1 to 5 days.,,,,
Cystotomy is the most common complication seen with this procedure.,,, About 80% of patients do not require any further adjuvant treatment. We reported similar findings in our case.
Thus concluding, radical parametrectomy is a challenging procedure that requires surgical expertise due to the presence of dense pelvic adhesions as a result of previous surgery, which modifies the anatomical landmarks. The three-dimensional view provided by the robotic platform creates images with increased resolution and the hydraulic ergonomics combined with the increased degrees of freedom and dexterity, greatly enhances the surgeon’s ability to perform a complex surgery like radical parametrectomy with relative ease.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]