Endometrial cancer affects women during menopause with a peak incidence in women aged 55-60. An increase in incidence has recently been observed in the under 50s, mainly due to the increasing impact of obesity in younger women.
Initially, surgery for the disease consisted of the classical approach, but with time treatment by minimally invasive surgery has shown its superiority and benefits for patients. Because it frequently occurs in older patients who find it difficult to tolerate general anaesthesia, a “milder” solution was sought that would provide oncologic targeted treatment.
What is modern surgical treatment of endometrial cancer?
Treatment of endometrial cancer consists of total hysterectomy with bilateral adnexectomy and pelvic lymph node evaluation.
Pelvic lymph node evaluation can be performed by pelvic and, if appropriate, lumbo-aortic lymphadenectomy or sentinel lymph node evaluation.
While it was originally said that in well-differentiated stage G1 endometrial cancer, which does not invade the myometrium, you can avoid pelvic lymphadenectomy, unfortunately 15% of cases have positive lymph nodes, and in 25% of cases you may be told on biopsy that it’s a well-differentiated G1 cancer, and then when you send a whole piece to the biopsy, post-operatively you may be told that it’s actually a moderate or poorly differentiated cancer (G2, G3), which changes the facts of the matter. For the patient’s safety, the best option remains hysterectomy and pelvic lymphadenectomy.
The current surgical treatment technique involves the use of the sentinel lymph node technique – the first lymph node to drain the target organ. The sentinel node is evaluated intraoperatively.After sampling, the protocol is as follows: the lymph node is sent for extratemporaneous histopathological examination.
- If the lymph node is negative, pelvic lymphadenectomy should not be performed.
- If the lymph node is positive, there are 2 alternatives: 1. pelvic and para-aortic lymphadenectomy with hysterectomy and adnexectomy. 2: patient referred for radiotherapy, because from stage I, she goes to stage III.
Benefits of using robotic technique in sentinel lymph node detection
The sentinel node brought an added advantage to minimally invasive surgery. To identify it, coloured substances are used: methyl blue, the newer approved indocyanine green, which requires a near-infrared light filter to identify the change in tissue colour.
Identification of the sentinel lymph node has added benefit to minimally invasive surgery, because pelvic lymphadenectomy is burdened with long-term morbidity, namely lymphoedema or the appearance of lymphocysts. When using robotic surgery, the advantage of visibility offered by robotic technology is superior to other techniques.
The specific deep green colouring allows us to identify the tracer, the lymph channel draining the lymph node.
Identification of the sentinel lymph node with indocyanine green by robotic surgery, which, unlike laparoscopic surgery, uses a laser technology that makes it easier to identify the lymph node in en easier and more accurate way, allowing us to perform a much finer dissection in a very sensitive area, rich in vessels, nerves, and vital structures. It should be stressed that indocyanin green is non-toxic.
Patient advantages after robotic intervention, compared to open abdominal surgery:
- Minimal intra-operatory blood loss;
- Fewer post-operatory complications;
- Shorter hospitalization period;
- Faster patient recovery – the patient is mobilized 8 hours after the surgery, she can walk, feed and can easily resume the routine, being in good shape.
What should patients undergoing this type of surgical treatment for endometrial cancer know?
The classic intervention in this pathology is related to morbidity in the post-operative period, because it often leads to wound infection, wound dehiscence, late mobilization, as well as thromboembolic risk due to neoplastic disease and prolonged bed rest.
The minimally invasive approach supports patients both in terms of faster recovery and reduction of long-term complications.
The prognosis after this procedure is very good, if the patient has no invasion in more than half of the myometrial thickness, G1, G2 differentiation grade, negative lymph nodes, and no additional treatment is needed.
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