Chérazade Bensaid

Postoperative lymphocysts after lymphadenectomy for gynaecological malignancies: preventive techniques and prospects

Postoperative lymphocyst formation is an insufficiently recognised complication of lymphadenectomy for gynaecological malignancies. Lymphocysts are collections of lymph organised into cysts that develop in contact with lymphadenectomy compartments. There has been considerable debate about the relevance of lymphocyst prevention using surgical or pharmacotherapeutic methods. Here, we review the available studies about the impact of these methods on the incidence of lymphocysts. This review suggests that several techniques may decrease the incidence of lymphocysts when used in combination. On a literature basis, the peritoneum should be left open over the lymphadenectomy sites at the end of the procedure and drains should not be placed at the end of the procedure. Omentoplasty should be encouraged and further studies are needed to assess the potential benefits of new energies. Postoperative octreotide therapy seems beneficial but the role of this drug in pelvic oncological surgery remains to be determined.

Robotic extraperitoneal paraaortic lymphadenectomy in gynecological cancers: feasibility, safety, and short-term outcomes of isolated and combined procedures.

Objective The aim of our study was to report the technique, the feasibility, and perioperative results of robotic extraperitoneal paraaortic lymphadenectomy in gynecological cancers performed for isolated or combined procedures. Methods This is a retrospective study of 24 consecutive patients undergoing robotic extraperitoneal paraaortic lymphadenectomy using the Da Vinci Surgical system (Intuitive Inc, Sunnyvale, CA) (cervical cancer, n = 15; high-risk endometrial cancer, n = 8; and ovarian cancer, n = 2, including 1 synchronous tumor). Extraperitoneal paraaortic lymphadenectomy was performed using the surgical technique previously described by laparoscopy. Results Of the 24 included patients, 12 patients had isolated robotic extraperitoneal paraaortic lymphadenectomy, whereas the others underwent the following associated procedures: total hysterectomy with bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and omentectomy (n = 7); pelvic transperitoneal lymphadenectomy (n = 3), laparotomic Bricker procedure (n = 1), and colpectomy (n = 1). The median age of patients was 55 (42–64) years, and body mass index was 24.1 kg/m2 (20.9–26.1). The operation was completed in all patients except three with associated procedures. Perioperative difficulties were encountered in 9 patients (gas leakage, n = 7; adhesions, n = 2; and dissection difficulties, n = 1). The number of removed paraaortic lymph nodes was 18 (14–25). The operating times were 180 (150–210) minutes for isolated extraperitoneal paraaortic lymphadenectomy and 240 (180–300) minutes in case of associated procedures. There were 2 intraoperative (pneumothorax and renal artery injury) and 5 postoperative (3 grades 1–2 and 2 grade 3) complications. Conclusions If robotic-assisted extraperitoneal paraaortic lymphadenectomy seems feasible in case of isolated procedure, further studies are required to prove its benefit compared with conventional laparoscopy.

Evidence for the use of robotically assisted surgery in gynecologic cancers.

Purpose of review Robotically assisted laparoscopy has been introduced in the armamentarium of gynaecologic oncology surgeons. A lot of studies compared robotic surgery and laparotomy when the real issue is to demonstrate the interest and added value of robotically assisted laparoscopy versus standard laparoscopy. In this review, we will describe the most meaningful indications and advantages of robotically assisted laparoscopy in gynaecologic oncology. Recent findings The learning curve for advanced procedures in robot-assisted laparoscopy is shorter and easier than with the standard laparoscopy, especially for beginners. In most of the series, operating time is longer with robot, but complication rates are often decreased, especially in obese patients with a conversion rate to laparotomy that is decreased compared with standard laparoscopy. Robot-assisted laparoscopy can be used for surgery of high-risk endometrial cancer, staging of early-ovarian cancer, and pelvic exenteration in case of recurrent malignancies. Furthermore, more recent robots allow performing sentinel node biopsy in endometrial or cervical cancer using fluorescence detection with indocyanine green. Summary The spreading of robotic surgery led to an enhancement of minimal invasive surgical approach in general, and to the development of new indications in gynaecologic oncology. The superiority of robot-assisted laparoscopy still has to be demonstrated with properly designed trials.

Lower-Limb Drainage Mapping for Lymphedema Risk Reduction After Pelvic Lymphadenectomy for Endometrial Cancer

OBJECTIVES Pelvic lymphadenectomy is associated with a significant risk of lower-limb lymphedema. In this proof-of-concept study, we evaluated the feasibility of identifying the lower-limb drainage nodes (LLDNs) during pelvic lymphadenectomy for endometrial cancer. Secondary objectives were to map lower-limb drainage and to assess the diagnostic value of our mapping technique. METHODS This prospective study included patients with endometrial cancer requiring pelvic lymphadenectomy, without neoadjuvant radiotherapy or chemotherapy and without history of lower-limb surgery. A radiopharmaceutical was injected into both feet on the day before surgery. LLDNs were identified using preoperative lymphoscintigraphy and intraoperative isotopic probe detection, then removed before complete pelvic lymphadenectomy. LLDNs and pelvic lymphadenectomy specimens underwent separate histological analysis. RESULTS Of the 12 patients with early-stage endometrial cancer, 10 underwent preoperative lymphoscintigraphy, which consistently identified inguinal, femoral, and pelvic LLDNs (detection rate: 100%). The intraoperative detection rate was 83% (10/12). Median number of hot nodes per patient was 5 nodes (range: 3-7) on the right and 3 nodes (range: 2-6) on the left. Of 107 LLDNs, 106 were in the external iliac area, including 38 in the lateral group and 45 in the intermediate and medial groups. None of the patients had node metastases at any site. No early complications related to the technique occurred. CONCLUSION Our mapping technique appears feasible, safe, and associated with a high LLDN identification rate. LLDN mapping may allow the preservation of LLDNs, thereby decreasing the risk of lower-limb lymphedema and improving quality of life.

Robot-Assisted Laparoscopic Partial Colpectomy and Intracorporeal Ileal Conduit Urinary Diversion (Bricker) for Cervical Adenocarcinoma Recurrence.

Ileal conduit urinary diversion (Bricker) is a standard surgical open procedure. The Da Vinci robot allowed precision for this surgical procedure, especially for intracorporeal suturing. Meanwhile, few reports of robot-assisted laparoscopic ileal conduit diversion (Bricker) are described in the literature. We report the case of a 69-year-old patient with a vaginal recurrence of cervical adenocarcinoma associated with vesicovaginal fistula treated by robot-assisted laparoscopic partial colpectomy and ileal conduit urinary diversion (Bricker). The robot-assisted laparoscopic procedure followed all surgical steps of the open procedure. Postoperative period was free of complications.

Cancer de l’ovaire et personnes âgées

Avec l’augmentation de l’esperance de vie, la pathologie cancereuse des personnes âgees represente un probleme majeur de sante publique. L’âge avance est un facteur de risque pejoratif pour la survie dans le cancer de l’ovaire. C’est aussi un facteur determinant de traitement sous-optimal, independamment des comorbidites. Le succes de la chirurgie de cytoreduction initiale optimale est significativement lie a un meilleur pronostic de la maladie. Plusieurs etudes retrospectives ont suggere que les femmes âgees pouvaient tolerer une chirurgie de cytoreduction optimale et recevoir des doses standard de chimiotherapie. Le concept actuel « d’evaluation geriatrique standardisee » inclut une approche globale, avec une identification des zones de vulnerabilite, et permettrait potentiellement de predire la tolerance et la reponse aux traitements contre le cancer. Il est necessaire et primordial de developper de nouveaux essais geriatriques specifiques afin de comparer les traitements standard a d’autres schemas therapeutiques en termes de dose et de duree de traitement afin d’ameliorer la tolerance. Ces precautions pourraient permettre de reduire les deces precoces evitables dans cette tranche de population