Emanuele Perrone

3 mm Senhance robotic hysterectomy: a step towards future perspectives

In the last two decades, surgical approach for hysterectomy has evolved significantly [1]. On the one hand single-site surgery, minilaparoscopy and the more recent percutaneous approach have led to an increasing search of minimal invasiveness [2]; on the other hand, technology reached the highest expression in robotics [3, 4]. Whereas minimizing laparoscopic access permitted to achieve a further and significant reduction of invasiveness while maintaining surgical adequacy, robotic technology allowed the possibility to overcome common limits of laparoscopic approach extending the advantages of endoscopic surgery to “difficult cases” for whom the only surgical way would have been an extensive laparotomy. Apparently, these two trends deeply diverge from each other. However, technological improvement is constantly redefining the concept of the “minimal” surgical approach. In 2013 the introduction of Telelap ALF-X robotic system (now called SenhanceTM—Transenterix USA) represented a unique innovation in this panorama: robotic technology applied to a pure laparoscopic setting with reusable instruments and 5 mm ancillary trocar [5]. System description Senhance surgical platform is based on three independent robotic arms that are remotely controlled by the Surgeon. From the control unit, named “cockpit”, the surgeon drives the robotic arms by utilizing robotic controls that replicate the laparoscopic manipulators. Immediately below the 3D-HD screen, an infrared sensor, the “eye tracking system”, constantly tracks the surgeon’s eye movement and drives the camera according to the specific point the surgeon is looking at. On each robotic arm, 5 or 3 mm strength and reusable instruments can be hooked and inserted in the peritoneal cavity through standard trocars. A 10-mm balloon trocar is inserted in the umbilicus for the 10-mm 3D-HD camera (Viking System). Once the operative procedure has started, each robotic arm detects the force applied on tissues: these data are processed by the system and translated in “haptic feedback” on the control manipulator. Main characteristics of this innovative technology have been widely investigated in terms of safety and efficacy in gynecological procedures in our Division of Gynecologic Oncology of the Policlinico Agostino Gemelli in Rome [6]. Basing on this premises, looking back to published data in terms of ultra-minimally invasive instrumentation and considering the high versatility of the system, Transenterix recently introduced a totally new CE-marked robotic instrumentation: driven by utilizing surgeons’ requests, a set of 3-mm monopolar reusable robotic instruments was developed to cross the line of both minimally invasive and robotic surgery. Representing an absolute innovation, for the first time in the robotic era, 3 mm instruments are hooked on a robotic platform. From July to September 2017, four patients with indication of hysterectomy with bilateral salpingo-oophorectomy for risk-reducing purpose or premalignant endometrial disease were considered eligible for 3 mm Senhance surgery. IRB approval was obtained and the patients were enrolled after the signing of informed consent. The same surgeon with an experience of more than 100 Senhance procedures performed all surgeries. A standard laparoscopic port placement was adopted for the surgical procedures. * Salvatore Gueli Alletti gueliallettis@gmail.com

Robotic video endoscopic inguinal lymphadenectomy (R-VEIL) for vulvar cancer with sentinel node mapping using indocyanine green and near-infrared fluorescence imaging technology

Objectives Video endoscopy inguinal lymphadenectomy (VEIL) has emerged as the new frontier for the surgical staging of vulvar cancer (VC) [1, 2]. In this surgical film we show a step-by-step video presentation of a Robotic SLNmapping using ICG (Canadian Task Force classification III). Although the therapeutic benefit of SLN remains controversial in clinical N0 (cN0) with VC N 4 cm [3], it provides prognostic information that can guide further adjuvant treatment. Robotic sentinel lymphnode (SLN) mapping using indocyanine green (ICG) appears to be a suitable and attractive alternative to provide reliable staging with respect to other tracers [3, 4]. Methods A 75-year-old severely obesewoman (BMI:47.8 kg/m2) with squamous VC grading 3, clinical stage II (cT = 5 cm, cN0, cM0) and with a pre-operative PET-CT scan negative for metastatic localizations, was admitted for surgery. Surgical staging was performed including radical vulvectomy with macroscopic resection margins larger than 2 cm., SLN mapping with ICG followed by systematic inguinal lymphadenectomy. Da Vinci Xi System® was used to perform it. Results The operation was performed successfully with no intraoperative or postoperative complication. Operative time was 310 min overall. Twenty-five inguinal lymph nodes were removed (11 on the left, 14 on the right). The pathology report came back positive for SLN removed. The patient was discharged on day #4 and 20 days later started adjuvant radiochemotherapy. Conclusions SLN with ICG is robotically feasible. However, we notice that further prospective trials are needed to compare ICG with other colorimetric and/or radioactive tracers in this subset of patients.

Preoperative serum human epididymis protein 4 levels in early stage endometrial cancer: A prospective study

Objective The aim of the study was to evaluate the prognostic value of human epididymis protein 4 (HE4) and cancer antigen 125 markers with pathological prognostic factor to complete the preoperative clinical panel and help the treatment planning. Methods This prospective multicenter study was conducted in 2 gynecologic oncology centers between 2012 and 2014 (Institute for Maternal and Child Health IRCCS Burlo Garofolo in Trieste and Catholic University of the Sacred Heart in Rome, Italy). We enrolled 153 patients diagnosed with clinical early (International Federation of Gynecology and Obstetrics stages I–II) type I endometrial cancer. Results Human epididymis protein 4 levels seemed to be strictly related to age (P < 0.001) and menopausal status (P < 0.002). Compared with myometrial invasion (MI), the HE4 values were significantly higher in case of invasion of greater than 50% of the thickness: MI of greater than 50%, median of 94.85 pmol/L (38.3–820.8 pmol/L), versus MI of less than 50%, median of 65.65 pmol/L (25.1–360.2 pmol/L), (P < 0.001). The HE4 levels increase significantly with increasing tumor size: diameter of larger than 2 cm, median of 86.9 pmol/L (35.8–820.8 pmol/L), versus diameter of smaller than 2 cm, median of 52.2 pmol/L (33.3–146.8 pmol/L), (P < 0.001). In our population, HE4 did not correlate with the histological grade, endometrial cancer type I versus type II (P = 0.86), the lymphovascular infiltration (P = 0.12), and the cervical invasion (P = 0.6). We established a new variable, considering 3 high-risk tumor features: MI of greater than 50% and/or histological G3 and/or type II. Human epididymis protein 4 levels significantly increase in high-risk tumors (high risk HE4, 93.6 pmol/L vs low-medium risk, 65.5 pmol/L; P < 0.001). Conclusions A preoperative HE4 evaluation could help stratify patients with deep invasion and/or metastatic disease and is correlated with other relevant prognostic factors to be considered to tailor an adequate surgical strategy.