Peter Rusch

Intraoperative navigation in robotically assisted compartmental surgery of uterine cancer by visualisation of embryologically derived lymphatic networks with indocyanine-green (ICG)

To evaluate feasibility of intraoperative visualization of embryologically defined organ compartments and their drainage by ICG in uterine cancer.

Zinc distribution within breast cancer tissue: A possible marker for histological grading?

PurposeFocusing on the trace metal zinc as a potential biomarker for breast cancer, the literature describes bulk zinc concentrations in breast cancer tissue to be higher than in normal tissue. From a histopathological point of view, cancer cells are intermingled with normal cells of the stroma within breast cancer tissues; therefore, bulk analysis cannot reflect this situation adequately. To address this problem, analysis of zinc distribution in histological sections is the method of choice.MethodsIn the present study, nine samples of invasive ductal and lobular breast carcinoma of histological grade 1–3 were investigated, clearly differentiating between cancer and stroma areas. Zinc concentrations were determined by laser ablation inductively coupled plasma mass spectrometry applying a calibration technique based on spiked polyacrylamide gels.ResultsDirect comparison between hematoxylin- and eosin-stained tissues and zinc contour plots revealed that zinc is enriched in cancer tissue containing tumor cells in contrast to normal stroma. Moreover, zinc concentration in carcinomatous tissues directly correlates with the histological malignancy grade.ConclusionsDifferentiation between carcinomatous tissue and stroma by determination of zinc content and the correlation of zinc concentration with the histological malignancy grade not only provides a key feature for clinical decision making for cancer therapy but also suggests the trace metal zinc as a potential biomarker for breast cancer.

Technique of ICG-guided Targeted Compartmental Pelvic Lymphadenectomy (TCL) combined with Pelvic Peritoneal Mesometrial Resection (PMMR) for locoregional control of endometrial cancer – A proposal

Highlights • PMMR is a compartment based radical hysterectomy in endometrial cancer.• Pelvic PMMR may be combined with ICG guided Targeted Compartmental Lymphadenectomy (TCL).• Video of Pelvic PMMR and TCL technique may be basis for a prospective study.

The Society of European Robotic Gynaecological Surgery (SERGS) Pilot Curriculum for robot assisted gynecological surgery

PurposeTo set forth experiences in the context of the SERGS Pilot Curriculum—the first standardized educational program for robotic use in gynecological surgery—in terms of feasibility, effectiveness and potential for certification.MethodsThe Society of European Robotic Gynecological Surgery (SERGS) outlined a Pilot Curriculum for standardized education in robot-assisted laparoscopic gynecological surgery. Its feasibility and acceptance were checked in the form of a fellowship pilot program conducted at four European Centers of Excellence for robot-assisted surgery. Results and conclusions derived from this pilot program are presented.ResultsThe SERGS Pilot Curriculum defines criteria for a standardized training and assessment of performance, boosts the learning curve of the candidate and increases contentment at work. Regarding face validity, it proves valuable as finally all candidates could perform the outlined procedure safely and efficiently without supervision.ConclusionDue to the immense increase of robotic procedures in gynecology standardized training curricula are indispensable. This seems highly necessary to ensure patients’ safety and surgical outcome. The SERGS Pilot Curriculum sets standards for a stepwise theoretical and practical training in gynecological robotic procedures. It seems feasible as instrument for accreditation as gynecologic robotic surgeon. Though as a general applicable guideline for systematic training in robot-assisted surgery, a definite curriculum should have a more definite timeline and implementation of a structured assessment of performance.

Surgical treatment of early ovarian cancer with compartmental resection of regional lymphatic network and indocyanine-green-guided targeted compartmental lymphadenectomy (TCL, paraaortic part)

Objective Whether pelvic and para-aortic lymphadenectomy is of therapeutic benefit in advanced ovarian cancer will remain unclear until the publication of the Arbeitsgemeinschaft Gynäkologische Onkologie lymphadenectomy in ovarian neoplasms (AGO LION) trial. In early ovarian cancer, however, lymphadenectomy seems mandatory for diagnostic and also therapeutic reasons [123]. Methods Complete systematic lymphadenectomy is accompanied by morbidity which may be reduced by sentinel node biopsy already established for several solid tumors [456]. In ovarian cancer there are 2 main pathways in lymphatic drainage: along the ovarian vessels to the para-aortic nodes and the uterine vessels to the iliac lymph compartments [7]. Following injection of radioactive dye into the ovarian ligaments this could be confirmed suggesting that there is bidirectional flow at this level of the ovarian and uterine lymphatic pathways [8]. Indocyanine-green-guided (ICG) injection to the uterine corpus seems to be equally effective in labelling the “uterine Müllerian” and the “ovarian mesonephric” lymphatic drainage of the ovary [910]. Results This technique [9] was applied and will be outlined in the video showing the procedure with respect to the para-aortic lymphatic drainage. Isolated sentinel node biopsy and tumor excision will not resect the organ compartment together with its super-ordinated draining lymphatic system at risk. Conclusion Thus, the authors suggest to remove the malignancy together with its draining lymphatic vessels and at least the first 2 sentinel nodes in each channel en bloc; we propose to analyze this procedure consistent with the ontogenetic approach [1112] with respect to diagnostic accuracy and loco-regional control. This could potentially avoid most of systematic lymphadenectomies in early ovarian cancer.

Early ovarian cancer surgery with indocyanine-green-guided targeted compartmental lymphadenectomy (TCL, pelvic part)

Objective Para-aortic indocyanine-green (ICG)-guided targeted compartmental lymphadenectomy is feasible in early ovarian cancer [1]; systematic pelvic and para-aortic lymphadenectomy could potentially be avoided if thoroughly investigated sentinel nodes could predict whether residual nodes will be involved or free of disease. In contrast to advanced ovarian cancer, where the therapeutic potential of lymphadenectomy will soon be clarified by the results of the Arbeitsgemeinschaft Gynäkologische Onkologie lymphadenectomy in ovarian neoplasms (AGO LION) trial, systematic lymphadenectomy seems to be mandatory for diagnostic and also therapeutic purposes in early ovarian cancer [234]. Sentinel node biopsy or resection of the regional lymphatic network may reduce morbidity compared to systematic lymphadenectomy as shown already for other entities [567]. Apart from the ovarian mesonephric pathway [1], a second Müllerian uterine pathway exists for lymphatic drainage of the ovary [8]. Lymphatic valves apparently do not exist at this level of the utero-ovarian network since injection of radioactivity into the ovarian ligaments also labelled pelvic nodes [9]. Methods We applied ICG using 4×0.5 mL of a 1.66 mg/mL ICG solution for transcervical injection into the fundal and midcorporal myometrium at each side [10] instead of injection into the infundibulopelvic ligament, since the utero-ovarian drainage was intact. Results In this case a 1.8 cm cancer of the right ovary was removed in continuity with its draining lymphatic vessels and at least the first 2 sentinel nodes in each channel “en bloc” as shown in this video for the pelvic part, consistent with the loco-regional ontogenetic approach [1112]. Conclusion This could potentially avoid most of systematic lymphadenectomies in early ovarian cancer.

Surgical anatomy of the ligamentous mesometrium and robotically assisted ICG-guided resection in cervical cancer

The ligamentous mesometrium is a 3-dimensional structure consisting of a rectouterine/-vaginal part with attachment to the anterior lateral mesorectum and a sacrouterine part surrounding the mesorectum attached to the pelvic fascia and the mesorectum dorsolaterally. The lymphatic network draining the posterior cervix connected caudally ventrally to the deep venous lymph network of the vascular mesometrium is running at the lateral surface of the sacrouterine part and dorsomedially of the inferior hypogastric plexus; it drains to the deep internal iliac, prespinal and preischiadic nodes.

Aortic utero-ovarian sentinel nodes and left infrarenal aortic lymph node dissection by ICG supported navigation

Highlights • Visualization of paraaortic sentinel compartments in endometrial cancer• Nerve sparing dissection of left paraaortic infrarenal lymph compartment• Educational video may be basis for standardization of paraaortic sentinel node dissection.

Left paraaortic, inframesenteric lymphadenectomy preserving the superior hypogastric plexus supported by indocyanine green (ICG) labeling of the lymphatic compartment in cervical cancer

Superior hypogastric plexus (SHG) contains mainly sympathetic and most probably also postganglionic parasympathetic fibers. Thus, surgical damage of SHG may cause autonomic pelvic organ dysfunction (Kraima et al., 2015). As already shown for rectal cancer, preservation of the autonomic nerves is facilitated by robotic surgery and may avoid sexual dysfunctions and voiding disorders (Kim et al., 2015). In this educational video, we demonstrate left lower paraaortic lymph node dissection preserving the SHG using ICG fluorescence to label the lymphatic compartment. Prior to total mesometrial resection (TMMR) with therapeutic lymphadenectomy for cervical cancer (Höckel et al., 2009, Kimmig et al., 2013) 4 × 0.5 ml of a 1.66 mg/ml Indocyanine green solution (ICG Pulsion®, PMS SE, Feldkirchen, Germany) was injected into the uterine cervix at all four quadrants, 0.5 cm in depth (Kimmig et al., 2016). The lymphatic network of the downstream common iliac and inferior paraaortic lymph compartments of the uterine cervix is visualized (ICG fluorescence) including the individual connecting vessels between the different compartments. As can be demonstrated, the medial upper common iliac (subaortic) compartment drains preferentially into the anterior (mesenteric) compartment, whereas lateral common iliac lymphatic vessels mainly drain to the posterior (lumbar) paraaortic compartment. The autonomic nerve fibers of the SHP may easily be identified and preserved due to the excellent image resolution and the discrimination from fluorescent lymphatic structures. The video shows the preparation of left lower paraaortic nodes in cervical cancer following ICG labeling using a da Vinci Xi system®. This technique seems not only advantageous for preserving SHP, but even more highly educational to learn surgical anatomy for trainees.

The Society of European Robotic Gynaecological Surgery (SERGS) Pilot Curriculum for robot-assisted gynaecological surgery: authors’ reply to a letter to the editor

We thank Dr. Moglia for his clear summary of our pilot study. Indeed, he confirms our observation that despite well defined and structured endpoints of training, evaluation was often still performed with irregular and open feedback. This once more stresses the need for teach-the-teachers courses to educate those responsible for surgical training. Similarly, Dr. Moglia rightfully points out that Global Evaluative Assessment of Robotic Skills (GEARS) was not always completely used in our Pilot Curriculum. Nevertheless, we demonstrated considerable variation between trainees in the development of skills. The real-life experience of our study turned out to be helpful in drafting a standardised educational programme for training in robot-assisted surgery. On the basis of this experience, we completely agree with Dr. Moglia that modular training should be the standard and that proficiency should be based more on the portfolio with systematic and structured assessments rather than on case volume. Author contributions PR: Manuscript writing, project administration. RHMV: Manuscript writing, project administration.