Journal of Robotic Surgery

, Volume 12, Issue 1, pp 49–58 | Cite as

Robot-assisted laparoscopic transperitoneal infrarenal lymphadenectomy in patients with locally advanced cervical cancer by single docking: Do we need a backup procedure?

  • Fatih Gucer
  • Selim Misirlioglu
  • Nuri Ceydeli
  • Cagatay Taskiran
Original Article


To present our initial experience on the feasibility of robotic transperitoneal para-aortic lymphadenectomy up to left renal vein via single docking approach by high port insertion technique followed by left shoulder docking as a rescue backup procedure in surgically obstructed patients undergoing surgical staging because of locally advanced cervical cancer (LACC). Prospective observational preliminary study. Canadian Task Force classification II-3. Tertiary-care academic affiliated private hospital. Ten patients with LACC who underwent robotic transperitoneal infrarenal para-aortic lymphadenectomy between January 2012 and December 2014. All patients with pathologically proven cervical cancer underwent a PET/CT scanning in a similar fashion at the department of nuclear medicine. PET/CT scans were evaluated by the nuclear medicine specialist. Following pre-operative work-up, robot-assisted transperitoneal infrarenal para-aortic lymphadenectomy was performed up to left renal vein by the same experienced surgeon. Sections of 5 mm were performed and stained with routine hematoxylin and eosin (H&E), and node count was done separately by experienced gynecopathologist. During the study period, 12 consecutive patients with LACC were counseled for pre-therapeutic robot-assisted transperitoneal para-aortic lymphadenectomy. Two patients declined the procedure and underwent standardized chemo-radiation therapy whereas remaining ten patients constituted the study group. In the study group, the median age was 46 years (range 33–59 years), and the median body mass index 28.5 kg/m2 (range 18.5–35.1 kg/m2). Clinical staging was stage IIB in four patients, IIIB in four, and IVA in one. Histopathological diagnosis was squamous cell carcinoma in nine patients, and adenocarcinoma in one. On PET/CT scans, seven out of ten patients were positive for pelvic lymph node metastasis. With respect to para-aortic area, only one of the ten patients had suspected metastasis in PET/CT. For nine patients with LACC, the median docking time was 6.5 min (range 4–15 min), and the median operating time for para-aortic lymphadenectomy was 120 min (range 60–165 min). The median trocar time was 14.5 min (range 5–45 min). In two out of ten patients, the surgical removal of whole lymphatic tissue between inferior mesenteric artery and left renal vein was not completely possible by a single docking of robotic column. Therefore, a new optic trocar was placed in the umbilicus and the robotic column was relocated over the left shoulder of the patient and residual lymphatic tissue measuring approximately 2 cm in the long axis immediately below the left renal vein was removed and the surgery was completed up to the left renal vein. All para-aortic lymphadenectomies have been completed by robotic route. There were no intra-operative complications. No patient received a blood transfusion. Early post-operative grade 2 and 3a complications according to Dindo classification occurred in two patients: one symptomatic lymphocyst and one local infection on assistant port site in one patient. The patient with suspected para-aortic lymph node metastasis in PET/CT showed no metastatic disease on histopathologic exam of para-aortic lymph nodes. The patient with recurrent disease and negative para-aortic lymph nodes on frozen section examination underwent robot-assisted total pelvic exenteration. Five of the residual eight patients had histologically proven metastasis in the para-aortic lymph node(s). Treatment modification occurred in six patients related to pre-treatment staging surgery. According to pathological results, extended field radiation therapy has been added in five patients and it was omitted in one patient. The median time interval between surgery and initiation of radiotherapy was 12 days (range 6–23 days). Robotic transperitoneal infrarenal para-aortic lymphadenectomy up to left renal vein by high port insertion technique is a safe and feasible option for staging and treatment planning. However, technically, it is obstructed in a small group of patients and nodal staging surgery up to left renal vein can be completed by consecutive left shoulder docking approach as a backup rescue plan.


Robotic surgery Tansperitoneal Para-aortic lymphadenectomy 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Michel G et al (1998) Lymphatic spread in stage Ib and II cervical carcinoma: anatomy and surgical implications. Obstet Gynecol 91(3):360–363CrossRefPubMedGoogle Scholar
  2. 2.
    Vandeperre A et al (2015) Para-aortic lymph node metastases in locally advanced cervical cancer: comparison between surgical staging and imaging. Gynecol Oncol 138(2):299–303CrossRefPubMedGoogle Scholar
  3. 3.
    Gouy S et al (2013) Prospective multicenter study evaluating the survival of patients with locally advanced cervical cancer undergoing laparoscopic para-aortic lymphadenectomy before chemoradiotherapy in the era of positron emission tomography imaging. J Clin Oncol 31(24):3026–3033CrossRefPubMedGoogle Scholar
  4. 4.
    Frumovitz M et al (2014) Lymphadenectomy in locally advanced cervical cancer study (LiLACS): phase III clinical trial comparing surgical with radiologic staging in patients with stages IB2-IVA cervical cancer. J Minim Invasive Gynecol 21(1):3–8CrossRefPubMedGoogle Scholar
  5. 5.
    Leblanc E et al (2016) Should systematic ınfrarenal para-aortic dissection be the rule in the pretherapeutic staging of primary or recurrent locally advanced cervix cancer patients with a negative preoperative para-aortic pet ımaging? Int J Gynecol Cancer 26(1):169–175CrossRefPubMedGoogle Scholar
  6. 6.
    Scheidler J et al (1997) Radiological evaluation of lymph node metastases in patients with cervical cancer. A meta-analysis. JAMA 278(13):1096–1101CrossRefPubMedGoogle Scholar
  7. 7.
    Magne N et al (2008) New trends in the evaluation and treatment of cervix cancer: the role of FDG-PET. Cancer Treat Rev 34(8):671–681CrossRefPubMedGoogle Scholar
  8. 8.
    Ramirez PT et al (2011) Laparoscopic extraperitoneal para-aortic lymphadenectomy in locally advanced cervical cancer: a prospective correlation of surgical findings with positron emission tomography/computed tomography findings. Cancer 117(9):1928–1934CrossRefPubMedGoogle Scholar
  9. 9.
    Uzan C et al (2011) Analysis of morbidity and clinical implications of laparoscopic para-aortic lymphadenectomy in a continuous series of 98 patients with advanced-stage cervical cancer and negative PET-CT imaging in the para-aortic area. Oncologist 16(7):1021–1027CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Marnitz S et al (2005) Is there a benefit of pretreatment laparoscopic transperitoneal surgical staging in patients with advanced cervical cancer? Gynecol Oncol 99(3):536–544CrossRefPubMedGoogle Scholar
  11. 11.
    Leblanc E et al (2007) Therapeutic value of pretherapeutic extraperitoneal laparoscopic staging of locally advanced cervical carcinoma. Gynecol Oncol 105(2):304–311CrossRefPubMedGoogle Scholar
  12. 12.
    Brockbank E et al (2011) Pre-treatment surgical para-aortic lymph node assessment in locally advanced cervical cancer. Cochrane Database Syst Rev 4:Cd008217Google Scholar
  13. 13.
    Gil-Moreno A et al (2011) Pretherapeutic extraperitoneal laparoscopic staging of bulky or locally advanced cervical cancer. Ann Surg Oncol 18(2):482–489CrossRefPubMedGoogle Scholar
  14. 14.
    Vidaurreta J et al (1999) Laparoscopic staging in locally advanced cervical carcinoma: a new possible philosophy? Gynecol Oncol 75(3):366–371CrossRefPubMedGoogle Scholar
  15. 15.
    Lowe MP et al (2006) Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program. J Minim Invasive Gynecol 13(5):391–397CrossRefPubMedGoogle Scholar
  16. 16.
    Ramirez PT, Milam MR (2007) Laparoscopic extraperitoneal paraaortic lymphadenectomy in patients with locally advanced cervical cancer. Gynecol Oncol 104(2 Suppl. 1):9–12CrossRefPubMedGoogle Scholar
  17. 17.
    Tillmanns T, Lowe MP (2007) Safety, feasibility, and costs of outpatient laparoscopic extraperitoneal aortic nodal dissection for locally advanced cervical carcinoma. Gynecol Oncol 106(2):370–374CrossRefPubMedGoogle Scholar
  18. 18.
    Chong GO et al (2009) Learning curve of laparoscopic radical hysterectomy with pelvic and/or para-aortic lymphadenectomy in the early and locally advanced cervical cancer: comparison of the first 50 and second 50 cases. Int J Gynecol Cancer 19(8):1459–1464CrossRefPubMedGoogle Scholar
  19. 19.
    Gouy S et al (2011) Single-port laparoscopy and extraperitoneal para-aortic lymphadenectomy: about fourteen consecutive cases. Gynecol Oncol 123(2):329–332CrossRefPubMedGoogle Scholar
  20. 20.
    Benito V et al (2012) Laparoscopic extraperitoneal para-aortic lymphadenectomy in the staging of locally advanced cervical cancer: is it a feasible procedure at a peripheral center? Int J Gynecol Cancer 22(2):332–336CrossRefPubMedGoogle Scholar
  21. 21.
    Hong DG et al (2012) Laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy in patients with FIGO stage IB1-II B cervical carcinoma. Jsls 16(2):229–235CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Hudry D et al (2015) Robotically assisted para-aortic lymphadenectomy: surgical results: a cohort study of 487 patients. Int J Gynecol Cancer 25(3):504–511CrossRefPubMedGoogle Scholar
  23. 23.
    Diaz-Feijoo B et al (2014) Comparison of robotic-assisted vs conventional laparoscopy for extraperitoneal paraaortic lymphadenectomy. Gynecol Oncol 132(1):98–101CrossRefPubMedGoogle Scholar
  24. 24.
    Fastrez M et al (2013) Multi-center experience of robot-assisted laparoscopic para-aortic lymphadenectomy for staging of locally advanced cervical carcinoma. Acta Obstet Gynecol Scand 92(8):895–901CrossRefPubMedGoogle Scholar
  25. 25.
    Narducci F et al (2009) Early experience of robotic-assisted laparoscopy for extraperitoneal para-aortic lymphadenectomy up to the left renal vein. Gynecol Oncol 115(1):172–174CrossRefPubMedGoogle Scholar
  26. 26.
    Vergote I et al (2008) Robotic retroperitoneal lower para-aortic lymphadenectomy in cervical carcinoma: first report on the technique used in 5 patients. Acta Obstet Gynecol Scand 87(7):783–787CrossRefPubMedGoogle Scholar
  27. 27.
    Fastrez M et al (2009) Robot assisted laparoscopic transperitoneal para-aortic lymphadenectomy in the management of advanced cervical carcinoma. Eur J Obstet Gynecol Reprod Biol 147(2):226–229CrossRefPubMedGoogle Scholar
  28. 28.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Gouy S et al (2012) Nodal-staging surgery for locally advanced cervical cancer in the era of PET. Lancet Oncol 13(5):e212–e220CrossRefPubMedGoogle Scholar
  30. 30.
    Leblanc E et al (2011) Accuracy of 18-fluoro-2-deoxy-d-glucose positron emission tomography in the pretherapeutic detection of occult para-aortic node involvement in patients with a locally advanced cervical carcinoma. Ann Surg Oncol 18(8):2302–2309CrossRefPubMedGoogle Scholar
  31. 31.
    Gold MA et al (2008) Surgical versus radiographic determination of para-aortic lymph node metastases before chemoradiation for locally advanced cervical carcinoma: a Gynecologic Oncology Group Study. Cancer 112(9):1954–1963CrossRefPubMedGoogle Scholar
  32. 32.
    Magrina JF et al (2010) Robotic transperitoneal infrarenal aortic lymphadenectomy: technique and results. Int J Gynecol Cancer 20(1):184–187CrossRefPubMedGoogle Scholar
  33. 33.
    Coronado PJ et al (2014) Comparison of perioperative outcomes and cost between robotic-assisted and conventional laparoscopy for transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL). J Minim Invasive Gynecol 21(4):674–681CrossRefPubMedGoogle Scholar
  34. 34.
    Tinelli R et al (2011) Robotics versus laparoscopic radical hysterectomy with lymphadenectomy in patients with early cervical cancer: a multicenter study. Ann Surg Oncol 18(9):2622–2628CrossRefPubMedGoogle Scholar
  35. 35.
    Vizza E et al (2012) Robotic transperitoneal aortic lymphadenectomy in gynecologic cancer: a new robotic surgical technique and review of the literature. Ann Surg Oncol 19(12):3832–3838CrossRefPubMedGoogle Scholar
  36. 36.
    Magrina JF et al (2009) Robotic extraperitoneal aortic lymphadenectomy: development of a technique. Gynecol Oncol 113(1):32–35CrossRefPubMedGoogle Scholar
  37. 37.
    Zanagnolo V et al (2013) Robotic-assisted transperitoneal aortic lymphadenectomy as part of staging procedure for gynaecological malignancies: single institution experience. Obstet Gynecol Int 2013:931318CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Lambaudie E et al (2012) Robotically assisted laparoscopy for paraaortic lymphadenectomy: technical description and results of an initial experience. Surg Endosc 26(9):2430–2435CrossRefPubMedGoogle Scholar
  39. 39.
    Geppert B, Persson J (2015) Robotic infrarenal paraaortic and pelvic nodal staging for endometrial cancer: feasibility and lymphatic complications. Acta Obstet Gynecol Scand 94(10):1074–1081CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag London 2017

Authors and Affiliations

  • Fatih Gucer
    • 1
  • Selim Misirlioglu
    • 2
  • Nuri Ceydeli
    • 1
  • Cagatay Taskiran
    • 2
  1. 1.Department of Gynecologic OncologyAnadolu Medical CenterIstanbulTurkey
  2. 2.Division of Gynecological Oncology, Department of Obstetrics and GynecologyVKF Koc University School of MedicineIstanbulTurkey

Personalised recommendations