Peritoneal Mesometrial Resection (PMMR) with Therapeutic Lymphadenectomy (tLNE) in Endometrial Cancer
PMMR (peritoneal mesometrial resection) is the surgical equivalent to TMMR (total mesometrial resection) in endometrial cancer and has first been described in detail in 2013. Principles of compartmental surgery and differences of the surgical approach due to the different subcompartment of tumour origin are outlined in short: With respect to the tumour bearing subcompartment of uterine corpus, there is no drainage to the ligamentous mesometrium (i.e. sacrouterine ligament) and nodes of the sacrouterine and preischiadic region. Thus, neither the ligamentous mesometrium nor the preischiadic nodes have to be dissected; on the other hand, there is drainage from the fundus along the mesonephric ovarian vessel system suggesting complete resection of these structures including the para-aortic mesenteric lymph nodes being first-order regional lymph compartments on the basis of the concept of compartmental surgery. There is first evidence that compartmental also in endometrial cancer is able to reduce locoregional recurrence even in absence of radiotherapy. The technique, first results and future perspectives are summarized.
KeywordsPeritoneal mesometrial resection PMMR Therapeutic lymphadenectomy Pelvic lymphadenectomy Para-aortic lymphadenectomy Compartmental surgery Uterine cancer Endometrial cancer Targeted lymphadenectomy
(MP4 577741 kb)
(MP4 367711 kb)
- 1.Kimmig R, Aktas B, Buderath P, Wimberger P, Iannaccone A, Heubner M. Definition of compartment-based radical surgery in uterine cancer: modified radical hysterectomy in intermediate/high-risk endometrial cancer using peritoneal mesometrial resection (PMMR) by M Höckel translated to robotic surgery. World J Surg Oncol. 2013;11:198. https://doi.org/10.1186/1477-7819-11-198.CrossRefPubMedPubMedCentralGoogle Scholar
- 2.Kimmig R, Iannaccone A, Buderath P, Aktas B, Wimberger P, Heubner M. Definition of compartment based radical surgery in uterine cancer-part I: therapeutic pelvic and periaortic lymphadenectomy by Michael Höckel translated to robotic surgery. ISRN Obstet Gynecol. 2013;2013:297921. https://doi.org/10.1155/2013/297921.CrossRefPubMedPubMedCentralGoogle Scholar
- 3.Kimmig R, Aktas B, Buderath P, Rusch P, Heubner M. Intraoperative navigation in robotically assisted compartmental surgery of uterine cancer by visualisation of embryologically derived lymphatic networks with indocyanine-green (ICG). J Surg Oncol. 2016;113(5):554–9. https://doi.org/10.1002/jso.24174.CrossRefPubMedGoogle Scholar
- 4.Kimmig K. Video 1. Robotic surgery in gynaecology—therapeutic lymphadenectomy of the pelvic nodes (TPL1)—module I: common iliac, subaortic and presacral nodes. ESGO eAcademy. 10 Oct 2013;38736. http://eacademy.esgo.org/esgo/2000/dvds/38736/k.rainer.kimmig.robotic.surgery.in.gynaecology.-.therapeutic.lymphadenectomy.html?f=l5987m10.
- 5.Kimmig K. Video 2. Robotic surgery in gynaecology—therapeutic lymphadenectomy of the pelvic nodes (TPL1)—module II: lower paravisceral and external iliac nodes. ESGO eAcademy. 3 Oct 2013;38737. http://eacademy.esgo.org/esgo/2000/dvds/38737/k.rainer.kimmig.robotic.surgery.in.gynaecology.-.therapeutic.lymphadenectomy.html?f=s49121m10.39.
- 6.Kimmig K. Video 3. Robotic surgery in gynaecology—therapeutic paraaortic lymphadenectomy (TPL2)—module IV: inframesenteric periaortic nodes. ESGO eAcademy. 8 Oct 2013; 95407. http://eacademy.esgo.org/esgo/2000/dvds/95407/k.rainer.kimmig.robotic.surgery.in.gynaecology.-.therapeutic.paraaortic.html?f=l5987m10.
- 7.Kimmig K. Video 4. Robotic surgery in gynecology—therapeutic paraaortic lymphadenectomy (TPL2)—module V2: infrarenal periaortic nodes with resection of ‘mesonephric’ compartment of ovarian vessels. ESGO eAcademy. 3 Jun 2014; 95406. http://eacademy.esgo.org/esgo/2000/dvds/95406/k.rainer.kimmig.robotic.surgery.in.gynecology.-.therapeutic.paraaortic.html?f=s49121m10.
- 8.Kimmig K. Video 5. Robotic surgery in gynecology—peritoneal mesometrial resection (PMMR) in endometrial cancer—part one: compartmental lymphatic network of uterine corpus and its drainage. ESGO eAcademy. 18 Jan 2017; 166631. https://eacademy.esgo.org/esgo/2016/video.library/166631/k.rainer.kimmig.pmmr.in.endometrial.cancer.-.part.one.-.compartmental.html?f=menu=14*media=10*speaker=49121
- 9.Kimmig K. Video 6. Robotic surgery in gynecology—peritoneal mesometrial resection (PMMR) in endometrial cancer—part two: surgical technique. ESGO eAcademy. 18 Jan 2017; 166632. https://eacademy.esgo.org/esgo/2016/video.library/166632/k.rainer.kimmig.pmmr.in.endometrial.cancer.-.part.two.-.surgical.technique.html?f=menu=14*media=10*speaker=49121
- 11.Kimmig R, Iannaccone A, Aktas B, Buderath P, Heubner M. Embryologically based radical hysterectomy as peritoneal mesometrial resection (PMMR) with pelvic and para-aortic lymphadenectomy for loco-regional tumor control in endometrial cancer: first evidence for efficacy. Arch Gynecol Obstet. 2016;294(1):153–60. https://doi.org/10.1007/s00404-015-3956-y.CrossRefPubMedGoogle Scholar
- 12.Abu-Rustum NR, Gomez JD, Alektiar KM, Soslow RA, Hensley ML, Leitao MM Jr, Gardner GJ, Sonoda Y, Chi DS, Barakat RR. The incidence of isolated paraaortic nodal metastasis in surgically staged endometrial cancer patients with negative pelvic lymph nodes. Gynecol Oncol. 2009;115(2):236–8. https://doi.org/10.1016/j.ygyno.2009.07.016.CrossRefPubMedGoogle Scholar
- 13.Kim TH, Kim HS, Kim TJ, Chang SJ, Kim DY, Ryu SY, Kim BG, Kim YT, Bae DS, Ryu HS, Nam JH. Survival impact based on the thoroughness of pelvic lymphadenectomy in intermediate- or high-risk groups of endometrioid-type endometrial cancer: a multi-center retrospective cohort analysis. Gynecol Oncol. 2016;141(3):440–6. https://doi.org/10.1016/j.ygyno.2016.03.031.CrossRefPubMedGoogle Scholar
- 14.Holloway RW, Gupta S, Stavitzski NM, Zhu X, Takimoto EL, Gubbi A, Bigsby GE, Brudie LA, Kendrick JE, Ahmad S. Sentinel lymph node mapping with staging lymphadenectomy for patients with endometrial cancer increases the detection of metastasis. Gynecol Oncol. 2016;141(2):206–10. https://doi.org/10.1016/j.ygyno.2016.02.018.CrossRefPubMedGoogle Scholar
- 15.Zahl Eriksson AG, Ducie J, Ali N, McGree ME, Weaver AL, Bogani G, Cliby WA, Dowdy SC, Bakkum-Gamez JN, Abu-Rustum NR, Mariani A, Leitao MM Jr. Comparison of a sentinel lymph node and a selective lymphadenectomy algorithm in patients with endometrioid endometrial carcinoma and limited myometrial invasion. Gynecol Oncol. 2016;140(3):394–9. https://doi.org/10.1016/j.ygyno.2015.12.028.CrossRefPubMedGoogle Scholar
- 16.Kumar S, Podratz KC, Bakkum-Gamez JN, Dowdy SC, Weaver AL, McGree ME, Cliby WA, Keeney GL, Thomas G, Mariani A. Prospective assessment of the prevalence of pelvic, paraaortic and high paraaortic lymph node metastasis in endometrial cancer. Gynecol Oncol. 2014;132(1):38–43. https://doi.org/10.1016/j.ygyno.2013.10.002.CrossRefPubMedGoogle Scholar
- 18.Kimmig R, Buderath P, Rusch P, Aktas B. Technique of ICG-guided targeted compartmental pelvic lymphadenectomy (TCL) combined with pelvic peritoneal mesometrial resection (PMMR) for locoregional control of endometrial cancer—a proposal. Educational video. Gynecol Oncol Rep. 2017;20:125–6.CrossRefPubMedPubMedCentralGoogle Scholar