Introduction

Report regarding single-site laparoscopic radical trachelectomy (RT) is still absent at the present stage, for which the feasibility and safety of this surgery remains a question. We herein introduce the single-site laparoscopic RT without a uterine manipulator for a nulligravida patient with early-stage cervical cancer to preserve fertility without compromising the oncology outcomes.

Description

A 29-year-old woman who was diagnosed with stage IB1 (FIGO 2018) cervical cancer underwent the single-site laparoscopic (RT) plus pelvic lymphadenectomy without the manipulator. We used our expertise with single-site laparoscopic technique to perform space development as much as possible before the ligaments were resected. First, the bilateral round ligaments were sutured to form a coil, and the uterus was suspended by sutures from different directions according to the different operative requirements. Second, prior to colpotomy, a vagino-purse-string suture was formed to avoid spreading of tumor cells. The operative time was 300 minutes, and blood loss was 20 mL. No perioperative complications occurred and the residual cervix and vagina were restored to its original anatomy after 6 months. Postoperative pathological results suggested that the patient did not need radiotherapy or chemotherapy. So far, the surgical scar becomes invisible and the patient has resumed normal menstruation and sexual life.

Conclusion/Implications

Single-site laparoscopic RT plus pelvic lymphadenectomy without the manipulator should be deemed as a safe and feasible therapeutic option for patients with early-stage cervical cancer for fertility preservation. More cases shall be in place to better evaluate the postoperative efficacy and pregnancy outcomes of such procedure to a further step.

Introduction

Early-stage cervical cancer cases are still recorded among young age patients despite awareness about screening and vaccination. Fertility preserving surgery is the management of choice for those age group.

Previously, radical trachelectomy was done with different approaches. Nowadays, Robotic-assisted surgery is replacing previous techniques for better outcomes.

This video is representing Robotic-assisted radical vaginal trachelectomy.

Description

Robotic Phase :

- Sentinel pelvic lymph-node sampling

- Dissection of pelvic spaces ( Para-vesical, para-rectal )

- Ureterolysis

- Dissection of vesicouterine ligaments, cardinal ligaments, uterosacral lligaments

- Colpotomy

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Vaginal Phase:

- Cervical amputation

- Cervical Cerclage

-Utero-vaginal anastomosis

Conclusion/Implications

To enhance the Robotic approach for such cases.

Introduction

In our department, the technique of sentinel lymph node with indocyanine green guided by infrared technique is currently being validated, the advantages and benefits that it will have in surgical and postoperative morbidity for the patient makes it significant, as well as the subsequent ultrastaging of these sentinel nodes in case it is negative due to the possible implications that it will have in the adjuvant treatment, on this occasion a 31-year-old woman. Gesta 2 para 2, whit a 2 month history of irregular vaginal bleeding that presented in our departament. The patient had no prior cervical cancer screening. Physical examination reveal a 2 cm exophytic mass. Biopsies were performed and histopathology revealed squamous-cell cervical carcinoma. CT of the thorax and abdomen revealed no distant metastasis. She was staged according to the International Federation of Gynecology and Obstetrics staging of cancer of the cervix uteri (2018) as FIGO IB1.The patient was scheduled for Radical Hysterectomy (type C1) + Sentinel Lymph Node Mapping with Indocyanine green dye with near infrared technique + Pelvic Lymphadenectomy (currently validation study for SLN mapping).

Description

a surgical film that includes the administration of the dye for sentinel mapping, the development of the paravesical and pararectal spaces, whose adequate development is vital for the identification of the sentinel nodes, and the different forms that can be visualized.

Conclusion/Implications

Importance of sentinel mapping has on surgical/morbidity is what gives significance to this technique, with ultrastaging we will not lose low-volume-disease and we will be able to provide adequate adjuvant treatment

Introduction

Radiotherapy is preferred in the cases if lymph node involvement is detected before surgery. However, radiotherapy with standard dose is insufficient to sterilize bulky lymph nodes > 2cm. The resection of bulky lymph node metastasis before radiotherapy has been proposed to provide a therapeutic benefit.

Description

A sixty-four-year-old woman had been diagnosed of cervical adenocarcinoma with a biopsy. Gynecological examination and computed tomography detected both parametrial involvement and metastatic nodes about 3.3 cm and 2.1 cm in size at bilateral obturator fossa. Concurrent chemoradiation therapy was planned after the removal of the bulky nodes. A two-trocar transperitoneal approach with accessary port for assistant was used. After establishing retroperitoneal space, the ureter was retracted medially. Right node that was 3.3cm in size was between the external iliac vein and internal iliac artery and extended to the obturator fossa. The operation was followed by the left pelvic node removal. The robotic-assisted operation time was 124 minutes and the hospital stay was four days. The patient received concurrent chemoradiation therapy and had well been for one year with no evidence of disease.

Conclusion/Implications

The bulky lymph nodes which were difficult to be eradicated with standard radiation therapy were successfully resected with robotic-assisted surgery. The removal of bulky nodes followed by radiation therapy may provide a therapeutic benefit.

Introduction

Radical Trachelectomy is a choice for cervical cancer treatment andpreserve fertility in selected cases. Good uterine perfusion is necessary for fertility. Sampson's arteries preservation may be a good way of uterine perfusion. Blood flow evaluation by indocyanine greenfluorescence on round ligament and uterus shows uterine perfusion through Sampson's arteries after clipping uterine arteries for radical trachelectomy.

Description

Preserve round ligaments and Sampson's arteries when performing radical tracuelectomy. Blood flow evaluation by indocyanine greenfluorescence on round ligament and uterus.

Conclusion/Implications

•Sampson’s arteries may be a good option of uterine perfusion

•We could preserve round ligament for good uterine blood suply

Introduction

The standard treatment for patients from FIGO stage Ia2 to IIa1 cervical cancer who do not wish to preserve fertility is radical hysterectomy with pelvic lymph node dissection. During radical hysterectomy, the risk of ureter injury is increased. IRIS U-kit (Stryker, Kalamazoo, MI, USA) is a lighted ureteral stent comprising a 6 F translucent ureteral sheath for the bilateral ureters, with optical fibers inserted into the ureteral sheath, and a device for light source. It is placed in the bilateral ureters using cystoscopic approach. It enables the visualization of the bilateral ureter lining during surgery. L10 AIM light source (Stryker, Kalamazoo, MI, USA) was used in this case. We report a case report of robot assisted single-site radical hysterectomy by inserting lighted ureteral stent for cervical cancer treatment.

Description

A 41-year-old woman who was diagnosed with cervical cancer FIGO stage Ib1 underwent robotic single-site modified radical hysterectomy (type II) with insertion of lighted ureteral stent. da Vinci® Xi Surgical system (Intuitive Surgical, Sunnyvale, CA, USA) platform was used for the surgery. Both ureters were fully visualized during the radical hysterectomy. Total operation time was 105 minutes and time taken for lighted ureteral stent insertion was 7 minutes. There was no immediate or delayed complication.

Conclusion/Implications

A prophylactic lighted ureteral stent insertion in robotic single-site radical hysterectomy for early cervical cancer treatment may be a safe and cost-effective procedure option. The lighted ureteral stent insertion helps to safeguard against intraoperative ureteral injury and overcome the limitation of single site operation may have.

Introduction

Among the complications of sentinel node mapping is the injury to the obturator nerve. With an incidence between 0.5 and 2%. Reported consequences vary in severity. As for the mode of repair, there are only a few standardized recommendations: how to avoid nerve tension, and that the fibers do not twist. However, there are few case reports in the literature. This is a surgical video of an injured obturator nerve during a sentinel node mapping with its repair in the same surgical procedure through the laparoscopic approach.

Description

We present the case of a 66-year-old patient diagnosed with cervical cancer, IB1 FIGO 2018 stage. Once in the abdominal cavity, after the cervical injection of Indocyanine green, the retroperitoneum is opened, the ureter and iliac vessels are identified. The right sentinel node is identified, and during its sectioning with a bipolar device, an almost complete sectioning of the right obturator nerve is observed. We performed neurolysis of the nerve, and a tension-free end-to-end epineural anastomosis is performed with 6-0 polypropylene with separate stiches, in the same laparoscopic procedure. A neurologic assessment was done in the immediate postoperative and on day2, no alteration of motor function or any neurological deficiency was found.

Conclusion/Implications

Obturator nerve injury is a rare complication. Laparoscopic repair is feasible. It is important to recognize the injury intraoperatively, maximizing the feasibility of simultaneous repair. Careful dissection and a good understanding of pelvic anatomy are essential for its prevention