Definition of compartment-based radical surgery in uterine cancer: radical hysterectomy in cervical cancer as 'total mesometrial resection (TMMR)' by M Höckel translated to robotic surgery (rTMMR)

Abstract

Background: Radical hysterectomy has been developed as a standard treatment in Stage I and II cervical cancers with and without adjuvant therapy. However, there have been several attempts to standardize the technique of radical hysterectomy required for different tumor extension with variable success. Total mesometrial resection as ontogenetic compartment-based oncologic surgery - developed by open surgery - can be standardized identically for all patients with locally defined tumors. It appears to be promising for patients in terms of radicalness as well as complication rates. Robotic surgery may additionally reduce morbidity compared to open surgery. We describe robotically assisted total mesometrial resection (rTMMR) step by step in cervical cancer and present feasibility data from 26 patients.

Methods: Patients (n = 26) with the diagnosis of cervical cancer were included. Patients were treated by robotic total mesometrial resection (rTMMR) and pelvic or pelvic/periaortic robotic therapeutic lymphadenectomy (rtLNE) for FIGO stage IA-IIB cervical cancer.

Results: No transition to open surgery was necessary. No intraoperative complications were noted. The postoperative complication rate was 23%. Within follow-up time (mean: 18 months) we noted one distant but no locoregional recurrence of cervical cancer. There were no deaths from cervical cancer during the observation period.

Conclusions: We conclude that rTMMR and rtLNE is a feasible and safe technique for the treatment of compartment-defined cervical cancer.

Figure 1

Positioning of trocars for rTMMR and rtLNE in cervical cancer. rtLNE, robotic therapeutic lymphadenectomy; rTMMR, robotic total mesometrial resection.

Figure 2

The structures of the female genital tract with reference to the embryologic Müllerian compartment (green) and the corresponding primary and secondary lymph basins (from Höckel et al., Resection of the embryologically defined uterovaginal (Müllerian) compartment and pelvic control in patients with cervical cancer: a prospective analysis. Lancet Oncol 2009, with permission from ELSEVIER).

Figure 3

Incision of the pouch of Douglas to develop the rectovaginal space and prepare the medial aspect of ligamentous mesometria (rectovaginal ligaments).

Figure 4

Preparation of the lateral part of ligamentous mesometria demonstrated on the right. Developing of the avascular space between the ureter, the mesureter and the inferior hypogastric plexus laterally/ventrally and the ligamentous mesometrium medially/dorsally (the sacrouterine ligament).

Figure 5

Overview following the preparation of the ligamentous mesometria with simultaneous demonstration of the medial (rectovaginal, on the left) and the lateral aspect (sacrouterine, on the right).

Figure 6

Lateral resection line of the ligamentous mesometrium on the right starting from the ‘ridge’ pararectally, following the dorsal/lateral rim of the inferior hypogastric plexus to the insertion along the iliococcygeal and pubococcygeal muscle and the fascia endopelvina.

Figure 7

Medial resection of the ligamentous mesometrium on the right starting from the ‘ridge’ dissecting the connective tissue junction along the descendant branch of the rectal artery to separate the mesorectum.

Figure 8

Topography demonstrating complete resection of the ligamentous mesometrium on the right keeping the mesorectum and the inferior hypogastric plexus intact.

Figure 9

Lateral resection line of the ligamentous mesometrium on the left during resection.

Figure 10

Separation of the Müllerian compartment from the bladder compartment anteriorly, preparing the ureteral entrance to the bladder wall from medially exposing the vesicouterine arterial vessels connecting the Müllerian with the bladder compartment (the anterior part of the vesicouterine ligament) shown on the right.

Figure 11

Preparation of the vascular mesometrium (the upper ridge marked by the uterine artery) on the right dissecting the avascular plane dorsally with separation of the ureter, the mesureter and the inferior hypogastric plexus dorsally/medially.

Figure 12

Dissection of the vesical compartment (the proximal bladder mesentery) from the anterior surface of the vascular mesometrium by separating the bordering lamella of the two compartments on the right to prepare its complete resection containing blood and lymphatic vessels and intercalated nodes.

Figure 13

Identification of the deep uterine vein and dissection of vascular mesometrium at the level of the origin from internal iliac vessels shown on the left.

Figure 14

Elevation of the dissected vascular mesometrium and dissection of the ureteral branches of the uterine vessels to separate the ureter from the vascular mesometrium on the left.

Figure 15

The vascular mesometrium can now be flipped dorsally without elevating the ureter and the vesicouterine vascular junction can be exposed from laterally on the left (the vesicouterine ligament). The connecting vessels and the accompanying connective tissue are dissected at their free part close to their junction to the bladder vessels.

Figure 16

To separate the inferior hypogastric plexus, the mesureter and the ureter en bloc from the Müllerian compartment, the uterus-supplying nerve fibers have to be dissected at their branching laterodorsally of the cervix as shown on the left.

Figure 17

Finally, the vesicouterine/vesicovaginal venous anastomoses dorsally to the ureter representing the posterior part of vesicouterine ligament have to be dissected to complete the dissection of the vascular mesometrium as shown on the left.

Figure 18

Following the definition of the vaginal resection line and adequate preparation of the mesocolpium, the incision of the vaginal wall starts dorsally on the left and will be continued dorsally to the right following the right side wall to the anterior wall ending up again on the left. Tumor exposition has to be avoided during removal of the specimen.

Figure 19

Closure of the vagina by running suture. A tight closure of the lateral angles can avoid the development of vaginal vault dehiscense.

Figure 20

Pelvic topography following TMMR demonstrating complete resection of the Müllerian compartment including the vascular and ligamentous mesometria except for the retained part of the vagina. It is clearly visible that the plane of the ureter, mesureter and inferior hypogastric nerve plexus are completely intact on both sides. TMMR, total mesometrial resection.