title: Robotic transperitoneal infra-renal aortic lymphadenectomy in early-stage endometrial cancer.
abstract: OBJECTIVE
  To assess the clinical performance of robotic-assisted infra-renal aortic lymphadenectomy (IRL) using a single center-docked approach for patients with endometrial cancer.
  
  
  METHODS
  Robotic-assisted hysterectomy with pelvic and aortic lymphadenectomy was performed in 97 clinical stage I endometrial cancer (EC) patients with the intent to remove infra-renal aortic lymph nodes. Peri-operative data was contemporaneously accessioned and a retrospective database analysis was performed to examine clinical outcomes.
  
  
  RESULTS
  IRL versus infra-mesenteric artery (IMA) dissections were accomplished in 88 (90.7%) and nine (9.3%) cases, respectively. There were no laparotomy conversions. Histology included 20.6% G1, 41.2% G2, and 38.1% G3 (endometrioid and Type II histologies). Forty-four (45.4%) cases had >50% depth-of-invasion and 43 (44.3%) cases had lymphovascular space invasion. Lymph node metastases were detected in 39 (40.2%) cases [37 (38.1%) pelvic, 16 (16.5%) pelvic+aortic, two (2.1%) isolated aortic lymph nodes]. Aortic metastasis was identified in 16/37 (43.2%) pelvic node positive cases, and 6/34 (17.7%) IRL cases with positive pelvic nodes had infra-renal metastasis, yet normal aortic nodes below the IMA. Harvested aortic lymph nodes for IRL exceeded IMA cases (15.9±6.3 vs. 8.9±4.6; p<0.01). Mean BMI for IMA cases exceeded IRL cases (37.4±3.3 vs. 31.4±7.1kg/m(2); p<0.001). Twenty-five (81%) patients with BMI >35kg/m(2) underwent successful IRL (range 36-47kg/m(2)) compared to 95% of cases <35kg/m(2) (p=0.03).
  
  
  CONCLUSIONS
  IRL was accomplished in 95% of EC patients with BMI <35kg/m(2) and 81% with BMI >35kg/m(2) using a single center-docked approach. A strict 35kg/m(2) BMI cut-off for avoiding IRL is therefore not advised.
authors.affiliation: Florida Hospital Gynecologic Oncology, Florida Hospital Cancer Institute and the Global Robotics Institute, Orlando, FL 32804, USA.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: James
authors.affiliation: Florida Hospital Gynecologic Oncology, Florida Hospital Cancer Institute and the Global Robotics Institute, Orlando, FL 32804, USA.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Rakowski
authors.affiliation: Florida Hospital Gynecologic Oncology, Florida Hospital Cancer Institute and the Global Robotics Institute, Orlando, FL 32804, USA.
authors.forename: Corinne N
authors.initials: CN
authors.lastname: Jeppson
authors.affiliation: Florida Hospital Gynecologic Oncology, Florida Hospital Cancer Institute and the Global Robotics Institute, Orlando, FL 32804, USA.
authors.forename: Nicole M
authors.initials: NM
authors.lastname: Stavitzski
authors.affiliation: Florida Hospital Gynecologic Oncology, Florida Hospital Cancer Institute and the Global Robotics Institute, Orlando, FL 32804, USA.
authors.forename: Sarfraz
authors.initials: S
authors.lastname: Ahmad
authors.affiliation: Florida Hospital Gynecologic Oncology, Florida Hospital Cancer Institute and the Global Robotics Institute, Orlando, FL 32804, USA. Electronic address: robhollowaymd@gmail.com.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Holloway
mesh_terms: D000368:Aged; D016889:Endometrial Neoplasms / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods; D007668:Kidney / Q000098:blood supply; D008197:Lymph Node Excision / Q000379:methods*; D008198:Lymph Nodes / Q000473:pathology / Q000601:surgery*; D010388:Pelvis; D012371:Robotics / Q000379:methods*
keywords: Early-stage; Endometrial cancer; Infra-renal aortic lymphadenectomy; Robotic surgery; Trans-peritoneal