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Evidence - complete hysterectomy, bilateral adnexectomy, sentinel node biopsy pelvic bilateral laparoscopic, robot-assisted laparoscopy (DaVinci)

gynecology
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Frequencies of lymph node metastases

    Pelvic Lymph Node Metastases

    • Nll. iliaci interni, externi & communes, obturatorii: ~10–20%
      • According to the ASTEC study, pelvic lymph node metastases occur in about 10% of patients with clinical stage I.
      • In patients with poorly differentiated tumors and deep myometrial invasion, the likelihood increases to ~20%.
      • The SENTI-ENDO study confirms that pelvic lymph nodes are the primary sentinel lymph nodes in endometrial carcinoma.

    Paraaortic Lymph Node Metastases

    • Nll. lumbales (paraaortic lymph nodes): ~8–12%
      • The SEPAL study shows that 8–12% of patients with endometrial carcinoma have paraaortic lymph node metastases.
      • Interestingly, only 1–3% of patients had isolated paraaortic metastases without involvement of the pelvic lymph nodes.

    Isolated Paraaortic Metastases (without Pelvic Involvement)

    • 1–3% of patients with negative pelvic lymph nodes have isolated paraaortic metastases
      • This low rate confirms that a complete paraaortic lymphadenectomy may not be necessary if the pelvic lymph nodes are negative.

    Sacral and Subaortic Lymph Node Metastases

    • Nll. sacrales & subaortici: 3–5%
      • These lymph nodes are less frequently affected but are a relevant pathway for metastasis in advanced tumors.

    Inguinal Lymph Node Metastases

    • Nll. inguinales superficiales: 2–3%
      • This route is rare in endometrial carcinoma and is usually associated with spread via the round ligament of the uterus.

    Summary of Updated Metastasis Distribution (%)

    Lymph Node RegionFrequency of Metastases (%)
    Pelvic (iliac, obturator)10–20%
    Paraaortic (lumbar)8–12%
    Isolated Paraaortic Metastases (with negative pelvic nodes)1–3%
    Sacral & Subaortic3–5%
    Inguinal2–3%

     

    Reference: 

    1. ASTEC study group; Kitchener H, Swart AM, Qian Q, Amos C, Parmar MK. Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomized study. Lancet. 2009 Jan 10;373(9658):125-36. doi: 10.1016/S0140-6736(08)61766-3. Epub 2008 Dec 16. Erratum in: Lancet. 2009 May 23;373(9677):1764. PMID: 19070889; PMCID: PMC2646126.
    2. Todo Y, Kato H, Kaneuchi M, Watari H, Takeda M, Sakuragi N. Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis. Lancet. 2010 Apr 3;375(9721):1165-72. doi: 10.1016/S0140-6736(09)62002-X. Epub 2010 Feb 24. Erratum in: Lancet. 2010 Aug 21;376(9741):594. PMID: 20188410.
    3. Ballester M, Dubernard G, Lécuru F, Heitz D, Mathevet P, Marret H, Querleu D, Golfier F, Leblanc E, Rouzier R, Daraï E. Detection rate and diagnostic accuracy of sentinel-node biopsy in early stage endometrial cancer: a prospective multicenter study (SENTI-ENDO). Lancet Oncol. 2011 May;12(5):469-76. doi: 10.1016/S1470-2045(11)70070-5. Epub 2011 Apr 12. PMID: 21489874.

  2. Indications: Systematic lymphadenectomy vs. sentinel lymph node biopsy in endometrial carcinoma

    The choice between sentinel lymph node biopsy (SLN mapping) and systematic lymphadenectomy (LNE) in endometrial carcinoma depends on several factors, including the FIGO stage, histology, molecular markers (p53, POLE, L1CAM), and lymphovascular invasion (LVSI).

     

    Indication-Dependent Choice of SLN vs. LNE

    CriterionSentinel Lymph Node Biopsy (SLN Mapping)Systematic LNE
    FIGO I, G1-G2, no LVSIRecommended as standardNot recommended
    FIGO I, G3 or ≥50% myometrial infiltrationPossible if detected bilaterallyConsideration if SLN is not detected on both sides
    FIGO II (cervical stromal infiltration)Possible in low-/intermediate-riskRecommended in high-risk or unclear SLN detection
    FIGO III-IV (lymph node metastases, distant metastases)Not recommendedMandatory
    Serous, clear cell carcinoma, carcinosarcoma, p53 abnormalPossible, but complete LNE preferredRecommended
    POLE-mutated carcinomaSufficient due to low metastasis rateNot recommended
    L1CAM expression >10%Possible if no LVSIRecommended
    LVSI (lymphovascular invasion)Possible with focal LVSIExtensive LVSI → LNE recommended
    Macroscopic enlarged lymph nodes (bulky nodes)Not recommendedMandatory
    Unilateral SLN detection (no SLN found on one side)Systematic LNE for the undetected sideRecommended

    Interpretation of Molecular Markers for Lymphadenectomy

    Molecular MarkerSignificanceRecommended Strategy
    POLE mutationLow metastasis rate, favorable prognosisSLN sufficient, no LNE necessary
    p53 abnormal tumorsHigh metastasis rate, aggressive courseSLN possible, but systematic LNE preferred
    L1CAM >10%Increased risk of distant metastasesSLN possible, LNE recommended for high-risk patients
    LVSI focalLower risk of nodal metastasisSLN possible
    LVSI extensiveHigh likelihood of pelvic and para-aortic metastasisSystematic LNE recommended

    Comparison of Guideline Recommendations for SLN vs. LNE

    GuidelineRecommendation for SLNRecommendation for Systematic LNE
    German S3 Guideline (2024)SLN as preferred method for low-/intermediate-riskLNE recommended for high-risk patients or visible lymph nodes
    ESGO/ESTRO/ESP (2021)SLN as standard for FIGO I-II, optional for type II carcinomasRecommended for high-risk tumors (serous, clear cell, p53 abnormal)
    NCCN (2025)SLN as primary staging procedure, also in high-risk tumors under certain conditionsSystematic LNE recommended for macroscopic metastases or unclear SLN results

    Differences Between SLN and LNE

    Argument for SLNArgument for Systematic LNE
    Reduces postoperative morbidity (lymphedema, intraoperative complications)Higher sensitivity for high-risk tumors
    High sensitivity for micrometastases (≥97%)Increased detection rate in high-risk types like serous or clear cell tumors
    SLN offers improved detection of micrometastases through ultrastagingSEPAL study shows improved survival through systematic LNE in high-risk patients
    Recommended in low-/intermediate-risk patientsRecommended for macroscopic lymph node metastases or extensive LVSI

     

    • SLN mapping is the preferred strategy for most low- and intermediate-risk patients.
    • Systematic LNE remains standard for high-risk tumors, especially serous or clear cell carcinomas and p53 abnormal tumors.
    • If SLN is not detected bilaterally, additional LNE is required.
    • The choice between SLN and LNE should be made individually based on histological and molecular risk factors.

    Reference:

    1. Frost JA, Webster KE, Bryant A, Morrison J. Lymphadenectomy for the management of endometrial cancer. Cochrane Database Syst Rev. 2017;10:Cd007585 
    2. Sueoka K, Umayahara K, Abe A, Usami T, Yamamoto A, Nomura H, et al. Prognosis for endometrial cancer patients treated with systematic pelvic and para-aortic lymphadenectomy followed by platinum-based chemotherapy. Int J Gynecol Cancer. 2014;25:81-6.
    3. Sirisabya N, Manchana T, Worasethsin P, Khemapech N, Lertkhachonsuk R, Sittisomwong T, et al. Is complete surgical staging necessary in clinically early-stage endometrial carcinoma?. Int J Gynecol Cancer. 2009;19:1057-61.
    4. Kitchener H, Swart AM, Qian Q, Amos C, Parmar MK. Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study. Lancet. 2008;373:125-36.
    5. Benedetti Panici P, Basile S, Maneschi F, Alberto Lissoni A, Signorelli M, Scambia G, et al. Systematic pelvic lymphadenectomy vs no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial. J Natl Cancer Inst. 2008;100:1707-16.
    6. Frost JA, Webster KE, Bryant A, Morrison J. Lymphadenectomy for the management of endometrial cancer. Cochrane Database Syst Rev. 2015;2015:Cd007585 
    7. Body N, Grégoire J, Renaud M, Sebastianelli A, Grondin K, Plante M. Tips and tricks to improve sentinel lymph node mapping with Indocyanin green in endometrial cancer. Gynecol Oncol. 2018;150(2):267-273.
    8. Lambrou NC, Gomez-Marin O, Mirhashemi R, Beach H, Salom E, Almeida-Parra Z, et al. Optimal surgical cytoreduction in patients with Stage III and Stage IV endometrial carcinoma: a study of morbidity and survival. Gynecol Oncol. 2004;93:653-8.
    9. Shih KK, Yun E, Gardner GJ, Barakat RR, Chi DS, Leitao MM. Surgical cytoreduction in stage IV endometrioid endometrial carcinoma. Gynecol Oncol. 2011;122:608-11.
    10. Setiawan VW, Yang HP, Pike MC, McCann SE, Yu H, Xiang YB, et al. Type I and II endometrial cancers: have they different risk factors?. J Clin Oncol. 2013;31:2607-18.
    11. Todo Y, Kato H, Kaneuchi M, Watari H, Takeda M, Sakuragi N. Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis. Lancet. 2010;375:1165-72. 
    12. Odagiri T, Watari H, Kato T, Mitamura T, Hosaka M, Sudo S, et al. Distribution of lymph node metastasis sites in endometrial cancer undergoing systematic pelvic and para-aortic lymphadenectomy: a proposal of optimal lymphadenectomy for future clinical trials. Ann Surg Oncol. 2014;21:2755-61.
    13. Alay I, Turan T, Ureyen I, Karalok A, Tasci T, Ozfuttu A, et al. Lymphadenectomy should be performed up to the renal vein in patients with intermediate-high risk endometrial cancer. Pathol Oncol Res. 2015;21:803-10.
    14. Nemani D, Mitra N, Guo M, Lin L. Assessing the effects of lymphadenectomy and radiation therapy in patients with uterine carcinosarcoma: a SEER analysis. Gynecol Oncol. 2008;111:828.
    15. Wortman B, Creutzberg C, Putter H, Jürgenliemk-Schulz I, Jobsen J, Lutgens L, et al. Ten-year results of the PORTEC-2 trial for high-intermediate risk endometrial carcinoma: improving patient selection for adjuvant therapy. Br J Cancer. 2018;119(9):1067-1074.
    16. Rossi E, Kowalski L, Scalici J, Cantrell L, Schuler K, Hanna R, et al. A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging (FIRES trial): a multicentre, prospective, cohort study. Lancet Oncol. 2017;18(3):384-392.
    17. Imboden S, Mereu L, Siegenthaler F, Pellegrini A, Papadia A, Tateo S, et al. Oncological safety and perioperative morbidity in low-risk endometrial cancer with sentinel lymph-node dissection. Eur J Surg Oncol. 2019;45(9):1638-1643.
    18. Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza M, Marnitz S, et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int J Gynecol Cancer. 2021;31(1):12-39.
    19. Abu-Rustum N, Yashar C, Bradley K, Campos S, Chino J, Chon H, et al. NCCN Guidelines® Insights: Uterine Neoplasms, Version 32021. J Natl Compr Canc Netw. 2021;19(8):888-895

  3. Conducting Sentinel Lymph Node Dissection

    There are three primary tracers used for sentinel lymph node (SLN) mapping in endometrial carcinoma:

    Technetium-99m (Tc99m) – A radioactive tracer administered preoperatively and detected intraoperatively via scintigraphy.

    Methylene blue – A dye used for intraoperative visual identification.

    Indocyanine green (ICG) – A fluorescent dye visualized using near-infrared imaging.

    Several injection techniques are used to identify sentinel lymph nodes:

    Cervical injection: The most commonly employed technique. Tc99m, methylene blue, or ICG is injected into the cervical stroma and submucosa, typically 0.5 ml at the 3 and 9 o’clock positions (alternatively, 2, 4, 8, and 10 o’clock). Cervical injection is considered superior to hysteroscopic peritumoral injection.

    Uterine fundus injection: Subserosal or myometrial injection of Tc99m or dye.

    Hysteroscopic injection: Direct injection into the endometrium, though there are concerns about potential dissemination of tumor cells into the peritoneal cavity.

    Detection rates vary depending on the technique:

    Cervical injection: Detection rates range from 35–100%.

    The FIRES study (a multicenter prospective cohort study) demonstrated SLN detection in 86% of patients, with a sensitivity of 97.2% and a negative predictive value of 99.6%.

    Histopathological examination of sentinel lymph nodes follows a standardized ultrastaging protocol:

    Stepwise sectioning of the lymph nodes along their short axis into 0.2 cm thick slices.

    Hematoxylin and eosin (HE) staining.

    Additional immunohistochemistry (IHC) with pan-cytokeratin antibodies (e.g., AE1/AE3) if no tumor cells are identified on HE staining.

    Classification of Lymph Node Metastases

    Category

    Definition

    Macrometastases

    Tumor cells >2 mm

    Micrometastases

    Tumor cells between 0.2–2 mm

    Isolated Tumor Cells (ITC)

    Tumor cells <0.2 mm (not constituting a true metastasis)

    Therapeutic relevance:

    Macrometastases – Have prognostic significance and may necessitate adjuvant therapy.

    Micrometastases – Clinical significance remains uncertain; however, associated with higher recurrence rates.

    ITC – Do not typically require standard therapy, but careful follow-up is recommended.

    Reference:

    1. Ditto A, Casarin J, Pinelli C, Perrone A, Scollo P, Martinelli F, et al. Corrigendum to "Hysteroscopic versus cervical injection for sentinel node detection in endometrial cancer: A multicenter prospective randomised controlled trial from the Multicenter Italian Trials in Ovarian cancer (MITO) study group" [European Journal of Cancer Volume 140, November 2020, Pages 1-10]. Eur J Cancer. 2021;144:399.
    2. Ballester M, Dubernard G, Lecuru F, Heitz D, Mathevet P, Marret H, et al. Detection rate and diagnostic accuracy of sentinel-node biopsy in early stage endometrial cancer: a prospective multicentre study (SENTI-ENDO). Lancet Oncol. 2011;12:469-76. 
    3. Ballester M, Naoura I, Chereau E, Seror J, Bats AS, Bricou A, et al. Sentinel node biopsy upstages patients with presumed low- and intermediate-risk endometrial cancer: results of a multicenter study. Ann Surg Oncol. 2012;20:407-12
    4. Koskas M, Chereau E, Ballester M, Dubernard G, Lecuru F, Heitz D, et al. Accuracy of a nomogram for prediction of lymph-node metastasis detected with conventional histopathology and ultrastaging in endometrial cancer. Br J Cancer. 2013;108:1267-72.
    5. Darai E, Dubernard G, Bats AS, Heitz D, Mathevet P, Marret H, et al. Sentinel node biopsy for the management of early stage endometrial cancer: long-term results of the SENTI-ENDO study. Gynecol Oncol. 2014;136:54-9.
    6. Cormier B, Rozenholc AT, Gotlieb W, Plante M, Giede C. Sentinel lymph node procedure in endometrial cancer: A systematic review and proposal for standardization of future research. Gynecol Oncol. 2015;138:478-85.
    7. Rossi E, Kowalski L, Scalici J, Cantrell L, Schuler K, Hanna R, et al. A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging (FIRES trial): a multicentre, prospective, cohort study. Lancet Oncol. 2017;18(3):384-392.
    8. Mueller J, Pedra Nobre S, Braxton K, Alektiar K, Leitao M, Aghajanian C, et al. Incidence of pelvic lymph node metastasis using modern FIGO staging and sentinel lymph node mapping with ultrastaging in surgically staged patients with endometrioid and serous endometrial carcinoma. Gynecol Oncol. 2020;157(3):619-623.
    9. Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza M, Marnitz S, et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int J Gynecol Cancer. 2021;31(1):12-39.
    10. Ignatov A, Lebius C, Ignatov T, Ivros S, Knueppel R, Papathemelis T, et al. Lymph node micrometastases and outcome of endometrial cancer. Gynecol Oncol. 2019;154(3):475-479.

  4. Comparison of Surgical Methods

    CriterionLaparoscopyRobot-Assisted LaparoscopyLaparotomy
    Oncological OutcomeNon-inferior to laparotomy for low-/intermediate-risk tumorsComparable to conventional laparoscopy, no disadvantages for high-risk tumors demonstratedStandard for advanced tumors, studies show no better overall survival for early stages
    Blood Loss (intraoperative)Less than with laparotomyLeast of all procedures, robot-assisted surgery offers more precise hemostasisHigher than with minimally invasive procedures
    Operation DurationShorter than robot-assisted proceduresLonger operation time than conventional laparoscopy, but faster learning curve effectShorter operation time than minimally invasive procedures, but longer wound healing
    Complication RateLower than with laparotomyEven lower rate than with conventional laparoscopyHigher rate of postoperative complications (wound infections, thrombosis)
    Hospital StayShorter than with laparotomyShortest stay, often only 1–2 daysLongest hospitalization duration, usually 5–7 days
    Conversion Rate to Laparotomy10–15% in very obese patientsLowest conversion rate of all proceduresNot relevant
    Recovery & Quality of LifeFaster recovery than laparotomyFastest recovery, less postoperative painLonger recovery phase, higher postoperative morbidity
    CostsLower than robot-assisted laparoscopy, higher than laparotomyHighest costs, longer operation time, higher acquisition costsCheaper than robotic surgery, but longer hospitalization increases costs

     

     

    Evidence-Based Recommendations from Guidelines

    GuidelineRecommendation for LaparoscopyRecommendation for Robot-Assisted LaparoscopyRecommendation for Laparotomy
    German S3 Guideline (2024)Standard for low-/intermediate-risk tumors, should be preferredAlternative to conventional laparoscopy, advantageous for obese patientsIndicated for advanced tumors or extensive adhesions
    ESGO/ESTRO/ESP (2021)Recommended as the standard method, unless contraindications existAcceptable as an alternative, no oncological disadvantagesReserved for advanced tumors (FIGO III–IV) and complex cases when laparoscopy is not possible
    NCCN (2025)Preferred method, when surgically feasibleEquivalent to laparoscopy, especially for patients with high BMINot recommended for early stages, unless specific indications exist

     

     

    Reference: 

    1. Asher R, Obermair A, Janda M, Gebski V. Disease-Free and Survival Outcomes for Total Laparoscopic Hysterectomy Compared With Total Abdominal Hysterectomy in Early-Stage Endometrial Carcinoma: A Meta-analysis. Int J Gynecol Cancer. 2018;28(3):529-538. 
    2. Galaal K, Bryant A, Fisher AD, Al-Khaduri M, Kew F, Lopes AD. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database Syst Rev. 2012;9:Cd006655. 
    3. Galaal K, Donkers H, Bryant A, Lopes A. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database Syst Rev. 2018;10:CD006655.
    4. Cusimano M, Simpson A, Dossa F, Liani V, Kaur Y, Acuna S, et al. Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: a systematic review and metaanalysis of conversions and complications. Am J Obstet Gynecol. 2019;221(5):410-428.e19. 
    5. Wang L, Liu F. Meta-analysis of laparoscopy sentinel lymph node mapping in endometrial cancer. Arch Gynecol Obstet. 2018;298(3):505-510. URL: 
    6. Ind T, Laios A, Hacking M, Nobbenhuis M. A comparison of operative outcomes between standard and robotic laparoscopic surgery for endometrial cancer: A systematic review and meta-analysis. Int J Med Robot. 2017;13(4)
    7. Lindfors A, Heshar H, Adok C, Sundfeldt K, Dahm-Kähler P. Long-term survival in obese patients after robotic or open surgery for endometrial cancer. Gynecol Oncol. 2020;158(3):673-680.
    8. Wright JD, Burke WM, Wilde ET, Lewin SN, Charles AS, Kim JH, et al. Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer. J Clin Oncol. 2012;30:78391.
    9. Ran L, Jin J, Xu Y, Bu Y, Song F. Comparison of robotic surgery with laparoscopy and laparotomy for treatment of endometrial cancer: a meta-analysis. PLoS One. 2014;9:e108361.
    10. Chan JK, Gardner AB, Taylor K, Thompson CA, Blansit K, Yu X, et al. Robotic versus laparoscopic versus open surgery in morbidly obese endometrial cancer patients - a comparative analysis of total charges and complication rates. Gynecol Oncol. 2015;139:300-5. 
    11. Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza M, Marnitz S, et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int J Gynecol Cancer. 2021;31(1):12-39.
    12. Abu-Rustum N, Yashar C, Bradley K, Campos S, Chino J, Chon H, et al. NCCN Guidelines® Insights: Uterine Neoplasms, Version 32021. J Natl Compr Canc Netw. 2021;19(8):888-895

  5. literature search

    Literature search on the pages of pubmed.