Kimmig Rainer, Aktas Bahriye, Buderath Paul, Wimberger Pauline, Iannaccone Antonella, Heubner Martin
World J Surg Oncol. 2013 Aug 16;11:198. doi: 10.1186/1477-7819-11-198.
The technique of compartment-based radical hysterectomy was originally described by M Höckel as total mesometrial resection (TMMR) for standard treatment of stage I and II cervical cancer. However, with regard to the ontogenetically-defined compartments of tumor development (Müllerian) and lymph drainage (Müllerian and mesonephric), compartments at risk may also be defined consistently in endometrial cancer. This is the first report in the literature on the compartment-based surgical approach to endometrial cancer. Peritoneal mesometrial resection (PMMR) with therapeutic lymphadenectomy (tLNE) as an ontogenetic, compartment-based oncologic surgery could be beneficial for patients in terms of surgical radicalness as well as complication rates; it can be standardized for compartment-confined tumors. Supported by M Höckel, PMMR was translated to robotic surgery (rPMMR) and described step-by-step in comparison to robotic TMMR (rTMMR).
Patients (n = 42) were treated by rPMMR (n = 39) or extrafascial simple hysterectomy (n = 3) with/without bilateral pelvic and/or periaortic robotic therapeutic lymphadenectomy (rtLNE) for stage I to III endometrial cancer, according to International Federation of Gynecology and Obstetrics (FIGO) classification. Tumors were classified as intermediate/high-risk in 22 out of 40 patients (55%) and low-risk in 18 out of 40 patients (45%), and two patients showed other uterine malignancies. In 11 patients, no adjuvant external radiotherapy was performed, but chemotherapy was applied.
No transition to open surgery was necessary. There were no intraoperative complications. The postoperative complication rate was 12% with venous thromboses, (n = 2), infected pelvic lymph cyst (n = 1), transient aphasia (n = 1) and transient dysfunction of micturition (n = 1). The mean difference in perioperative hemoglobin concentrations was 2.4 g/dL (± 1.2 g/dL) and one patient (2.4%) required transfusion. During follow-up (median 17 months), one patient experienced distant recurrence and one patient distant/regional recurrence of endometrial cancer (4.8%), but none developed isolated locoregional recurrence. There were two deaths from endometrial cancer during the observation period (4.8%).
We conclude that rPMMR and rtLNE are feasible and safe with regard to perioperative morbidity, thus, it seems promising for the treatment of intermediate/high-risk endometrial cancer in terms of surgical radicalness and complication rates. This could be particularly beneficial for morbidly obese and seriously ill patients.
基于筋膜间隙的根治性子宫切除术最初由M·赫克尔描述为全子宫系膜切除术（TMMR），用于I期和II期宫颈癌的标准治疗。然而，关于肿瘤发生（苗勒管）和淋巴引流（苗勒管和中肾管）在个体发育上定义的筋膜间隙，子宫内膜癌中存在风险的筋膜间隙也可以得到一致定义。这是文献中关于基于筋膜间隙的子宫内膜癌手术方法的首次报告。腹膜子宫系膜切除术（PMMR）联合治疗性淋巴结切除术（tLNE）作为一种基于个体发育、筋膜间隙的肿瘤手术，在手术根治性和并发症发生率方面可能对患者有益；对于局限于筋膜间隙的肿瘤，该手术可以标准化。在M·赫克尔的支持下，PMMR被转化为机器人手术（rPMMR），并与机器人TMMR（rTMMR）进行了逐步描述。
根据国际妇产科联盟（FIGO）分类，42例患者接受了rPMMR（n = 39）或筋膜外单纯子宫切除术（n = 3），并伴有/不伴有双侧盆腔和/或腹主动脉旁机器人治疗性淋巴结切除术（rtLNE），用于治疗I至III期子宫内膜癌。40例患者中有22例（55%）的肿瘤被分类为中/高风险，40例患者中有18例（45%）为低风险，2例患者患有其他子宫恶性肿瘤。11例患者未进行辅助外照射放疗，但接受了化疗。
无需转为开放手术。术中无并发症。术后并发症发生率为12%，包括静脉血栓形成（n = 2）、感染性盆腔淋巴囊肿（n = 1）、短暂性失语（n = 1）和短暂性排尿功能障碍（n = 1）。围手术期血红蛋白浓度的平均差异为2.4 g/dL（±1.2 g/dL），1例患者（2.4%）需要输血。在随访期间（中位时间17个月），1例患者发生远处复发，1例患者发生子宫内膜癌远处/区域复发（4.8%），但均未发生孤立的局部区域复发。观察期内有2例患者死于子宫内膜癌（4.8%）。
我们得出结论，rPMMR和rtLNE在围手术期发病率方面是可行且安全的，因此，就手术根治性和并发症发生率而言，它似乎有望用于治疗中/高风险子宫内膜癌。这对病态肥胖和重症患者可能特别有益。
