robotic compartmental resection in uterine cancer: tmmr ... · 1. uterus 2. fallopian tubes 3....
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Robotic compartmental resection in uterine cancer:
TMMR, PMMR and FMMR and tLNE
Marseille, June 13-15, 2012
Rainer Kimmig, Martin Heubner, Pauline Wimberger
Department of Gynecology and Obstetrics
West-German Tumor Center Essen
University of Duisburg-Essen
TMMR = Total Mesometrial Resection
Embryologically defined compartments of the Cervix corresponding to the Müllerian compartment 1. Uterus 2. Fallopian tubes 3. Vagina 4. Fibrofatty mesometria (sacro/rectouterine ligg.) 5. Vascular mesometria (uterine basin)
Höckel et al. Lancet Oncol 2009 Höckel et al. Gynecol Oncol 2011
FMMR = Fertility preserving TMMR
Embryologically defined compartments of the Cervix corresponding to the Müllerian compartment 1. Uterus 2. Fallopian tubes 3. Vagina 4. Fibrofatty mesometria (sacro/rectouterine ligg.) 5. Vascular mesometria (uterine basin)
Preservation of uterine corpus/isthmus and Fallopian tubes downstream!
Höckel et al. Lancet Oncol 2009 Höckel et al. Gynecol Oncol 2011
PMMR = Peritoneal Mesometrial Resection
Embryologically defined compartments of the uterine corpus (corresponding to the Müllerian compartment and regional Downstream compartments) 1. Uterus 2. Fallopian tubes 3. Vagina 4. Vascular mesometria (uterine basin) 5. Ovaries and infundibulopelvic ligaments
Höckel et al. Gynecol Oncol 2011
t-LNE = therapeutic lymphadenectomy:
Embryological defined compartments of lymph basins 1. mesometrial (mm) 2. paravisceral (pv) 3. Iliaca externa (ei) 4. Iliaca communis (ci) 5. praesacral (ps)
6. periaortic inframesenterial (pim) 7. periaortic supramesenterial, infrarenal (pir) 8. periaortic suprarenal (psr)
Höckel et al. Lancet Oncol 2009 Höckel et al. Gynecol Oncol 2011
pim
pir
psr
TMMR = Total Mesometrial Resection
t-LNE = therapeutic lymphadenectomy
Hoeckel et al. Int J Gynecol Cancer 2003 Hoeckel et al. Gynecol Oncol 2011
TMMR and t-LNE in cervical cancer Stage Ib-IIb without any adjuvant radiotherapy
Locoregional control
Hoeckel et al. Gynecol Oncol 2011
n=305
Complete resection uterus, fallopian tube, vascular and fibrofatty mesometria and vaginal cuff
1. Mesometrial compartment
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Complete resection of the vascular mesometrium containing local uterine lymph basin (left side)
1a. Vascular mesometrium (mm)
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Complete resection of the fibrofatty mesometrium (left side)
1b. Fibrofatty mesometrium (TMMR/FMMR)
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Sacrouterine and rectouterine ligament
Inferior hypogastric plexus
Left ureter
Left ovary
Uterus
1c. Right hypogastric nerve (TMMR/FMMR)
Caudally this basin is developed around the obturatoric vessels Between the mesometrium of the bladder medially and the internal obturator muscle and the pubo- and iliococcygeal muscles up to the prespinal region
2. Paravisceral lymph basin
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right Vena iliaca ext.
Cranially the basin corresponds to region along the internal iliac branches e.g. glutea sup., glutea inf., iliolumbalis, rectalis, pudenda interna etc. and ………
2. Paravisceral lymph basin
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right
… the preischiadic region (here on the left)
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2. Paravisceral lymph basin
left
From branching of common iliac artery to the femoral channel
3. External iliac basin
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Bifucation of Aorta to bifurcation of common iliac vessels
4. Common iliac basin
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Subaortic basin down to S2
5. Presacral basin
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Preservation of superior hypogastric plexus
6. Periaortic inframenterial basin
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From mesenteric artery to aortic bifurcation
6. Periaortic inframenterial basin
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From renal vessels to mesenteric artery
7. Infrarenal periaortic basin
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Uterus, fallopian tubes, mesometria, pelvic nodes „en bloc“
8. Specimen
R.K.2012
Highly standardizable and reproducible surgery, applicable without any changes in radicality in cervical cancer (FIGO IB, IIA ) and high risk endometrial cancer (FIGO I and II) Robotic surgery enables to perform identical surgery nearly independent of anatomical variations, obesity or adhesions and patients risk situation Lower morbidity due to nerve sparing, blood sparing minimal invasive approach Potentially no need for adjuvant radiotherapy even in high risk cases if R0
Educational videos on: www.uk-essen.de/robotic-surgery/
Possible Participation in „Multicentric Prospective Observational Study TMMR In Cervical Cancer FIGO IB to IIA without Radiotherapy“ by open, laparoscopic or robotic approach - interested? e-Mail: [email protected]
TMMR and PMMR by robotic surgery
Highly standardizable and reproducible surgery, applicable without any changes in radicality in cervical cancer (FIGO IB, IIA ) and high risk endometrial cancer (FIGO I and II) Robotic surgery enables to perform identical surgery nearly independent of anatomical variations, obesity or adhesions and patients risk situation Lower morbidity due to nerve sparing, blood sparing minimal invasive approach Potentially no need for adjuvant radiotherapy even in high risk cases if R0
Educational videos on: www.uk-essen.de/robotic-surgery/
Possible Participation in „Multicentric Prospective Observational Study TMMR In Cervical Cancer FIGO IB to IIA without Radiotherapy“ by open, laparoscopic or robotic approach - interested? e-Mail: [email protected]
TMMR and PMMR by robotic surgery
Thank you very much! Best wishes from Essen, Germany!