AbstractMinimally invasive surgery is the method of choice in endometrial cancer. Experience in procedures assisted by a robotic system is growing rapidly. One of the new bipolar ones is a Vessel Sealer, with sealing and cutting function. The aim of the study was to compare robotic surgery assisted with the da Vinci X system with use of the Vessel Sealer or without it. The study included 25 patients with high-risk endometrial cancer after completed pelvic and paraaortic lymphadenectomy with mean age 60.07 ± 10.67 (range 34.69–83.23) years divided into two groups: one with use of the Vessel Sealer; the second one only with monopolar scissors and subdivided by one-site versus dual docking. Duration of the operation was significantly associated with previous surgery (p < 0.005). Use of the Vessel Sealer was associated with lower blood loss during surgery (p < 0.05). The number of removal pelvic lymph nodes was higher in case of Vessel Sealer with no relation to BMI. Experience in robotic surgery allowed for shortened operation time and led to better outcomes. The Vessel Sealer used in robotic surgery appears to reduce blood loss during surgery and operation time, especially in the case of previous surgery, however, it increases costs of the procedure.
IntroductionOne of the most common gynecologic cancers in Europe is endometrial cancer. Every year nearly 417 000 women are diagnosed with endometrial cancer worldwide. Increasing morbidity is correlated with risk factors such as obesity, hypertension and diabetes1. Endometrial cancer is associated with estrogen stimulation which can induce hyperplasia and neoplastic transformation of endometrium in some types or accumulation of somatic aberrations correlated with others type of endometrial cancer2. Nowadays, new classification of endometrial cancer is introduced. Apart from histological staging also molecular classification is significant for further adjuvant therapy. In molecular classification 4 types are included: Pole mut, MSI, dMMR and p53 mutation which classified endometrial cancer for low, intermediate, high-intermediate and high-risk group. Obesity is more commonly correlated with Pole mut, MSI and dMMR types3. According to European Society of Gynaecological Oncology (ESGO), European Society for Radiotherapy and Oncology (ESTRO) and European Society of Pathology (ESP) guidelines published in 2021, magnetic resonance imaging (MRI) is highly specific for deep invasion of myometrium, cervical stromal invasion and lymph node metastasis. Thoracic, abdominal and pelvic CT scan is recommended for detection of metastases in ovaries, lymph nodes, peritoneum and other sites. In case of inconclusive patients 18FDG PET-CT should be considered4,5.Kim et al. in publication in 2016 revealed better detection of metastatic lymph nodes in patients with endometrial cancer for FDG PET/CT than MRI view6. However, Legros et al. in 2019 performed 18FDG PET-CT in high-risk endometrial cancer with followed paraaortic lymphadenectomy and calculated sensitivity of 50%, specificity of 100% with positive predictive value of 100%. Diagnostic methods should be performed before radical oncological treatment due to unexpected complications in case of not indicated and escalation surgery7.A minimally invasive approach is recommended for treatment of endometrial cancer according to National Comprehensive Cancer Network (NCCN), ESGO and Society of Gynecologic Oncology (SGO) guidelines. Hysterectomy with bilateral salpingo-ophorectomy and biopsy of sentinel lymph nodes is performed. In case of serous endometrial carcinoma, carcinosarcoma and undifferentiated carcinoma also infracolic omentectomy staging should be performed. It can be omitted in stage I in clear cell endometrioid carcinoma4,5 Staging of lymph nodes should be considered in high-risk endometrial cancer. Sentinel lymph node is an alternative option of systematic lymphadenectomy with less complications4,5.High-risk endometrial cancer is a type with worse prognosis and according to new molecular classification with detected p53 mutation of endometrial carcinoma or other histological types like serous, undifferentiated carcinoma, carcinosarcoma with NSMP/MMRd type.Benefits of robotic surgery include precision of movements due to the enlarged three-dimensional view, elimination of instrument tremor and articulated arms. These advantages are extremely important in gynecologic oncological procedures especially in obese patients which are typical ones for endometrial cancer8.As a result of using diathermic methods less blood loss is observed during the operation. However, bleeding is one of the most common reasons for conversion to laparotomy from minimally invasive surgery9. Various methods are used for closure of vessels during bleeding, e.g. metallic or resorbable clips or electrocautery devices. Monopolar electrocautery can seal 1–3 mm vessels, but there is a danger for closer tissues because of thermal spread10,11. Electrocoagulation diathermy is not reliable for vessels larger than 2 mm in diameter12. Devices with bipolar energy can seal vessels up to 7 mm in diameter, with thermal energy spreading between the closed branches of the instrument. There is a lower risk of lateral thermal spread10. Hemostatic system based on a combination of high mechanical and low voltage pressure and bipolar electrical energy, allowing sealing of vessels up to 7 mm in diameter with high current electricity is a new way how to improve properties of diathermic hemostasis13,14.Vessel Sealer is a device specially designed for the da Vinci system with advanced bipolar energy, function of cutting and fully wristed function for better precise movements15.The aim of the study was to compare cases of systematic (completed) pelvic and paraaortic lymphadenectomy during robotic surgery assisted with the da Vinci X system performed by using a bipolar device as Vessel Sealer or monopolar instrument in high-risk endometrial cancer according to intraoperative and short and long-term oncological outcomes.Materials and methodsCharacteristics of populationThe prospective study was conducted from December 2020 to December 2022 with data from 25 patients diagnosed with high-risk endometrial cancer who were recommended hysterectomy and bilateral salpingoovariectomy with systematic pelvic lymphadenectomy and paraaortic lymphadenectomy. Omentectomy was performed in cases of serous or clear-cell carcinoma. All procedures were performed by the same gynecological oncologists with 2 and 12 years of experience in robotic surgery. Decision of performing procedure with or without Vessel Sealer was made just before the surgery with random assignment to groups. Data analyses of all patients who gave informed consent were included.Patients were recruited with consecutive and completed criteria. Inclusion and exclusion criteria are presented in Table 1. The study involved only cases of high-risk endometrial cancer qualified to surgery. Locally advanced disease and contraindications for robotic surgery are mainly exclusion criteria. The analyzed population was divided into two groups. The first one (VS+) consisted of 14 patients after radical hysterectomy with completed pelvic and paraaortic lymphadenectomy using the Vessel Sealer and the second one (VS-) with 11 patients without using the Vessel Sealer. The Vessel Sealer is presented in Figs. 1 and 2.Table 1 Inclusion and exclusion criteria.Full size tableFig. 1Vessel Sealer used for cuttingFull size imageFig. 2Vessel Sealer used for coagulationFull size imageProcedure of robotic surgery and usage of instrumentsOperation time is the time from the first incision below the umbilicus and placement of the Veress needle inside to create peritoneal emphysema. The first step of robotic procedures is to put four robotic and one assistant troackars in the abdominal cavity. The robotic system is docked when the robotic arms are inserted into the robotic troackars and the instruments are placed inside the abdominal cavity. In every case, a camera, bipolar forceps and ProGrasp forceps are obligatory equipment. Before the surgery it was randomly chosen which instrument will be used for cutting function either a Vessel Sealer or monopolar scissors by lottery machine.In the analyzed population because of paraaortic lymphadenectomy and omentectomy if needed, different types of docking (one-site docking and dual docking) were introduced in random choice to compare also which type of docking seems to be better.One-site docking means that robotic system is docked after insufflation and inserted the troackars between the legs. In this study one-site docking was introduced in 8 cases, while 4 was performed with Vessel Sealer and 4 without.Another type of docking is dual docking where firstly robot is docked above the patient’s head for upper abdominal part of operation (paraaortic lymphadenectomy and omentectomy if recommended) and then after undocking secondly presented caudally between the legs, like in one-site docking. This type of docking was introduced in 17 patients, while 10 with using of Vessel Sealer and 7 without.Dual docking because of double position of robot can prolong time of the surgery, however access to paraaortic lymph nodes is wider than in one-site docking.Statistical methodsCalculation analysis was performed using MS Excel, while statistical analysis was presented using R programming language version 4.1.2 (R Core Team, Vienna, Austria). To compare variables, the U-Mann Whitney test was performed, to evaluate categorical variables, the chi-square test was used.A p-value < 0.05 was considered statistically significant.ResultsOperation time, blood loss and use of vessel sealerOperation timeMean operation time of the whole analyzed population was 196 (110–295) minutes, while in the VS + group it was 193 (135–225) minutes and in the VS- group it was 199 (110–295) minutes.Additionally, 8 patients from the whole group had undergone surgery in the past (upper abdominal and pelvic area), which can prolong the follow operation because of adhesions. In this group mean operation time was 225 (range 170–295) minutes, while in the other it was 182 (range 110–250) minutes. Previous laparotomies prolong operation time significantly (p < 0.05).Furthermore, use of the Vessel Sealer shortened the operation time in groups after previous surgery to 216 (range 200–225) minutes and stood for 184 (range 135–210) minutes with no history of laparotomy. In comparison to this, operation time with no Vessel Sealer was 233 (range 170–295) minutes after previous abdominal surgery and 179 (range 110–250) minutes with no surgery in the past.Operation time of both groups is presented in Table 2. However, these data are not statistically significant.Table 2 History of previous surgeries, operation time and use of bipolar device.Full size tableBlood lossMean blood loss for the total population was 50 (range 5–150) ml. Use of the Vessel Sealer was associated with lower blood loss: in the VS + group 38.5 (range 15–80) ml and in the VS- group 64 (5–150) ml (p < 0.05). No significant association of blood loss with age or BMI was found (p > 0.05). Characteristics of the population are presented in Table 3. All analyzed population consist of 25 patients with mean age 60.07 ± 10.67 (range 34.69–83.23) years and BMI 28.4 (range 18–41.5) kg/m2. Data considered in Table 3 are statistically significant (p < 0.05).Table 3 Characteristics of analyzed population.Full size tableValue of BMI and lymphadenectomyIn every case completed paraaortic and pelvic lymphadenectomy was performed. The mean number of paraaortic lymph nodes was 17.3 (range 6–35) and pelvic lymph nodes 24.8 (range 11–50). A correlation was observed between BMI and number of paraaortic lymph nodes (p = 0.0152) and pelvic lymph nodes (p = 0.0852). Patients were divided into groups with BMI under 25 kg/m2, between 25 and 30 kg/m2 and above 30 kg/m2.No correlation was found between number of lymph nodes and age (p > 0.05). No significant association between BMI and experience of surgeons was found (p > 0.05).Additionally, the Vessel Sealer was used randomly. All data regarding BMI values and use of the Vessel Sealer are presented in Table 4.Table 4 Characteristics of analyzed patients with high risk of endometrial cancer in different groups depending on BMI level. VS(-) vessel sealer not used; VS(+) vessel sealer used.Full size tableUse of the vessel sealer in lymphadenectomyThe Vessel Sealer was used as a bipolar device throughout the study in 14 cases of endometrial cancer with mean age 57.04 (range 34.69–79.85) years and mean BMI 27.79 (range 17.98–36.49) kg/m2. The mean number of paraaortic lymph nodes in this group was 19.86 (range 8–35) and the mean number of pelvic lymph nodes was 25.21 (range 11–50). In every group of BMI number of removal pelvic lymph nodes was higher in case of use Vessel Sealer. Only in group with BMI more than 30 kg/m2 number of paraaortic lymph nodes was less in surgery with Vessel Sealer.Dual docking using the bipolar device was performed in 10 cases of this group with mean blood loss of 39 (range 15–80) ml and drainage was applied in 8 cases. The mean number of paraaortic lymph nodes removed during dual docking procedures was 20.2 (range 9–35) and the mean number of pelvic lymph nodes was 26.6 (11–50) in this group.The remaining 4 operations were done by one-site docking. There was no drainage. Mean blood loss was 37.5 (20–50) ml. The mean number of paraaortic lymph nodes was 19 (range 8–24) and the mean number of pelvic lymph nodes was 21.75 (range 14–28).The Vessel Sealer was not used in 11 patients while in 8 drainage was placed. The mean age of this population was 63.94 (44.43–83.23) years and mean BMI 29.21 (19.15–41.52) kg/m2. Mean blood loss was 64.09 (5–150) ml. The mean number of paraaortic lymph nodes was 14.18 (6–29) and the mean number of pelvic lymph nodes was 24.18 (13–43).There was no significant correlation between use of the Vessel Sealer and BMI (p > 0.05). Previous surgery and BMI were not statistically significantly associated (p > 0.05).No statistically significant association between age and use of the Vessel Sealer was observed (p > 0.05).Follow-upDuring the study no conversion to laparotomy was registered. The anesthetic management was not modified by the robotic route. No blood transfusion and no re-operation were needed after surgery. No lymphocele was registered. All cases were assessed as the I grade in Clavien-Dindo classification.Follow-up visits took place every 3 months after surgery. Clinical follow up for the patients last 24 months. Under observation there was no recurrence and no progression of disease. In 7 cases brachytherapy was introduced as an adjuvant treatment. Six patients underwent chemotherapy because of advanced disease and histological type (serous, clear-cell carcinoma and mixed type). No long-term complications after surgery were observed.DiscussionMinimally invasive surgery is now the surgical method of choice recommended in endometrial cancer by ESGO/ESTRO and ESP guidelines4. Nowadays, number of robotic systems all over the world is increased although costs of this kind of surgery is more expensive. There are some centers worldwide more specialized in the robotic approach where laparoscopic procedures in endometrial cancer are not performed. Robotic surgery is more ergonomic for the surgeons because of less fatigue and more stable movements of instruments than laparoscopic ones.In comparison to laparoscopic instruments, robotic ones are fully wristed and can rotate in every direction, which is impossible for laparoscopic instruments. In 2022 Lu et al. compared laparoscopic and robotic lymphadenectomy in gynecological oncology and observed less blood loss and a higher number of removed lymph nodes in cervical and endometrial cancer in the robotic technique. The results of the study favor use of robotic surgery, probably because of wrist endoscopy, which is more precise and results in decreased blood loss during surgery16. Mortality rate was not significantly different between techniques17. In both miniinvasive techniques diathermic instruments are used. Increasing number of miniinvasive procedures are correlated with requirement of instruments with function of coagulation which is extremely significant and shorter time of procedure.Levy et al. reported the important role of the electrosurgical bipolar vessel sealer in effective sutures during vaginal hysterectomy. In those procedures they observed reduced operative time and blood loss18. In our study, operation time with use of the Vessel Sealer last 193 (range 135–225) minutes, while without 199 (110–295) minutes. On the other hand, there is an advantage in using the bipolar device due to the shorter mean operation time after previous laparotomies. Nevertheless, diathermic instruments are more expensive ones. Every additional function of the instrument with the newest technology increases costs of the operation.Dubey et al. in their study evaluated the costs of using Ligasure. Quicker recovery and shorter hospitalization were found to justify the higher costs of procedures using Ligasure19.Kyo et al. described the Ligasure vessel sealing system as a useful instrument to reduce blood loss and decrease operation time. In robotic surgery, a similar instrument is the Vessel Sealer20. In our study we observed that in patients with previous laparotomies, operation time was shorter and less blood loss was noticed.Endometrial cancer is a disease associated with obesity, hypertension and diabetes. What is more, fat tissue are risk factors of a high level of bleeding during surgery. The most frequent early complication after lymphadenectomy is lymphocele. The incidence is difficult to estimate, ranging from 0 to 58.5% in some cases21,22. Symptoms of lymphocele are observed in 5–18%22,23,24. Lymphocele is defined as a lymph collection organized in the abdominal cavity with or without septa, which can appear within one year after surgery25.Abaza et al. compared use of advanced bipolar energy for pelvic lymphadenectomy and a robotic vessel sealer and influence on lymphoceles. 114 patients were enrolled in the study. Lymphocele was identified in 22 cases with no symptoms. There was no increase in risk of lymphocele when using the vessel sealer device compared to the standard technique with clips and no prevention was observed in lymphocele using bipolar methods26. Lamblin et al. published benefits of ultrasonic advanced energy in laparoscopic paraaortic lymphadenectomy. They observed shorter blood loss, less intraoperative bleeding and a higher number of removed lymph nodes. On the other hand, it did not lead to reduction of lymphocele27. In our research we did not register cases of lymphocele, and the Vessel Sealer was more useful due to the shorter operation time in patients after previous surgery.In our study we observed no lymphocele and no other complications after lymphadenectomy. Additionally, less blood loss was noted when using the bipolar device compared to the standard technique (p < 0.05).During robotic surgery one of the first step of procedure is docking the robot. Endometrial cancer surgery assisted by robot can be performed with one-site or dual docking. In case of dual docking access to paraaortic lymph nodes is better than in one-site docking28,29,30.Franke et al. compared paraaortic lymphadenectomy assisted by robot with one-site and dual docking. Operation time and length of hospitalization were longer in procedures with dual docking. There were no differences in blood loss. However, in case of dual docking count of paraaortic lymph nodes was higher which improve histological results31. In our study, we have also observed longer operation time in case of dual docking, whereas blood loss was comparable in both technique. We also observed higher lymph nodes count with dual docking surgery. Franke et al. in their study do not concentrate on used instruments during operation. In our investigation using Vessel Sealer allow for lower blood loss with no requirement of blood transfusion, lower usage of drainage and shorter operation time.Benefits of paraaortic lymphadenectomy performed with dual docking was also presented by Ponce et al. in 2016. They confirmed additionally minimal morbidity and short learning curve32. In our study, number of paraaortic lymph nodes was also higher while performing dual docking in high-risk endometrial cancer.In recently publications based on advantages of paraaortic lymphadenectomy Ponce et al. described technique and indications for paraaortic lymphadenectomy in gynaecological cancers33. Development of the surgery and algorithms of procedures and indications for more radical procedures with possible less blood loss create new directions of production of diathermic instruments. Thanks to that safer surgery is feasible.Usage of diathermic methods was also described in benign gynecological procedures. Persyn et al. revealed advantages of the bipolar device by comparison of hysterectomies of small and large uteri in the robotic approach. There was no difference in perioperative outcomes between the two types of uteruses, but shorter operative time of hysterectomy of large uteri was possible thanks to use of the sealing device34.Hoste et al. used the Vessel Sealer for myomatous uteri during robotic hysterectomy. Their study showed no significance difference in uterine weight, BMI and operation time when using the Vessel Sealer. Also, the learning curve in these cases was shorter than in other technique35. In our study we found no correlation between operation time and body mass index (BMI). Blood loss was lower when using the Vessel Sealer, especially among patients with higher BMI, more than 30 kg/m2. What is more, the number of collected lymph nodes was higher during procedures with the Vessel Sealer, with no more blood loss.Additionally, experience in robotic surgery allowed for shortened operation time and led to better outcomes. Unfortunately, using Vessel Sealer increases costs of the procedure.The limitation of our study was a low number of patients recruited to the study, limited time for the research and effective costs of Vessel Sealer. Also, dual docking and one site docking can introduce bias of time limit of the surgical procedures. Further observation on larger groups of patients and long-term oncological outcomes are needed.In the case of the Vessel Sealer in robotic hysterectomies overall costs of surgery increased; however, the reduction of complication rate and blood loss, and quicker recovery led to better results of surgery [38, 39]. More studies on larger population regarding economic aspects are needed.ConclusionRobotic surgery is a common method of minimally invasive surgery. Using a bipolar device reduces blood loss and operation time, especially after previous surgery. The Vessel Sealer is an instrument with coagulating and cutting function which appears to improve oncological precision of the procedure however with higher costs than other instruments. Diathermic devices are the main instruments in the minimally invasive approach. The popularity of robotic surgery is growing dramatically. Further prospective investigations should be performed on larger population to introduce new instruments in robotic surgery.
Data availability
Raw data are available from the corresponding author on reasonable request.
ReferencesSung, H. et al. Global Cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. Ca Cancer J. Clin. 71, 209–249. https://doi.org/10.3322/caac.21660 (2021).Article
PubMed
MATH
Google Scholar
Urick, M. E. & Bell, D. W. Clinical actionability of molecular targets in endometrial cancer. Nat. Rev. Cancer. 19 (9), 510–521. https://doi.org/10.1038/s41568-019-0177-x (2019).Article
PubMed
PubMed Central
MATH
Google Scholar
Berek, J. S. et al. Concin, N. FIGO staging of endometrial cancer: 2023. Int. J. Gynecol. Obstet. 162, 383–394. https://doi.org/10.1002/ijgo.14923 (2023).Article
Google Scholar
Concin, N. et al. Creutzberg, C. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int. J. Gynecol. Cancer. 31, 12–39. https://doi.org/10.1136/ijgc-2020-002230 (2021). Bosse, T.Chargari, C., Fagotti, A., Fotopoulou, C., Gonzalez Martin, A., Lax, S., Lorusso, D., Marth, C., Morice, P., Nout, R., O’Donnell, D., Querleu, D., Raspollini, M., Sehouli, J., Sturdza, A., Taylor, A., Westermann, A., Wimberger, P., Colombo, N., Planchamp.Article
PubMed
Google Scholar
NCCN Clinical Practice Guidelines in. Oncology (NCCN Guidelines) Uterine Neoplasms Version 3.2024 – September 20, (2024).Kim, H. J., Cho, A., Yun, M., Kim, Y. T. & Kang, W. J. Comparison of FDG PET/CT and MRI in lymph node staging of endometrial cancer. Ann. Nucl. Med. 30 (2), 104–113. https://doi.org/10.1007/s12149-015-1037-8 (2016).Article
PubMed
MATH
Google Scholar
Legros, M. et al. Para-aortic lymph node invasion in High-risk endometrial cancer: performance of 18FDG PET-CT. Anticancer Re. 39 (2), 619–625. https://doi.org/10.21873/anticanres.13155 (2019).Article
MATH
Google Scholar
Gota, T. et al. The current status of robotic surgery for endometrial cancer in Japan. Glob Health Med. 28 (4), 21–25. https://doi.org/10.35772/ghm.2021.01077 (2022).Article
MATH
Google Scholar
Opitz, I., Gantert, W., Giger, U., Kocher, T. & Krähenbühl, L. Bleeding remains a major complication during laparoscopic surgery: analysis of the SALTS database. Langenbecks Arch. Surg. 390, 128–133. https://doi.org/10.1007/s00423-004-0538-z (2005).Article
PubMed
Google Scholar
Campagnacci, R. et al. Electrothermal bipolar vessel sealing device vs. ultrasonic coagulating shears in laparoscopic colectomies: a comparative study. Surg. Endosc. 21, 1526–1531. https://doi.org/10.1007/s00464-006-9143-2 (2007).Article
PubMed
MATH
Google Scholar
Spinoglio, G., Summa, M., Priora, F., Quarati, R. & Testa, S. Robotic colorectal surgery: first 50 cases experience. Dis. Colon Rectum. 51, 1627–1632. https://doi.org/10.1007/s10350-008-9334-0 (2008).Article
PubMed
Google Scholar
Kennedy, J., Stranahan, P. & Taylor, K. High-burst-strenght, feedback-controlled bipolar vessel sealing. Surg. Endosc. 12, 876–878. https://doi.org/10.1007/s004649900733 (1998).Article
PubMed
Google Scholar
Shiber, L. et al. Comparison of Industry-Leading energy devices for use in gynecologic laparoscopy: articulating ENSEAL versus LigaSure energy devices. J. Minim. Invasive Gynecol. 25, 467–473. https://doi.org/10.1016/j.jmig.2017.10.006 (2018).Article
PubMed
Google Scholar
Landman, J., Kerbl, K. & Rehman, J. Evaluation of a vessel sealing system, bipolar electrosurgery, harmonic scalpel, titanium clips, endoscopic Gastrointestinal anastomosis vascular staples and sutures for arterial and venous ligation in a Porcine model. J. Urol. 169, 697–700. https://doi.org/10.1097/01.ju.0000045160.87700.32 (2003).Article
PubMed
Google Scholar
Ortenzi, M., Ghiselli, R., Baldarelli, M., Cardinali, L. & Guerrieri, M. Is the bipolar vessel sealer device an effective tool in robotic surgery? A retrospective analysis of our experience and a meta-analysis of the literature about different robotic procedures by investigating operative data and post-operative course. Minim. Invasive Ther. Allied Technol. 27, 113–118. https://doi.org/10.1080/13645706.2017.1329212 (2018).Article
PubMed
Google Scholar
Lee, H. J., Lee, Y. H., Chong, G. O., Hong, D. G. & Lee, Y. S. Comparison of robotic - assisted versus laparoscopy for transperitoneal infrarenal para-aortic lymphadenectomy in patients with endometrial cancer. J. Obstet. Gynaecol. Res. 44, 547–555. https://doi.org/10.1111/jog.13535 (2018).Article
PubMed
MATH
Google Scholar
Lu, Y. et al. Application of robotic surgery and traditional laparoscopic surgery in lymph node dissection for gynecological cancer: A metaanalysis. Oncol. Lett. 25, 175. https://doi.org/10.3892/ol.2023.13761 (2023).Article
ADS
PubMed
PubMed Central
MATH
Google Scholar
Levy, B. & Emery, L. Randomized trial of suture versus electrosurgical bipolar vessel sealing in vaginal hysterectomy. Obstet. Gynecol. 102, 147–151. https://doi.org/10.1016/s0029-7844(03)00405-8 (2023).Article
MATH
Google Scholar
Dubey, P. et al. Electrothermal vessel sealing versus conventional suturing in abdominal hysterectomy: A randomised trial. Cureus 15, e34123. https://doi.org/10.7759/cureus.34123 (2023).Article
PubMed
PubMed Central
Google Scholar
Kyo, S. et al. Experience and efficacy of a bipolar vessel sealing system for radical abdominal hysterectomy. Int. J. Gynecol. Cancer. 19, 1658–1661. https://doi.org/10.1111/IGC.0b013e3181a840d1 (2009).Article
PubMed
MATH
Google Scholar
Achouri, A. et al. Complications of lymphadenectomy for gynecologic cancer. Eur. J. Surg. Oncol. 39, 81–86. https://doi.org/10.1016/j.ejso.2012.10.011 (2013).Article
PubMed
MATH
Google Scholar
Weinberger, V., Cibula, D. & Zikan, M. Lymphocele: prevalence and management in gynecological malignancies. Expert Rev. Anticancer Ther. 14, 307–317. https://doi.org/10.1586/14737140.2014.866043 (2014).Article
PubMed
MATH
Google Scholar
Zikan, M. et al. Cibula, D. A prospective study examining the incidence of asymptomatic and symptomatic lymphoceles following lymphadenectomy in patients with gynecological cancer. Gynecol. Oncol. 137, 291–298. https://doi.org/10.1016/j.ygyno.2015.02.016 (2015).Article
PubMed
MATH
Google Scholar
Neagoe, O. C., Ionica, M. & Mazilu, O. The role of pelvic lymphocele in the development of early postoperative complications. Medicine 97, e12353. https://doi.org/10.1097/MD.0000000000012353 (2018).Article
PubMed
PubMed Central
Google Scholar
Tam, K., Lam, K., Chan, K. & Ngan, H. Natural history of pelvic lymphocysts as observed by ultrasonoghraphy after bilateral pelvic lymphadenectomy. Ultrasound Obstet. Gynecol. 32, 87–90. https://doi.org/10.1002/uog.5345 (2008).Article
PubMed
Google Scholar
Abaza, R., Henderson, S. & Martinez, O. Robotic vessel sealer device for lymphocele prevention after pelvic lymphadenectomy: Results of a randomized trial. J. Laparoendosc Adv. Surg. Tech. A. 32, 721–726. https://doi.org/10.1089/lap.2021.0531 (2022).Article
PubMed
Google Scholar
Lamblin, G. et al. Does ultrasonic advanced energy reduce lymphocele incidence in laparoscopic para-aortic lymphadenectomy? Eur. J. Obstet. Gynecol. Reprod. Biol. 185, 53–58. https://doi.org/10.1016/j.ejogrb.2014.11.030 (2015).Article
PubMed
Google Scholar
Marek, R. et al. Robotic paraaortic lymphadenectomy in oncogynecology. Double side Docking of Da Vinci S system increases the success rates of high paraaortic lymph node dissection in endometrial cancer. Ceska Gynekol. 84 (1), 4–17 (2019).PubMed
Google Scholar
Loaec, C. et al. Dual Docking robotic surgical staging for high risk endometrial cancer. Eur. J. Obstet. Gynecol. Reprod. Biol. 225, 79–83. https://doi.org/10.1016/j.ejogrb.2018.04.009 (2018).Article
PubMed
Google Scholar
Maenpaa, M. M., Nieminen, K., Tomas, E. I., Luukkaala, T. H. & Maenpaa, J. U. Robotic-assisted infrarenal Para-aortic lymphadenectomy in gynecological cancers: Technique and surgical outcomes. Int. J. Gynecol. Cancer. 28 (5), 951–958. https://doi.org/10.1097/IGC.0000000000001249 (2018).Article
PubMed
MATH
Google Scholar
Franke, O. et al. Role of a double Docking to improve lymph node dissection: When robotically assisted laparoscopy for para-aortic lymphadenectomy is associated to a pelvic procedure. Int. J. Gynecol. Cancer. 25 (2), 331. https://doi.org/10.1097/IGC0000000000000338 (2015).Article
PubMed
MATH
Google Scholar
Ponce, J. et al. Robotic transperitoneal infrarenal Para-Aortic lymphadenectomy with double docking: Technique, learning curve, and perioperative outcomes. J. Minim. Invasive Gynecol. 23 (4), 622–627. https://doi.org/10.1016/j.jmig.2016.02.005 (2016).Article
PubMed
Google Scholar
Ponce, J. et al. Robotic-assisted para-aortic lymphadenectomy: Technique and indications in gynecological oncology. Best Pract. Res. Clin. Obstet. Gynaecol. 91, 102401. https://doi.org/10.1016/j.bpobgyn.2023.102401 (2023).Article
PubMed
MATH
Google Scholar
Persyn, B. & Van Trappen, P. Robotic hysterectomy using a sealing device: differences in complications and pain scores between small and large Uteri. Surg. Technol. Int. 28, 37:143–148 (2020).
Google Scholar
Hoste, G. & Van Trappen, P. Robotic hysterectomy using the vessel sealer for myomatous Uteri: Technique and clinical outcome. Eur. J. Obstet. Gynecol. Reprod. Biol. 194, 241–244. https://doi.org/10.1016/j.ejogrb.2015.09.030 (2015).Article
PubMed
Google Scholar
Download referencesAcknowledgementsThis work was supported by the grant funded by the European Union.FundingThis research was a part of trial funded by the European Union, grant number RPMP.01.02.01-12-0070/20 − 00.Author informationAuthors and AffiliationsLUX MED Oncology Hospital, św. Wincentego 103, Warsaw, PolandMagdalena Bizoń & Maciej OlszewskiNeohospital, Kostrzewskiego 47, Cracow, PolandMagdalena Bizoń, Maciej Olszewski, Agnieszka Grabowska, Joanna Siudek, Krzysztof Mawlichanów & Radovan PilkaPolitechnika Krakowska, Al. Jana Pawła II 37, Cracow, 31-864, PolandJoanna SiudekAndrzej Frycz Modrzewski Krakow University, Cracow, PolandKrzysztof MawlichanówDepartment of Obstetrics and Gynecology, Faculty Hospital Olomouc, Olomouc, Czech RepublicRadovan PilkaAuthorsMagdalena BizońView author publicationsYou can also search for this author in
PubMed Google ScholarMaciej OlszewskiView author publicationsYou can also search for this author in
PubMed Google ScholarAgnieszka GrabowskaView author publicationsYou can also search for this author in
PubMed Google ScholarJoanna SiudekView author publicationsYou can also search for this author in
PubMed Google ScholarKrzysztof MawlichanówView author publicationsYou can also search for this author in
PubMed Google ScholarRadovan PilkaView author publicationsYou can also search for this author in
PubMed Google ScholarContributionsAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by M.B., M.O., A.G., J.S., K.M. and R.P. The first draft of the manuscript was written by M.B. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.Corresponding authorCorrespondence to
Magdalena Bizoń.Ethics declarations
Competing interests
The authors declare no competing interests.
Ethical approval
This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Andrzej Frycz Modrzewski Krakow University (09.12.2020/No KBKA/47/O/2020).
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Consent to publish
The authors affirm that human research participants provided informed consent for publication.
Human and animal participants
This article does not contain any studies with animals performed by any of the authors.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Additional informationPublisher’s noteSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Reprints and permissionsAbout this articleCite this articleBizoń, M., Olszewski, M., Grabowska, A. et al. Use of the vessel sealer in paraaortic lymphadenectomy in the robotic assisted approach in endometrial cancer.
Sci Rep 15, 8175 (2025). https://doi.org/10.1038/s41598-025-93044-yDownload citationReceived: 13 September 2024Accepted: 04 March 2025Published: 10 March 2025DOI: https://doi.org/10.1038/s41598-025-93044-yShare this articleAnyone you share the following link with will be able to read this content:Get shareable linkSorry, a shareable link is not currently available for this article.Copy to clipboard
Provided by the Springer Nature SharedIt content-sharing initiative
KeywordsRobotic surgeryEndometrial cancerParaaortic lymphadenectomyBipolar device