Hypothesis / aims of study
Pelvic organ prolapse (POP) is a common condition in elderly women leading to a relevant decrease in health-related quality of life with social impact.
It is estimated that the demand for pelvic prolapse treatment will increase by 35% from 2010 to 2030, and surgical intervention rates for pelvic prolapse will increase by 42.7% by 2050. (1)(3)
Moreover, the incidence of malignancy is increased and risk peaks in the 75-84 years old population.
Endometrial cancer (EC) is the second most frequent gynecological cancer in the world and the first in continental Europe with an incidence rate of 15.8 cases /100000 women per year in 2018.
The predominant modifiable risk factor for EC development is the obesity along with a parallel increase in a wide cluster of other common risk factors such as diabetes, metabolic syndrome, smoking, reduced fertility rates and menopausal hormone use (especially estrogen formulations) may play a key role. The incidence of endometrial cancer coexistent with POP varies from 0.2% to 1.2% and it should increase in future. (1)
Due to the uncommon association of illnesses, standardized treatment is not established, and overall management is controversial. (2)(3)
The standard treatment for early-stage endometrial cancer in our institution is robotical-assisted-laparoscopy, with pelvic sentinel lymphonode dissection, radical hysterectomy and bilateral salpingo-oophorectomy
(RRH-BSO).
Laparoscopy seems to provide equivalent results in terms of disease-free survival and overall survival compared with laparotomy, with the advantages of decreased hospital length stay, less use of pain killers, lower rate of complications and improved quality of life. A potential enhancement to laparoscopy has been provided by the robotic approach with a high ‘benefit’ in obese women, reducing major complications rate as wound complications and infections(3). Due to high grade patient satisfaction and lower reintervention rate secondary to vaginal reconstructive surgery, we prefer to adopt native tissue repair (NTR) to correct primary POP (Pelvic organ prolapse).
To treat high grade prolapse concomitant with early endometrial cancer our hybrid surgical approach consists in a combination of vaginal route with robotic surgery. (2)
Study design, materials and methods
A well-being 70-year-old patient, without HRT (hormone replacement therapy), complains third degree prolapse (POP-Q III stage prolapse, anterior/posterior wall and central II stage) without urinary incontinence or obstructed defecation but a long history of constipation.
Due to abnormal uterine bleeding (AUB), she underwent to hysteroscopy.
Histopathological result demonstrated well-differentiated endometrial endometrioid G1 adenocarcinoma, ER positive, PgR receptor positive, hMSH6 present. No signs of distant infiltration at CT scan were reported.
Her medical history presented two vaginal deliveries (P2002), hiatal hernia, MRGE and previous HPV infection.
She underwent to hybrid surgery, an innovative therapeutic approach including double access route with a robot-assisted laparoscopy (Da Vinci Xi) for total Hysterectomy, bilateral Adnexectomy, peritoneal lavage, sentinel Lymph node excision and retrograde robotic cystopexy with a simultaneous repair of the rectocele by the vaginal route.
Under general endotracheal anesthesia, in a supine position a Clermont ferrand uterine manipulator was placed to mobilize the uterus during the procedure.
The first phase of procedure was the dissection of bilateral pelvic sentinel lymphonodes, sent for ultrastaging analysis. The second phase including RRH-BSO (radical hysterectomy and bilateral salpingo-oophorectomy), specimen was exctracted from vaginal route and subjected to a definitive histological analysis. An innovative approach to anterior prolapse named “Retrograde Cistopexy” was performed with a robotically assisted dissection of the vesicovaginal space until vesical trigone. A triangular piece of vaginofascial tissue with the apex at the urethrovescical junction was removed. A full thickness running longitudinal suture of the breach was performed.
A robotically inverted McCall suspension of the apex is performed including the cuff of the vagina and a running transversal suture of the vault with a partial peritonization of cuff completed the first part of our hybrid surgery.
Our native tissue repair (NTR) procedure was completed by vaginal route. A colpoperineorraphy was performed with dissection of rectovaginal septum, its duplication from the perineum to the apex of vagina, and reconstruction of perineal body. Minimal excision of vaginal and skin excess followed by a running vaginal suture including perineal skin concluded our procedure.
Results
Post-operative course was regular, except for post-void residual volume in second and third days after surgery resolved with intermittent catheterization and cortisone plus alphalitycs. Bowel movement, diuresis and urination were regular at redundancy.
At postoperative checkup, vaginal examination and ultrasound confirmed absence of prolapse, and good cicatrization. Histopathological results diagnosed endometrial adenocarcinoma endometroid type 1 (G2), FIGO 1A, staging pT1a, N0, Mx; with immunophenotype p53 (+) 50%, ER (+)90%, PR (+) 90%, MSH2 100%, MSH6 100%, MLH1 + 100%, PMS2+ 100%, ki67 80%; Sentinel Lymphonodes, parameters and peritoneal washing were negative for cancer. Multidisciplinary team rules on surveillance of 5 years.
Interpretation of results
In our experience, given the benefits in term of oncological radicality and patient's satisfaction, this new hybrid surgical approach to treat high degree pelvic organ prolapse associated with early endometrial cancer could represent an interesting alternative to classical surgical approaches.