To evaluate if extraperitoneal paraaortic lymphadenectomy using a robotic-assisted approach was associated with fewer complications when compared to all other approaches (conventional laparoscopic transperitoneal or extraperitoneal and robotic-assisted transperitoneal) without compromising lymph node yield, operative time or length of stay.
Post-hoc analysis of the prospective randomized open-label multicenter trial (STELLA-2) SETTING: Three academic reference hospitals.
Two-hundred and three eligible patients from STELLA-2 trial were included.
Patients were randomized to extraperitoneal or transperitoneal PALND using a minimally invasive approach (either laparoscopy or robotic-assisted) for surgical staging of endometrial or ovarian cancer. Minimally invasive approaches were not subjected to randomization.
Primary endpoint was evaluated through a composite variable which included at least one of the following events: bleeding during PALND ≥ 500 mL, any intraoperative complication related to PALND, severe postoperative complication (Dindo ≥ IIIA), impossibility to complete the procedure or conversion to laparotomy). Of the 203 patients analyzed, 68 patients were assigned to the extraperitoneal laparoscopic group (X-L), 62 to the transperitoneal laparoscopic group (T-L), 35 to the extraperitoneal robotic group (X-R), and 38 to the transperitoneal robotic group (T-R). A reduced trend in complications was observed in the extraperitoneal robotic-assisted arm when considering the primary endpoint (X-L: 25.0%, T-L:24.2%, X-R: 5.7%; T-R: 28.9%, p=0.073). In a multivariable analysis, age (OR: 1.05, 95% CI: 1.00-1.09), body mass index (OR: 1.09, 95% CI: 1.03-1.16), and waist-hip ratio (OR: 1.66, 95% CI: 1.12-2.47) were found to independently increase the risk of PALND complications, while extraperitoneal robotic approach (OR: 0.13, 95% CI 0.02-0.64) was an independent protective factor for complication occurrence.
Robotic-assisted extraperitoneal PALND is associated with fewer surgical complications, without compromising lymph node retrieval, operative time or length of stay. Robotic enhanced 3D visualization, surgeon’s ergonomy or hemostatic precision could explain our results.

Copyright © 2021. Published by Elsevier Inc.

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