Pelvic lymphadenectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) for early-stage endometrial cancer

Abstract

Objective Feasibility of vaginal natural orifice transluminal endoscopic surgery (vNOTES) has been reported for benign gynecologic diseases [1]. However, there is a limitation to applying vNOTES for gynecologic cancer surgery such as lymphadenectomy due to the difficulty in angulation and lack of adequate instruments [2]. Herein, we introduce pelvic lymphadenectomy by vNOTES for early-stage endometrial cancer. Methods A 59-year-old woman was referred for grade 2 endometrioid carcinoma confirmed on endometrial biopsy performed due to prolonged vaginal bleeding. Preoperative imaging studies showed a 2.7 cm sized endometrial tumor invading less than 50% of the myometrium with no evidence of lymph node metastasis. Thus, staging operation by vNOTES was performed. Results We opened the vesicouterine and rectouterine pouches after circumferential incision of the vaginal mucosa around the cervix. Next, we inserted the glove port through the vagina for vNOTES after resecting bilateral uterosacral ligaments. For hysterectomy, bilateral parametrium, uterine arteries, bladder pillars and infundibulopelvic ligaments were resected. Thereafter, we performed pelvic lymphadenectomy as follows. First, we identified the external iliac vessels and performed downward dissection of the external iliac lymph nodes. After confirming the ureter, we performed upward dissection of the external iliac lymph nodes, and then identified the umbilical artery. Next, we dissected the obturator lymph nodes after identifying the obturator nerve (Fig. 1). A total of 20 pelvic lymph nodes were retrieved. The final pathologic report showed stage IA, grade 2 endometrioid adenocarcinoma, suggesting low risk endometrial cancer. Conclusion Pelvic lymphadenectomy by vNOTES may be feasible for early-stage endometrial cancer.