Robotic Radical Trachelectomy with Primary Vaginal Closure to Spare Fertility in Young Patients with Early-Stage Cervical Cancer.

OBJECTIVE: Our aim was to present the surgical technique of robotic radical trachelectomy (RRT) for early-stage squamous cell cervical cancer in women with a desire to preserve fertility. DESIGN: A surgical case to illustrate the entire surgical technique of RRT and sentinel lymph node dissection. Institutional Review Board approval was not required for this video presentation. SETTING: University hospital. INTERVENTIONS: A 30-year-old patient with one child and no medical history. Pap smear and cervical biopsy were in favor of high-grade squamous intraepithelial lesion, and a conization procedure allowed the diagnosis of a 15 mm squamous cell carcinoma (International Federation of Gynecology and Obstetrics [FIGO] 1B1). An RRT was performed to preserve the fertility of this young patient, after bilateral sentinel lymph node dissection to ensure the absence of nodal metastasis. The trachelectomy specimen was negative at final pathology examination and the disease was confirmed as stage 1B1 (FIGO 2018). There were no surgical complications and no adjuvant treatment was indicated. Fertility-sparing surgery is acceptable for women of childbearing age who want to become pregnant. CONCLUSION: Minimally invasive surgery is safe, effective, and particularly adapted for women who wish to preserve their fertility without compromising oncological outcomes.1-2 This option may be safely proposed in expert centers for tumors smaller than 2 cm, with primary vaginal closure, and without use of a uterine manipulator.3 Complete information about oncological and obstetrical outcomes is mandatory and patients should agree to comply with a close follow-up protocol.

Anti-NMDA receptor encephalitis associated with ovarian tumor: the gynecologist point of view.

BACKGROUND: Anti-NMDA receptor antibody (anti-NMDAr) encephalitis, although still a rare condition, is well known to neurologists as it is the leading cause of non-infectious acute encephalitis in young women. However, this is less well known to gynecologists, who may have a decisive role in etiological management. Indeed, in 30-60% of cases in women of childbearing age, it is associated with the presence of an ovarian teratoma, whose removal is crucial in the resolution of symptomatology. OBJECTIVES: Primary objective of our work was to present a review in a very schematic and practical way for gynecologists, about the data on anti-NMDAr encephalitis in terms of epidemiology, clinical symptomatology, treatment and prognosis. The second objective was to propose a decision tree for gynecologists to guide them, in collaboration with neurologists and anesthesiologists, after the diagnosis of NMDAr encephalitis associated with an ovarian mass. METHOD: We conducted an exhaustive review of existing data using PubMed and The Cochrane Library. Then, we illustrated this topic by presenting two typical cases from our experience. RESULTS: Anti-NMDA antibody encephalitis association with an ovarian teratoma is common, especially in women of reproductive age. Complementary examinations in search of an ovarian teratoma must therefore be systematic to envisage a possible surgical excision that may improve patient prognosis. CONCLUSION: Anti-NMDA antibody encephalitis should not be ignored by gynecologists whose role in management is central.

How to perform a laparoscopic pelvic sentinel lymph node dissection using near-infrared fluorescence with indocyanine green in gynecological cancers.

The role of pelvic sentinel lymph node dissection (SLND) is increasing in oncological pelvic surgery, especially in the management of cervical and endometrial cancer.SLND using indocyanine green (ICG) is safe and effective, and its sensitivity is higher than with other detection methods. The advantages of ICG are its low toxicity, its confinement within the vascular compartment, its rapid excretion, and the rarity of allergic reaction. These advantages confer to this fluorescent dye a superiority over blue, which can cause anaphylactic reactions. Using ICG does not require advance planning involving nuclear protection and delayed surgery, as are mandatory when using 99Tc detection. ICG allows the surgeon to visualize the lymph nodes through the peritoneum and thus avoid wide dissection.According to European guidelines,1 the indications for SLND in cervical cancer are for patients with FIGO (International Federation of Gynecology and Obstetrics) IA1-IA2 disease, lymphovascular space involvement - positive status, without systematic pelvic lymphadenectomy - and patients with FIGO IB1-IIA1 disease, prior to systematic pelvic lymphadenectomy. Guidelines1 2 for endometrial cancer management state that SLND is indicated in cases of low-risk endometrial cancer (FIGO IA, grade 1-2), without systematic lymphadenectomy in cases of non-detection, with the technique being preferable to systematic lymphadenectomy in cases of intermediate-risk endometrial cancer (FIGO IB, grade 1-2, or FIGO IA, grade 3).2 Our objective is to review the technique of ICG injection and the real-time detection of pelvic SLNs using near-infrared imaging by means of a step-by-step explanation of the procedure using an instructional Video 1.

Treatment of Intramyometrial Pregnancy by In Situ Injection of Methotrexate.

Intramyometrial ectopic pregnancies are rare, and various management modalities have been described. We report a patient with intramyometrial pregnancy who was successfully treated by in situ injection of methotrexate (MTX) after the failure of 2 intramuscular injections of MTX. We emphasize the difficult management of intramyometrial pregnancy and show that in situ MTX injection may be indicated for this particular type of ectopic pregnancy.

Contribution of Computed Tomography Enema and Magnetic Resonance Imaging to Diagnose Multifocal and Multicentric Bowel Lesions in Patients With Colorectal Endometriosis.

STUDY OBJECTIVE: To evaluate the diagnostic contribution of the computed tomography (CT) enema and magnetic resonance imaging (MRI) for multifocal (multiple lesions affecting the same segment) and multicentric (multiple lesions affecting several digestive segments) bowel endometriosis. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). PATIENTS: Eighty-five patients. SETTING: Tenon University Hospital, Paris, France. INTERVENTION: All patients received a preoperative CT enema and underwent MRI interpreted by 2 radiologists. MEASUREMENTS AND MAIN RESULTS: Patients underwent colorectal resection for colorectal endometriosis from February 2009 to November 2012. Nineteen patients (22%) had multifocal lesions, and 11 patients (13%) had multicentric lesions. Six patients (7%) had both multifocal and multicentric lesions. The sensitivity, specificity, and positive and negative likelihood ratios (LRs) of MRI for the diagnosis of multifocal lesions were 0.58, 0.84, 3.55, and 0.5, respectively. The sensitivity, specificity, and positive and negative LRs of the CT enema for the diagnosis of multifocal lesions were 0.64, 0.86, 4.56, and 0.4, respectively. The sensitivity, specificity, and positive LR of MRI for the diagnosis of multicentric lesions were 1, 0.88, and 8.4, respectively. The sensitivity, specificity, and positive and negative LRs of MRI for the diagnosis of multicentric lesions were 0.46, 0.92, 5.6, and 0.59, respectively. No difference was observed between MRI and the CT enema for the diagnosis of multifocal and multicentric colorectal endometriosis. The interobserver agreement was good for MRI and the CT enema (κ = 0.45 and 0.45) for multifocality, and it was poor for both MRI and the CT enema (κ = 0.32 and 0.34) for multicentricity. CONCLUSIONS: Both MRI and the CT enema were able to diagnose multifocal and multicentric bowel endometriosis with similar accuracy.

Surgical and clinical impact of extraserosal pelvic fascia removal in segmental colorectal resection for endometriosis.

STUDY OBJECTIVE: To describe the characteristics of patients with colorectal endometriosis and extraserosal pelvic fascia (EPF) involvement and to assess the effect of EPF resection. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Two hundred twenty-seven patients who underwent segmental colorectal resection to treat symptomatic deep infiltrating endometriosis between 2001 and 2011, with or without EPF resection. INTERVENTIONS: Segmental colorectal resection with or without EPF resection. MEASUREMENTS AND MAIN RESULTS: One hundred twelve patients (49.4%) required EPF resection. In these patients the total American Society for Reproductive Medicine endometriosis scores were higher (p = .004), there were more associated resected lesions of deep infiltrating endometriosis (p <.001), and the operative time was longer (p <.001). They were more likely to require blood transfusion (p = .003) and to experience intraoperative complications (p = .01) and postoperative voiding dysfunction (p = .04). CONCLUSION: EPF infiltration reflects disease severity in patients with colorectal endometriosis. Its removal affects intraoperative morbidity and leads to a higher rate of voiding dysfunction.

Role of protective defunctioning stoma in colorectal resection for endometriosis.

STUDY OBJECTIVE: To evaluate the role of protective defunctioning stoma (PDS) on the occurrence of digestive tract complications after colorectal resection to treat endometriosis. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: All patients undergoing segmental colorectal resection to treat colorectal endometriosis with and without PDS between 2003 and 2011 at Tenon University Hospital, Paris, France. MEASUREMENTS AND MAIN RESULTS: Patients were assessed at 1, 6, and 12 months postoperatively and each year thereafter. Median follow-up was 60 months. Of 198 patients included for analysis, 53 (27%) had PDS. Overall, 15 (7.5%) digestive tract complications occurred: 9 (4.5%) rectovaginal fistulas and 6 (3%) anastomotic leakages. All rectovaginal fistulas occurred in patients with a low colorectal anastomosis (p < .001) and 88% (8 of 9) in patients with a partial colpectomy (p < .001). PDS was associated with a decrease in the number of rectovaginal fistulas in women undergoing partial colpectomy and low colorectal resection from 27% to 15%, without reaching significance (p = .4). No anastomotic leakage occurred in patients with PDS. CONCLUSION: Our results support that PDS can be omitted in patients with mid-colorectal anastomosis without partial colpectomy. In patients requiring partial colpectomy or partial colpectomy plus low colorectal anastomosis, PDS remains questionable.

[Endometriosis]. / Le caractère cyclique des symptômes avec une recrudescence cataméniale est evocateur. Endométriose.

Endometriosis is a benign disorder affecting 10 to 15% of women of reproductive age. It is defined by the presence of endometrium-like tissue outside the uterus. There are three different entities of endometriosis: superficial endometriosis, ovarian endometriotic cyst and deep infiltrating endometriosis. The main clinical features are dysmenorrhea, chronic pelvic pain and dyspareunia. Endometriosis is also responsible for infertility. Transvaginal sonography and magnetic resonance imaging are required to assess mapping of endometriotic lesions. Medical therapies based on progestins or combined oral contraceptives allow to relief symptoms. Despite a relative efficacy of medical treatment or in case of infertility, surgery is necessary preferentially in specialized centers.

Laparoscopic radical hysterectomy after preoperative brachytherapy for stage IB1 cervical cancer: feasibility, results, and surgical implications in a large bicentric study of 162 consecutive cases.

PURPOSE: To examine the feasibility and to report the results of laparoscopic radical hysterectomy (LRH) after initial uterovaginal brachytherapy (BT) for stage IB1 cervical cancer. METHODS: We retrospectively reviewed patients at 2 comprehensive cancer centers who underwent initial BT followed 6-8 weeks later by LRH and lymph node dissection. RESULTS: Between 2003 and 2010, a total of 162 patients underwent LRH. The procedure was feasible via this approach in 160 cases (98.8%) (2 conversions to laparotomy). Eight perioperative complications occurred. Nineteen patients had nodal involvement. Peri- or postoperative ureteral morbidity occurred in 10 patients (6%). Twenty-four patients (15%) experienced postoperative dysuria. Histologically, only 9 patients had residual cervical disease ≥5 mm, and only 1 patient had parametrial lymphovascular space involvement (associated with nodal spread). No patient had vaginal disease or involved surgical margins. After a median follow-up of 39 (range 3-118) months, 9 patients experienced relapse. Five-year overall survival was 95% (range 88.2-97.9%). CONCLUSIONS: Radical hysterectomy using a laparoscopic approach is feasible and reproducible after initial BT for stage IB1 cervical cancer and is associated with excellent survival. Morbidity is close to that reported in patients treated with up-front surgery. In this large series, the morbidity associated with parametrial dissection and the fact that parametrial spread was observed in only 0.6% of the patients suggest that a simple extrafascial hysterectomy is perhaps sufficient in this context; the rate of urinary tract morbidity would then be reduced.

Accuracy and reproducibility of the peritoneal cancer index in advanced ovarian cancer during laparoscopy and laparotomy.

BACKGROUND: The aim of this prospective study was to evaluate the accuracy of the peritoneal cancer index (PCI) between laparoscopy and laparotomy and to evaluate the reproducibility of this index between 2 surgeons (junior vs senior) in advanced-stage ovarian cancer (ASOC). In ASOC, the quality of cytoreductive surgery, which is the main prognostic factor, is correlated with the extent of the disease and thus with the PCI. The reliability of this scoring index between different surgeons during laparoscopy and laparotomy has not been investigated in this disease. METHODS: Between April 2010 and October 2011, for each of the 29 patients undergoing complete cytoreductive surgery, 1 senior surgeon and 1 junior surgeon quantified the PCI score at 3 time points on the same day: during laparoscopy and during laparotomy, at the beginning and at the end. A concordance analysis was conducted with Bland and Altman's method and estimated by intraclass correlation coefficients. RESULTS: There was high concordance of the PCI score between the junior and senior surgeons during the laparoscopic and laparotomic procedures: the mean differences were not significantly different from 0 (P < 0.05) and 95% limits of agreement were ± 3.5 and ± 3.0, respectively. Laparoscopy underestimated the PCI score by approximately 2 points compared to the beginning of the laparotomy: the mean biases were -2.0 (95% confidence interval, -2.8 to -1.2) for the senior surgeon and -2.2 (95% confidence interval, -3.1 to 1.3) for the junior surgeon. CONCLUSIONS: The PCI is reproducible and reliable for evaluating peritoneal spread in ASOC.

Robotic-assisted benign hysterectomy compared with laparoscopic, vaginal, and open surgery: a systematic review and meta-analysis.

The potential benefits and limitations of benign hysterectomy surgical approaches are still debated. We aimed at evaluating any differences with a systematic review and meta-analysis. PubMed, MEDLINE, and EMBASE databases were last searched on 6/2/2021 to identify English randomized controlled trials (RCTs), prospective cohort and retrospective independent database studies published between Jan 1, 2010 and Dec 31, 2020 reporting perioperative outcomes following robotic hysterectomy versus laparoscopic, open, or vaginal approach (PROSPERO #CRD42022352718). Twenty-four articles were included that reported on 110,306 robotic, 262,715 laparoscopic, 189,237 vaginal, and 554,407 open patients. The robotic approach was associated with a shorter hospital stay (p < 0.00001), less blood loss (p = 0.009), and fewer complications (OR: 0.42 [0.27, 0.66], p = 0.0001) when compared to the open approach. The main benefit compared to the laparoscopic and vaginal approaches was a shorter hospital (R/L WMD: - 0.144 [- 0.21, - 0.08], p < 0.0001; R/V WMD: - 0.39 [- 0.70, - 0.08], p = 0.01). Other benefits seen were sensitive to the inclusion of database studies. Study type differences in outcomes, a lack of RCTs for robotic vs. open comparisons, learning curve issues, and limited robotic vs. vaginal publications are limitations. While the robotic approach was mainly comparable to the laparoscopic approach, this meta-analysis confirms the classic benefits of minimally invasive surgery when comparing robotic hysterectomy to open surgery. We also reported the advantages of robotic surgery over vaginal surgery in a patient population with a higher incidence of large uterus and prior surgery.

[Diagnostic strategy for intrauterine lesions]. / Stratégie diagnostique des lésions intra-utérines.

DIAGNOSTIC STRATEGY FOR INTRAUTERINE LESIONS The diagnostic strategy for intrauterine lesions is a question that arises very frequently in gynecological consultations. Endometrial cancer is more frequent in postmenopausal women and bleeding is the first clinical sign in more than 90% of cases. Pelvic ultrasound and endometrial biopsy have a very important place in the diagnostic strategy. After a single episode of abnormal uterine bleeding and when the ultrasound estimates the thickness of the endometrium to be less than or equal to 4 mm, it is possible to postpone further uterine exploration. In the event of recurrent abnormal uterine bleeding or when the thickness of the endometrium is greater than 4 mm in a postmenopausal woman, additional uterine explorations (hysteroscopy and histology) are recommended. If endometrial cancer is discovered, the key examination is lumbopelvic MRI.

STRATÉGIE DIAGNOSTIQUE DES LÉSIONS INTRA-UTÉRINES La stratégie diagnostique des lésions intra-utérines est une question qui se pose très fréquemment en consultation de gynécologie. Le cancer de l'endomètre survient le plus souvent chez des femmes ménopausées, et les saignements sont le premier signe clinique dans plus de 90 % des cas. L'échographie pelvienne et la biopsie d'endomètre ont une place très importante dans la stratégie diagnostique. Lors d'un épisode unique de saignement utérin anormal et lorsque l'échographie estime l'épaisseur de l'endomètre inférieure ou égale à 4 mm, il est possible de surseoir à une exploration utérine complémentaire. En cas de saignements utérins anormaux récidivants ou lorsque l'épaisseur de l'endomètre est supérieure à 4 mm chez une femme ménopausée, des explorations utérines complémentaires (hystéroscopie et histologie) sont en revanche recommandées. En cas de découverte d'un cancer de l'endomètre, l'examen clé est l'IRM lombopelvienne.

[Evolution of endometrial cancer surgery]. / Évolution de la chirurgie des cancers de l'endomètre.

Minimally invasive surgery (laparoscopic or robotic assisted) is currently recommended when surgery is envisaged, including for patients in the high risk group. The place of the uterine manipulator in this indication still needs to be clarified by prospective studies. The indocyanine green sentinel lymph node procedure has become the reference technique for lymph node staging of FIGO stages I and II regardless of histological type. Management must be carried out in a specialized institution by a team specialised in the gynaecological cancers.

Concernant le cancer de l'endomètre, lorsqu'une chirurgie est envisagée, la voie miniinvasive (coelioscopique ou robot-assistée) est actuellement recommandée, y compris pour les patientes du groupe à haut risque. La place du manipulateur utérin dans cette indication doit encore être précisée par des études prospectives. La procédure du ganglion sentinelle au vert d'indocyanine est par ailleurs devenue la technique de référence pour la stadification ganglionnaire des stades FIGO I et II quel que soit le type histologique. La prise en charge doit être assurée dans un établissement spécialisé, par une équipe spécialisée dans les cancers gynécologiques.

Residual Microscopic Peritoneal Metastases after Macroscopic Complete Cytoreductive Surgery for Advanced High-Grade Serous Ovarian Carcinoma: A Target for Folate Receptor Targeted Photodynamic Therapy?

Despite conventional treatment combining complete macroscopic cytoreductive surgery (CRS) and systemic chemotherapy, residual microscopic peritoneal metastases (mPM) may persist as the cause of peritoneal recurrence in 60% of patients. Therefore, there is a real need to specifically target these mPM to definitively eradicate any traces of the disease and improve patient survival. Therapeutic targeting method, such as photodynamic therapy, would be a promising method for such a purpose. Folate receptor alpha (FRα), as it is specifically overexpressed by cancer cells from various origins, including ovarian cancer cells, is a good target to address photosensitizing molecules. The aim of this study was to determine FRα expression by residual mPM after complete macroscopic CRS in patients with advanced high-grade serous ovarian cancer (HGSOC). A prospective study conducted between 1 June 2018 and 10 July 2019 in a single referent center accredited by the European Society of Gynecological Oncology for advanced EOC surgical management. Consecutive patients presenting with advanced HGSOC and eligible for complete macroscopic CRS were included. Up to 13 peritoneal biopsies were taken from macroscopically healthy peritoneum at the end of CRS and examined for the presence of mPM. In case of detection of mPM, a systematic search for RFα expression by immunohistochemistry was performed. Twenty-six patients were included and 26.9% presented mPM. In the subgroup of patients with mPM, FRα expression was positive on diagnostic biopsy before neoadjuvant chemotherapy for 67% of patients, on macroscopic peritoneal metastases for 86% of patients, and on mPM for 75% of patients. In the subgroup of patients with no mPM, FRα expression was found on diagnostic biopsy before neoadjuvant chemotherapy in 29% of patients and on macroscopic peritoneal metastases in 78% of patients. FRα is well expressed by patients with or without mPM after complete macroscopic CRS in patients with advanced HGSOC. In addition to conventional cytoreductive surgery, the use of a therapeutic targeting method, such as photodynamic therapy, by addressing photosensitizing molecules that specifically target FRα may be studied.

Minimally invasive surgery for early-stage cervical cancer: Rediscovering the Schautheim robot-assisted procedure.

INTRODUCTION: The Laparoscopic Approach to Cervical Cancer (LACC) trial recently showed a significant inferiority of the minimally invasive surgery when we considered them both equivalent in the treatment of cervical cancer. The objective of this article is to describe and discuss the interest of the Schautheim procedure. SURGICAL TECHNIQUE: The Schautheim is the association of a radical hysterectomy by laparoscopy/robot assisted or not as described by Wertheim after a primary vaginal closure, like the first step of Schauta's hysterectomy. This technique is described in ten steps, with a video material. DISCUSSION: The return to open surgery could lead to a loss of benefits associated with the laparoscopic approach in terms of per and post-operative morbidity. One way to achieve similar results would be to prohibit the use of uterine manipulators and create a vaginal cuff. CONCLUSION: Several authors suggest that early-stage cervical cancer patients could still be operated by laparoscopy without reducing overall survival or increasing risk of recurrence if certain measures are followed.

FDG-PET/CT and Para-Aortic Staging in Endometrial Cancer. A French Multicentric Study.

BACKGROUND: FDG-PET/CT is a noninvasive examination that could be helpful for the management of endometrial cancer. The aim of this study was to evaluate the performance of FDG-PET/CT in assessing para-aortic lymph-node involvement in high-risk endometrial cancer. METHODS: We performed a retrospective multicenter study including all patients who had a high-risk endometrial cancer with a preoperative FDG-PET/CT and a para-aortic lymphadenectomy (PAL) between 2009 and 2019. The main objective was to evaluate the overall performance of FDG-PET/CT. The secondary objectives were to evaluate its performances according to the histological type and according to FDG-PET/CT date (before or after hysterectomy), and to compare its overall performance with that of the MRI scan. RESULTS: We included 200 patients from six different centers. After the false positive FDG-PET/CT was reread by nuclear physicians, FDG-PET/CT had a sensitivity of 61.8%, a specificity of 89.7%, a positive predictive value of 69.4%, a negative predictive value of 86.1%, and an AUC of 0.76. There were no statistically significant differences in the performances according to either histological type and or FDG-PET/CT date. The sensitivity of FDG-PET/CT was better than that of MRI (p < 0.01), but the specificity was not (p = 0.82). CONCLUSION: Currently, FDG-PET/CT alone cannot replace PAL for the lymph node evaluation of high-risk endometrial cancers. It seems essential to reread it in multidisciplinary meetings before validating the therapeutic management of patients, particularly in the case of isolated para-aortic involvement.

[Robots set up in the operating theater]. / Les robots s'installent au bloc opératoire.

"Robots set up in the operating theater. The patient's benefit after a minimally invasive approach stimulated the robotic approach of abdominal and thoracic surgical procedures. Although much more expensive, the robots improve the vision of the operating field, the precision of the gestures with a faster training course for the surgeon who operates more comfortably. Surgeons eager for technological progress quickly adopted this technique in urology and gynecology and then in thoracic and digestive procedures. In France, the support for this innovation by academic and medical institutions is limited by several factors including the supremacy of Intuitive which imposes its prices, the absence of scientifically proven superiority, the absence of surveys under the responsibility of scientific societies and the lack of criteria concerning the surgeon training."

"Les robots s'installent au bloc opératoire. Les bénéfices de l'approche mini-invasive abdominale et thoracique ont stimulé l'approche robotique. Bien que beaucoup plus coûteux, les robots améliorent la vision du champ opératoire, la précision des gestes avec un apprentissage plus rapide pour le chirurgien qui opère plus confortablement. Les chirurgiens avides de progrès technologiques s'emparent rapidement de cette technique en urologie et en gynécologie puis en thoracique et en digestif. Le monopole imposé par la société Intuitive qui impose ses prix, l'absence de supériorité démontrée scientifiquement, de registres sous la responsabilité de sociétés scientifiques et de critères concernant la formation des chirurgiens à cette nouvelle technique ne favorise pas le soutien des institutions françaises pour accompagner cette innovation."

Postoperative assessment of nosocomial transmission of COVID-19 after robotic surgical procedures during the pandemic.

OBJECTIVES: To assess potential nosocomial coronavirus disease-2019 (COVID-19) transmission in patients who underwent robot-assisted laparoscopic procedures during the pandemic. MATERIAL AND METHODS: Prospective study in patients undergoing robot-assisted laparoscopy in urology or gynaecology within 2 academic hospitals. Patients underwent local preoperative COVID-19 screening using a symptoms questionnaire. Patients with suspicious screening underwent coronavirus real time-polymerase chain reaction (RT-PCR) and were excluded from robotic surgery if positive. Patients with symptoms postsurgery were systematically tested for coronavirus by RT-PCR. One-month postsurgery, all patients had a telephone consultation to evaluate COVID-19 symptoms. RESULTS: Sixty-eight patients underwent robotic surgery during the study period (median age: 63-years [IQR: 53-70], 1.8 male: female ratio). Oncology was the main indication for robotic surgery (n = 62, 91.2%) and 26 patients (38.2%) received a chest CT-scan prior to surgery. Eleven patients (16.2%) were symptomatic after surgery of whom only 1 tested positive for coronavirus by RT-PCR (1.5%) and was transferred to COVID-19 unit with no life-threatening condition. No attending surgeon was diagnosed with COVID-19 during the study. CONCLUSIONS: Robot-assisted laparoscopic surgery seemed safe in the era of COVID-19 as long as all recommended precautions are followed. The rate of nosocomial COVID-19 transmission was extremely low despite the fact that we only used RT-PCR testing in symptomatic patients during the preoperative work-up. Larger cohort is needed to validate these results.

[Are there still indications of lymph node dissection in epithelial ovarian cancers after the LION trial?] / Reste-t-il des indications de curage ganglionnaire dans les cancers épithéliaux de l'ovaire après l'essai LION ?

In March 2019, Harter et al. published the results of the LION study (Lymphadenectomy in patients with advanced ovarian neoplasms) which raises the question of pelvic and para-aortic lymphadenectomy for patients with advanced-stage epithelial ovarian cancer (EOC). These results influenced the new French recommendations published in December 2018 by the French National Cancer Institute (INCa). Thus, it no longer seems consistent to perform a systematic lymphadenectomy for patients for whom there is no argument for nodal involvement, when a macroscopic complete peritoneal cytoreductive surgery has been performed. The question of preoperative lymph node assessment is therefore essential, whereas more than half of the patients in the LION study had metastatic lymph node involvement that was histologically proven. For the assessment of lymph node status by imaging, superior sensitivity for Positron Emission Tomography is demonstrated in comparison with CT-scan or Magnetic Resonance Imaging. Nevertheless, thoraco-abdomino-pelvic CT-scan with contrast injection remains the gold standard for this indication. In the absence of suspected involvement, supra-renal, mesenteric, coelio-hepatic, and cardio-phrenic lymphadenectomy are not recommended. Lymphadenectomies should always be performed in the other situations of EOC management apart from the rare case of stage 1 expansile subtype mucinous carcinoma. The aim of this review is to discuss lymphadenectomy indications for the surgical management of EOC by taking into account new data from the scientific literature.