New Retroperitoneal Transvaginal Natural Orifice Transluminal Endoscopic Surgery Approach to Sentinel Node for Endometrial Cancer: A Demonstration Video

Study ObjectiveTo assess whether sentinel node resection for endometrial cancer is feasible via retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and gives better exposure than transperitoneal vNOTES.DesignThis is a first small IDEAL (Idea Development Exploration Assessment Long-term follow up) stage 1 study to assess the feasibility of a new approach; the technique is explained step-by-step using videos (Video 1) and pictures.SettingThe gynecologic oncology department of a nonuniversity teaching hospital in Belgium.PatientsSince 2015, 15 patients were operated on via vNOTES for endometrial cancer [1].InterventionsOur initial experience showed that a transperitoneal approach via vNOTES [2] provided good access to the cranial pelvic retroperitoneum but not to the caudal pelvic retroperitoneum. Therefore, a new retroperitoneal vNOTES approach via a paracervical incision in the lateral vaginal fornix was developed. Via this incision, the obturator fossa is accessed, and a vNOTES port is placed for endoscopic dissection of the retroperitoneal space. This video article shows this new access route to the pelvic retroperitoneal space.Measurements and Main ResultsOur initial experience with vNOTES for endometrial cancer showed that transperitoneal access to the retroperitoneal space did not give optimal exposure to the caudal parts of the obturator space. The new retroperitoneal vNOTES approach shown in this video article gives better exposure to the entire retroperitoneal space including the caudal part of the obturator space; the sacral plexus; the external, internal, and common iliac arteries; and even the lower para-aortic region.ConclusionIt has been previously shown that vNOTES hysterectomy offers patient benefits over total laparoscopic hysterectomy [3]. The retroperitoneal vNOTES approach now also offers good transvaginal access to the entire retroperitoneal space for sentinel node resection. This is a new approach that requires further validation before vNOTES hysterectomy with retroperitoneal sentinel node resection can be used outside study settings for the treatment of endometrial cancer.