Robotic interval debulking with radical hysterectomy and partial urinary bladder resection for locally advanced carcinosarcoma of the uterus

Highlights

• •Extensive ureterolysis due to the lateral extent of the tumor with postoperative ureteral stenting.
• •Partial urinary bladder cystectomy due to clinical concern for invasion followed by two-layer cystorrhapy.
• •‘Port-hopping’ for development of the bilateral tunnels of Wertheim with the Vessel Sealer Extend.

47-year-old with locally advanced uterine carcinosarcoma underwent neoadjuvant chemotherapy with TAP (paclitaxel, doxorubicin, and cisplatin), followed by an interval debulking surgery.

The uterus was enlarged with lower uterine segment tumor replacing the majority of the ectocervix. An intrauterine manipulator was not used. The posterior supratrigonal wall of the urinary bladder was extensively involved with the tumor. Extensive ureterolysis was performed from above the pelvic brim to the ureterovesical junctions in order to safely lateralize bilateral ureters. Tedious bladder dissection was performed to prevent thermal injury. A modified (Type B) radical hysterectomy was performed, sacrificing the bladder pillars, distal uterosacral ligaments, and 2 cm of upper vagina.

The posterior urinary bladder wall had clinically-questionable residual tumor (preoperative MRI can be seen at 00:32) due to an obliterated vesicovaginal space with adherence of the lower uterine segment to the bladder dome, therefore intentional cystotomy was performed to resect the involved segment after backfilling the bladder with sterile water. Six French, 24 cm double-J stents were placed to decrease the risk of ureteral fistula and stricture, given anticipation of postoperative pelvic radiation. This can be achieved robotically by introducing the guidewire first through an assistant port followed by the stents. The bladder was repaired in two layers with barbed suture (Shapiro et al.).

The patient was discharged home on postoperative day 2, and received adjuvant chemotherapy and vaginal brachytherapy, per tumor board recommendations.

Locally advanced uterine carcinosarcoma can be managed on an individualized basis with neoadjuvant therapy followed by non-exenterative interval laparoscopic/robotic radical surgery, with emphasis on quality-of-life (Pant et al., 2014).

CRediT authorship contribution statement

Justin Harold: Investigation, Writing – review & editing. Colleen Murphy: Writing – original draft. Joan Tymon-Rosario: Writing – review & editing. Gulden Menderes: Conceptualization, Supervision, Writing – review & editing.

Appendix A. Supplementary data

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