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Study Objective: To present our minimally invasive laparoscopic approach for sentinel lymph node (SLN) mapping with indocyanine green (ICG) using 2 fluorescence systems., Design: A step-by-step video description of the technique showing the most frequent typical and atypical location of SLNs (educational video)., Setting: Lymph node staging in apparent confined endometrial cancer., Patients: Women underwent SLN mapping in a minimally invasive setting., Interventions: Laparoscopic SLN mapping before comprehensive staging including simple hysterectomy, bilateral salpingo-oophorectomy, and pelvic and aortic bilateral lymphadenectomy in case of unilateral or no identification of SLNs. The PINPOINT 0 degree HD S1 SPY camera (PINPOINT Endoscopic Fluorescence Imaging System; NOVADAQ, Mississauga, ON, Canada) or the Full HD Image 1S with ICG camera (Karl Storz Endoscopy, Tuttlingen, Germany) were used for SLN detection [1,2]. The ICG powder was diluted to a final solution of 1.25 mg/mL of fluorescent dye. After the induction of general anesthesia, a total of 4 mL of the ICG solution was injected into the cervix at the 3 and 9 o'clock positions. Attention to the technical details is crucial to correctly identify SLNs that sometimes are located in atypical locations [3]., Conclusion: Both fluorescence systems are valid and applicable for SLN mapping in the case of apparent confined endometrial cancer. In our experience, the PINPOINT system seems to allow surgeons easier and faster nodal staging of the SLNs, particularly with the color-segmented fluorescence function activated, which can better discriminate between the lymphatic channels and the real SLNs [4,5]., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To evaluate the added value of the fluorescence dye indocyanine green (ICG) for sentinel lymph node (SLN) mapping in women with cervical cancer who had undergone previous conization (stage 1A-1B1) by comparing ICG versus Tc99 m radiotracer + blue dye (BD)., Design: Retrospective study (Canadian Task Force classification II-2)., Setting: Two European academic medical centers, San Gerardo Hospital, Italy and University of Berne, Switzerland., Patients: Sixty-five women with early stage (IA-IB1) cervical cancer who had undergone previous conization and who underwent SLN mapping with Tc99 m  ± BD (n = 23) or ICG (n = 42) followed by pelvic lymphadenectomy and fertility-sparing surgery or hysterectomy were included in this analysis., Intervention: Overall detection rate and bilateral SLN mapping rates of ICG were compared with those obtained using the standard Tc99 m radiocolloid and BD., Measurement and Main Results: Overall, 220 SLNs were detected. The median number of SLNs per patient in the Tc99 m  ± BD group was 2 (range, 1-5) and in the ICG group, 3 (range, 2-15). The detection rate of SLNs was 95.7% in Tc99 m  ± BD group and 100% in the ICG group (p = .354). The women injected with ICG had a higher rate of bilateral mapping of the SLNs as compared with the Tc99 m  ± BD group (95.2% vs 69.6%, p = .016%). Only 12% of the patients (8/65) presented metastatic nodes, 2 in the Tc99 m  ± BD group and 6 in the ICG group., Conclusion: In early-stage cervical cancer patients conization had no significant impact on the SLN detection rate using both techniques (ICG and radiotracer ± BD). In this scenario a higher bilateral mapping rate was confirmed using the fluorescent dye ICG rather than the standard techniques., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Objective: To compare 3-mm minilaparoscopy and standard 5-mm laparoscopy for sentinel lymph node (SLN) detection in apparent early-stage endometrial cancer (EC)., Design: Retrospective study (Canadian Task Force classification II-2)., Setting: Two academic research centers., Patients: Consecutive women with apparent early-stage EC who underwent surgical staging with SLN detection between November 2015 and April 2016., Interventions: The surgical approach was a total laparoscopic extrafascial hysterectomy plus bilateral salpingo-oophorectomy and SLN detection. Systematic lymphadenectomy was performed in selected cases. In all patients, SLN detection was performed with cervical injection of indocyanine green and the use of an optical camera with a near-infrared high-intensity light source for detection of fluorescence imaging. All patients who underwent a minilaparoscopic approach (using one 5-mm scope and three 3-mm ancillary trocars) have been enrolled at the University of Insubria, whereas at the San Gerardo Hospital, standard laparoscopy was performed with one 10-mm scope and three 5-mm ancillary trocars., Measurements Ad Main Results: A total of 38 patients were enrolled, including 15 (39.5%) in the 3-mm group and 23 (60.5%) in the 5-mm group. No between-group differences were found in terms of demographic and tumor characteristics. Bilateral SLNs were detected in 73.3% of the patients in the 3-mm group and in 73.9% in the 5-mm group. Operative time, blood loss, hemoglobin drop, hospital stay, and the incidence and severity of complications were similar in the 2 groups. One patient (4.3%) in the standard 5-mm group had a positive SLN result (a micrometastasis in the left external iliac SLN). No positive SLNs were detected in the 3-mm group., Conclusion: Minilaparoscopic SLN biopsy appears to be a promising and feasible technique for EC staging. Further research is warranted to investigate the possible benefits of 3-mm instruments in this specific setting., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To show a novel minimally invasive approach to sentinel lymph node (SLN) detection of the ovary with near-infrared-guided surgery using indocyanine green (ICG)., Design: A step by step description of the technique with video and figures (educational video)., Setting: The standard surgical staging of early-stage I-II ovarian cancer includes systematic pelvic and aortic lymphadenectomy even in the absence of clear evidence regarding the survival benefits associated with comprehensive retroperitoneal staging. The ideal candidates are all women undergoing a surgical approach with frozen section analysis for highly suspicious ovarian masses or patients in whom an adnexal mass has been removed that appeared to be malignant and an open or laparoscopic surgical staging procedure is planned., Patient: A 31-year-old woman with occult ovarian cancer after simple left ovarian cystectomy., Interventions: Laparoscopic surgical staging including simple hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and aortic bilateral lymphadenectomy, and sentinel node biopsy from the left ovary., Measurements and Main Results: The surgical intervention was performed with the PinPoint 0 degree HD S1 SPY fluorescence camera (PinPoint Endoscopic Fluorescence Imaging System; NOVADAQ, Mississauga, ON, Canada). After the induction of the pneumoperitoneum, ICG was injected with 2 separate injections in the proper ovarian ligament and the infundibulopelvic ligament, just below the peritoneum, at a concentration of 1.25 mg/mL. A total amount of 0.4 mL ICG solution was injected using a percutaneous abdominal approach with a 12-cm-long 22-G spinal needle. SLN mapping should be preceded by the exposure of the aortic region with a gentle dissection on both sides along the Toldt fascia up to the left renal vein. Two SLNs were identified in the left inframesenteric para-aortic and superficial left common areas. Both SLNs were negative., Conclusion: The minimally invasive approach in combination with the ICG near-infrared fluorescence S1 PinPoint fluorescence system seems feasible, and, in our opinion, even if preliminary, this approach can further extend the range of indications of SLN mapping. In the future, this combined approach can prospectively involve ovarian SLN detection., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: The goal of this study was to evaluate the intraoperative and perioperative surgical outcomes of 2 different florescence systems commonly used for sentinel lymph node (SLN) mapping in women with early-stage cervical cancer or endometrial cancer., Design: Case-control study (Canadian Task Force classification II-2)., Setting: The Gynecology Oncology Surgical Unit of the San Gerardo Hospital, Italy., Patients: Thirty-four consecutive women with early stage-cervical cancer (stage IA-1B1) or apparent confined stage I endometrial cancer were included in the study., Interventions: Between October 2016 and May 2017, 34 patients underwent laparoscopic surgery with SLN mapping using indocyanine green dye: 22 women were mapped with the Storz 1S system (Karl Storz Endoscopy, Tuttlingen, Germany; Group A), whereas 12 women underwent planned surgery with the Novadaq PinPoint system (Novadaq, Mississauga, Ontario, Canada; Group B)., Measurement and Main Results: We compared the surgical and perioperative outcomes of Group A and Group B. Patients in Group B had a shorter duration of the SLN mapping time than those in Group A (p = .0003). The median number of SLNs removed was 2 (range, 0-5) in Group A and 2 (range, 1-3) in Group B (p = .501). Bilateral mapping was 77.3% in Group A and 83.3% in Group B (p = .334), respectively. No differences were recorded in terms of body mass index, length of hospital stay, type of tumor, bilateral mapping, or number of lymph nodes removed. Body mass index was found to have no impact on the duration of the mapping (p = .353)., Conclusion: From our preliminary experience we can conclude that both fluorescence systems are valid and applicable for SLN detection in the case of early-stage cervical or endometrial cancer. The PinPoint system seems to allow surgeons easier and faster identification of the SLNs, particularly in endometrial cancer patients., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To compare sentinel lymph node (SLN) mapping in women with cervical cancer stage >IB1 (tumor size >2 cm) using indocyanine green (ICG) versus the standard technique using radioisotope technetium 99m radiocolloid (Tc99 m ) radiotracer with or without blue dye., Design: European multicenter, retrospective observational study (Canadian Task Force classification II-2)., Setting: Four academic medical centers., Patients: Ninety-five women with stage IB1 cervical cancer (>2 cm) who underwent SLN mapping with Tc99 m with or without blue dye or ICG and radical hysterectomy., Intervention: The detection rate and bilateral mapping rate were compared between ICG and standard Tc99 m radiotracer with or without blue dye. Lymphadenectomy was performed, and the false-negative rate was assessed., Measurements and Main Results: Forty-seven patients underwent SLN mapping with Tc99 m with or without blue dye, and 48 did so with ICG. All patients underwent radical hysterectomy with or without bilateral salpingo-oophorectomy between 2008 and 2016. The overall detection rate of SLN mapping was 91.5% for Tc99 m with or without blue dye and 100% for ICG. A 91.7% rate of bilateral migration was achieved for ICG, significantly higher than the 66% obtained with Tc99 m with or without blue dye (p = .025). Nine of the 23 SLN-positive patients (39.1%) were diagnosed exclusively as a result of the ultrastaging used to identify micrometastases or isolated tumor cells only., Conclusions: In advanced cervical cancer (stage IB1 >2 cm), the detection rate and bilateral migration rate on real-time fluorescent SLN mapping were higher with ICG than with Tc99 m radiotracer with or without blue dye. SLN mapping and ultrastaging can provide additional information for nodal staging in advanced cervical cancer. In this setting, ICG is a promising tool for mapping, appearing less affected by higher disease stage compared with traditional methods., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Sentinel lymph node (SLN) mapping is emerging as an effective method for surgical staging of different gynecologic malignancies. Near-infrared (NIR) technology using a fluorescent dye such as indocyanine green (ICG) represents an interesting and feasible method for SLN mapping even in traditional open surgeries by applying video telescope operating microscope (VITOM) system technology. We report our preliminary experience in 12 women who underwent surgical nodal staging for early-stage vulvar and uterine or cervical cancer. Surgical and pathological outcomes are described, and the VITOM II ICG system's intraoperative image quality, handling and docking, and teaching value are assessed. The general impression of the surgical staff was that the VITOM II system is easy to use, and that the image quality of the anatomic structures is impressive. Traditional open SLN mapping with ICG appears to be easy to perform and reproducible, providing a new tool in the management of patients with gynecologic malignancies. Moreover, we believe that this technology has great potential as an operative teaching and learning modality for trainers for open surgical cases. Additional studies involving the VITOM system with a large sample size of patients are needed to confirm these promising results., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Indocyanine green (ICG) represents a feasible alternative to the more traditional methods of sentinel lymph node (SLN) mapping, and interest in this promising tracer is growing. This report outlines our experience with ICG in a minimally invasive laparoscopic approach in women with endometrial cancer and cervical cancer using the Storz SPIES ICG near-infrared fluorescence imaging technology. A total of 49 patients with clinical stage I endometrial cancer (n = 40) or stage I cervical cancer (n = 9) were retrospectively reviewed. All patients had undergone simple or radical laparoscopic hysterectomy with pelvic and/or aortic lymphadenectomy and SLN mapping by means of an intracervical injection of ICG dye at the 3 o'clock and 9 o'clock locations after the induction of general anesthesia. The detection rate of ICG was 100% (49 of 49). The rate of bilateral SLN detection was 86% (42 of 49). Positive lymph nodes were found in 6 patients (12%), with at least 1 positive SLN. The sensitivity and negative predictive value of SLN detection were 100%. All procedures were successfully completed without conversion to open laparotomy, and no intraoperative or postoperative complications occurred. In our preliminary experience, ICG showed a high overall detection rate, and bilateral mapping appears to be a feasible alternative to the more traditional methods of SLN mapping in patients with endometrial cancer and cervical cancer. Laparoscopic SLN mapping with ICG appears to be safe, easy, and reproducible, with a positive impact on patient management., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)