INTRODUCTION
Current guidelines recommend that patients with high-risk endometrial cancer undergo comprehensive surgical staging including the evaluation of aortic nodes 1,2. But surgical staging is still controversial 3. Minimally invasive surgery has long ago proved its well-known benefits, and more recent techniques have enhanced the options available. Laparoscopic para-aortic lymphadenectomy can be performed in four different ways using conventional or robotic-assisted laparoscopy, and the transperitoneal or extraperitoneal approach. The procedure is generally safe, but each technique and approach has its advantages and disadvantages. Although solid evidence is lacking, it appears that the extraperitoneal technique and robotic assistance are associated with less surgical morbidity4,5. But aortic evaluation is not without risks: morbidity rates can rise beyond 50% 6.
The prediction of surgical morbidity is fundamental in gynaecological oncology 6–10. One of the key factors associated with surgical morbidity is obesity 11–13. Patients with endometrial cancer are usually overweight, and a lot of them have abdominal or visceral obesity, defined as an excess of intra-abdominal fat 14. Some studies have shown a direct association between visceral obesity and surgical morbidity15–18. But only one was conducted in endometrial cancer patients 19.
Intra-abdominal fat can be evaluated by many anthropometric measurements (e.g. waist circumference, waist-hip ratio, visceral fat area, and sagittal abdominal diameter). Sagittal abdominal diameter (SAD) has been demonstrated to be the best surrogate of intra-abdominal fat20. It can be measured using the Holtain Kahn callipers in the office, but this can be a difficult task on obese patients. SAD and intra-abdominal fat can also be measured by several imaging methods (dual-energy X-ray absorptiometry, magnetic resonance [MRI], and computed tomography [CT]), but its measurement has not been standardized 21.
The current tools available to preoperatively assess surgical morbidity are limited. We lack a “one-size-fits-all” measurement since surgical outcomes depend on the technique, the approach, and each specific procedure. Moreover, the evaluation of obesity in gynaecological oncology is scarce, and most studies focus only on body mass index (BMI)—a widespread but limited measurement 22.
We asked whether the measurement of SAD in MRI is reliable and useful to predict surgical morbidity in high-risk endometrial cancer patients undergoing minimally invasive aortic lymphadenectomy. This is the first study to evaluate this measurement as a method to predict surgical morbidity in endometrial cancer patients.