Review Article Extraperitoneal Robotic-Assisted Para-Aortic Lymphadenectomy in Gynecologic Cancer Staging: Current Evidence Giorgio Bogani, MD*, Antonino Ditto, MD, Fabio Martinelli, MD, Mauro Signorelli, MD, Valentina Chiappa, MD, Ilaria Sabatucci, MD, Cono Scaffa, MD, Domenica Lorusso, MD, and Francesco Raspagliesi, MD From the Gynecologic Surgery Unit, IRCCS Foundation, National Cancer Institute, Milan, Italy (all authors). ABSTRACT We reviewed the current evidence on the safety, effectiveness, and applicability of extraperitoneal robotic-assisted para-aortic lymphadenectomy (ExtRA-PAL) as the staging procedure of gynecologic malignancies. PubMed (MEDLINE), Scopus, Web of Science databases, and ClinicalTrails.gov were searched for original studies reporting outcomes of ExtRA-PAL. Quality of the included studies and their level of recommendation were assessed using the Grading of Recommendations, Assessment, Development, and Evaluation and the American College of Obstetricians and Gynecologists guidelines, respectively. Overall, 62 studies were identified; after a process of evidence acquisition 5 original investigations were available for this review that included 98 patients undergoing ExtRA-PAL. The main surgical indication was staging for cervical cancer (n 5 71, 72%). The mean (SD) number of para-aortic node yielded was 15.4 (64.7) nodes. Blood transfusion and intraoperative complication rates were 2% and 6%, respectively. ExtRA-PAL was completed in 88 patients (90%). Six (6%) and 4 (4%) patients had conversion to other minimally invasive procedures and open surgery, respectively. Success rate was 99% among patients un- dergoing ExtRA-PAL without concomitant procedures. Overall, mean (SD) length of hospital stay was 2.8 (60.5) days. Twenty-four patients (24%) developed postoperative events. According to the Clavien-Dindo grading system, grades IIIa and IIIb morbidity rates were 12% and 2%, respectively. No grades IVand V morbidity occurred. ExtRA-PAL is associated with a high success rate and a relative low morbidity rate. However, because of the limited data on this issue, further studies are warranted to assess the long-term effectiveness of this procedure. Journal of Minimally Invasive Gynecology (2016) -, -–- Ó 2016 AAGL. All rights reserved. Keywords: Extraperitoneal; Retroperitoneal; Robotic; Para-aortic lymphadenectomy Para-aortic lymphadenectomy (PAL) represents an essen- tial step in surgical staging procedures of several gyneco- logic malignancies, including endometrial, cervical, and ovarian carcinoma [1–3]. The execution of PAL may provide useful information regarding the diffusion and prognosis of cancer, thus allowing targeting primary and adjuvant treatments [4,5]. However, the execution of complex surgical procedures such as PAL may lead to potentially severe short- and long-term events, including risk of developing intraperitoneal adhesions and potentially radiation-related complications. For this reason in 1997 Dargent et al [6] proposed their technique for extraperitoneal lymphadenectomy performed via laparoscopic surgery. Several studies have shown the safety and feasibility of lapa- roscopic extraperitoneal PAL [7–9]. The use of extraperitoneal laparoscopic PAL overcomes poor exposure of the surgical field (resulting from obesity and overlying of bowel loops) that characterize the conventional transperitoneal laparoscopic approach [7,8]. However, the embrace of this technique evolved slower than expected, and only a few centers adopted this technique. In fact, extraperitoneal laparoscopic PAL represents a challenging procedure, requiring a steep learning curve and high endoscopic skills. In recent years the introduction of robotic-assisted sur- gery has dramatically modified gynecologic surgery practice [10–13]. Robotic-assisted surgery was developed to over- come some technical difficulties of laparoscopy, improving surgery-related outcomes not only for patients but also There are no financial disclosures or conflicts of interest to report. Corresponding author: Giorgio Bogani, MD, IRCCS Foundation, National Cancer Institute, Via Venezian 1, 20133 Milan, Italy. E-mail: gorgio.bogani@istitutotumori.mi.it Submitted December 22, 2015. Accepted for publication January 14, 2016. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2016 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2016.01.016