*3.6.1 Radical robotic hysterectomy*

Radical hysterectomy with pelvic lymphadenectomy with or without adnexectomy remains the standard recommended surgical treatment for the different types of gynecological cancer. Depending on the type of cancer (cervical, endometrial, or ovarian), one of the types of radical hysterectomy from the Querleu classification and pelvic lymphadenectomy is performed [13, 14, 18].

Radical robotic hysterectomy is indicated for the early stages of cervical and endometrial cancer. In most cases, the procedure can be associated with pelvic or paraortic lymphadenectomy. If for cervical invasive cancer, the lymphadenectomy is mandatory for endometrial cancer lymphadenectomy aims at surgical staging.

The first part of the procedure is like all types of hysterectomies. It involves the disconnection of the superior connective vascular pedicle and the dissection of the bladder from the cervix and vagina [19]. For all the procedures the vascular pedicle sealing is performed using electrosurgical instruments: bipolar clamp, ultrasound clamp, Vessel Sealer Extend, or SynchroSeal.

Surgical staging with pelvic lymphadenectomy with or without para-aortic lymphadenectomy defines recurrence risk and determines the clinician's decision to give patients adjuvant treatment (radiation or chemotherapy) [15]. Systematic surgical staging significantly reduces the necessity of external radiation, avoiding the complications of complete pelvic lymphadenectomy [20–23].

The concept of the sentinel lymph node (SLN) has been proposed as a less invasive solution for nodal assessment. The state of the sentinel node ganglion reflects the status of the entire nodal basin of pelvic lymph nodes [24–26] (**Figure 21**).

The leading step of radical hysterectomy is the dissection of parametria. The extension of parametrial resection is decided according to the clinical stage of the tumor. For stage IB of the cervix and stage II for endometrial cancer is recommended parametrial resection C2 and pelvic lymphadenectomy. For stage I endometrial cancer SLN detection and B2 are recommended (**Figures 22** and **23**).

**Figure 21.** *SLN detection in obturator right fossa after 20 min after ICG intrastromal cervical injection.*

#### **Figure 22.**

*Right side parametrectomy. The parametrial tissue is lifting to allow unroofing of the ureter.*

#### **Figure 23.** *Left side parametrectomy. Opening the Lazko space. The uterine artery can be seen crossing the left ureter.*
