Critical view of safety assessment in sentinel node dissection for endometrial and cervical cancer: artificial intelligence to enhance surgical safety and lymph node detection (LYSE study)

Abstract

Objective: This study aims to evaluate the feasibility of video-based assessment rate of Critical Views of Safety criteria for sentinel lymph node dissection in endometrial and cervical cancer.Goal of these Critical Views of Safety is to help standardize the evaluation of surgical quality, improve the precision of sentinel lymph node identification, and lead to better patient outcomes.Methods: This international multi-center observational prospective study was conducted from April to September 2024.Surgical videos from patients with cervical and endometrial carcinoma undergoing minimally invasive sentinel lymph node dissection were collected.A total of 3 Critical Views of Safety criteria (lateral pararectal space, lateral paravesical space, internal iliac artery) were proposed based on the anatomical structures defined as mandatory to be identified before sentinel node dissection, according to previously published expert consensus.A total of 3 independent surgeons, blinded to each other's assessments, evaluated whether the proposed criteria were identifiable in the endoscopic surgical video to establish applicability (content validity) and inter-rater agreement (reliability).Results: A total of 80 patients were enrolled, of these, 71 cases (88.8%) had videos suitable for annotation, 64 (90.1%) underwent sentinel lymph node dissection for endometrial cancer, and 7 (9.9%) for cervical cancer; the median age was 52 years (IQR 34-71) and median body mass index was 28.8 kg/m 2 (IQR 23.7-32.17).The lateral pararectal space was identified in 62% of videos, the lateral paravesical space in 94%, and the internal iliac artery in the 32%.Inter-rater reliability was high for the lateral pararectal and paravesical spaces (Fleiss k of 0.90) and moderate for the internal iliac artery (Fleiss k of 0.73). Conclusions:The low assessment rate of the internal iliac artery criteria should raise concerns about missing sentinel lymph nodes in the internal iliac and pre-sacral area.The assessment of such standardized safety criteria could potentially standardize the procedures, thereby improving adherence to guidelines.The introduction of the video assessment of these criteria lays the foundation for exploring the feasibility of artificial intelligence algorithms to automatically assess and document the Critical Views of Safety in surgical videos. WHAT IS ALREADY KNOWN ON THIS TOPICSentinel lymph node dissection has replaced systematic lymphadenectomy, which is associated with higher morbidity in endometrial and cervical cancer.However, the rates of peri-operative complications, empty node packets, and mapping failures cannot be neglected, particularly, during the early stages of the learning curve. WHAT THIS STUDY ADDSThis study evaluates the feasibility of video assessment rate of 3 Critical Views of Safety through the analysis of laparoscopic and robotic videos of sentinel lymph node dissection in endometrial and cervical cancer to enhance the efficacy of sentinel lymph node technique.The low assessment rate of the internal iliac artery criteria should raise concerns about missing sentinel lymph nodes in the internal iliac and pre-sacral area.