Pelvic and paraaortic lymphadenectomy in gynecologic cancers
- Jeffrey M Fowler, MD
Jeffrey M Fowler, MD
- Vice Chairman and Professor
- Department of Obstetrics and Gynecology
- Division of Gynecologic Oncology
- John G. Boutselis Chair in Gynecologic Oncology
- The Ohio State University Medical Center
- Floor J Backes, MD
Floor J Backes, MD
- Assistant Professor
- Division of Gynecologic Oncology
- Department of Obstetrics and Gynecology
- The Ohio State University College of Medicine
- Section Editors
- Barbara Goff, MD
Barbara Goff, MD
- Section Editor — Gynecologic Oncology
- Department Chair, Gynecologic Oncology
- University of Washington Medical Center
- Tommaso Falcone, MD, FRCSC, FACOG
Tommaso Falcone, MD, FRCSC, FACOG
- Section Editor — Minimally Invasive Gynecologic Surgery
- Professor of Obstetrics and Gynecology
- Cleveland Clinic Lerner College of Medicine
Pelvic and paraaortic lymph node evaluation is a major component of the surgical staging procedure for several gynecologic malignancies, including endometrial and ovarian carcinoma . Cervical cancer is clinically staged, but assessment of pelvic and paraaortic lymph nodes is performed with lymphadenectomy and/or imaging.
The surgical and oncologic goals of the lymph node dissection are to define the extent of disease, and thereby, to guide further treatment. Lymphadenectomy may also have a therapeutic goal in conditions in which removing nodes harboring metastatic disease improves survival [2-5].
The role of the pelvic and paraaortic lymph node dissection for women diagnosed with a gynecologic malignancy has evolved since the 1990s. For each tumor site, there is controversy about the extent of dissection (complete lymphadenectomy versus lymph node sampling) and the anatomic level of dissection that is required (ie, pelvic with or without paraaortic nodes).
Techniques for pelvic and paraaortic lymphadenectomy in gynecologic malignancies are reviewed here. Staging of individual tumor sites are discussed separately. (See "Invasive cervical cancer: Staging and evaluation of lymph nodes" and "Endometrial carcinoma: Pretreatment evaluation, staging, and surgical treatment" and "Cancer of the ovary, fallopian tube, and peritoneum: Staging and initial surgical management".)
Retroperitoneal space — The retroperitoneal space is a potential space that is accessed via a transperitoneal incision, or directly via an extraperitoneal approach (figure 1). The kidneys, ureters, bladder, great vessels, lymphatic channels, lymph nodes, nerves, and muscles lie underneath the peritoneum and are enveloped in loose areolar connective tissue. Knowledge of the anatomy of the retroperitoneum and the surgical ability to dissect and develop these potential spaces greatly facilitates radical gynecologic surgery and pelvic and paraaortic lymph node dissection. The pararectal and paravesical pelvic spaces and the retroperitoneum of the lower abdomen are developed by the surgeon in order to define the boundaries of the lymph nodes and facilitate the surgical dissection.
Subscribers log in hereLiterature review current through: Nov 2017. | This topic last updated: May 27, 2016.References
- Papadia A, Remorgida V, Salom EM, Ragni N. Laparoscopic pelvic and paraaortic lymphadenectomy in gynecologic oncology. J Am Assoc Gynecol Laparosc 2004; 11:297.
- Cosin JA, Fowler JM, Chen MD, et al. Pretreatment surgical staging of patients with cervical carcinoma: the case for lymph node debulking. Cancer 1998; 82:2241.
- Gold MA, Tian C, Whitney CW, et al. Surgical versus radiographic determination of para-aortic lymph node metastases before chemoradiation for locally advanced cervical carcinoma: a Gynecologic Oncology Group Study. Cancer 2008; 112:1954.
- Goff BA, Muntz HG, Paley PJ, et al. Impact of surgical staging in women with locally advanced cervical cancer. Gynecol Oncol 1999; 74:436.
- Kilgore LC, Partridge EE, Alvarez RD, et al. Adenocarcinoma of the endometrium: survival comparisons of patients with and without pelvic node sampling. Gynecol Oncol 1995; 56:29.
- Ramondetta LM. Lymphatic anatomy and physiology: Operative techniques in gynecologic surgery. Operat Tech Gynecol Surg 2001; 6:7.
- Whitney CW, Spirtos N. Gynecologic Oncology Group surgical procedures manual, Gynecologic Oncology Group, Philadelphia 2010.
- Ben Shachar I, Fowler JM. The role of laparoscopy in the management of gynecologic cancers. In: Gynecologic Cancer: Controversies in Mangement, Gershenson DM, Gore M, McGuire WP, et al (Eds), Churchill Livingstone, London 2004.
- Shindo S, Kubota K, Kojima A, et al. Anomalies of inferior vena cava and left renal vein: risks in aortic surgery. Ann Vasc Surg 2000; 14:393.
- Mathews R, Smith PA, Fishman EK, Marshall FF. Anomalies of the inferior vena cava and renal veins: embryologic and surgical considerations. Urology 1999; 53:873.
- Klemm P, Fröber R, Köhler C, Schneider A. Vascular anomalies in the paraaortic region diagnosed by laparoscopy in patients with gynaecologic malignancies. Gynecol Oncol 2005; 96:278.
- Tewari KS, Monk BJ. Invasive cervical cancer. In: Clinical Gynecologic Oncology, 8th, DiSaia PJ, Creasman WT (Eds), Elsevier, Philadelphia 2012.
- Hunn J, Dodson MK, Webb J, Soisson AP. Endometrial cancer--current state of the art therapies and unmet clinical needs: the role of surgery and preoperative radiographic assessment. Adv Drug Deliv Rev 2009; 61:890.
- http://seer.cancer.gov/statfacts/html/ovary.html (Accessed on April 24, 2012).
- Krasner C, Duska L. Management of women with newly diagnosed ovarian cancer. Semin Oncol 2009; 36:91.
- Koulouris CR, Penson RT. Ovarian stromal and germ cell tumors. Semin Oncol 2009; 36:126.
- Kleppe M, Wang T, Van Gorp T, et al. Lymph node metastasis in stages I and II ovarian cancer: a review. Gynecol Oncol 2011; 123:610.
- Timmers PJ, Zwinderman K, Coens C, et al. Lymph node sampling and taking of blind biopsies are important elements of the surgical staging of early ovarian cancer. Int J Gynecol Cancer 2010; 20:1142.
- Berek JS. Lymph node-positive stage IIIC ovarian cancer: a separate entity? Int J Gynecol Cancer 2009; 19 Suppl 2:S18.
- Aletti GD, Dowdy S, Podratz KC, Cliby WA. Role of lymphadenectomy in the management of grossly apparent advanced stage epithelial ovarian cancer. Am J Obstet Gynecol 2006; 195:1862.
- du Bois A, Reuss A, Harter P, et al. Potential role of lymphadenectomy in advanced ovarian cancer: a combined exploratory analysis of three prospectively randomized phase III multicenter trials. J Clin Oncol 2010; 28:1733.
- Panici PB, Maggioni A, Hacker N, et al. Systematic aortic and pelvic lymphadenectomy versus resection of bulky nodes only in optimally debulked advanced ovarian cancer: a randomized clinical trial. J Natl Cancer Inst 2005; 97:560.
- Seamon LG, Cohn DE, Valmadre S, et al. Robotic hysterectomy and lymphadenectomy for endometrial cancer: technical aspects and details of success--the Ohio State University method. J Robotic Surg 2008; 2:71.
- Shafer A, Boggess JF. Robotic-assisted endometrial cancer staging and radical hysterectomy with the da Vinci surgical system. Gynecol Oncol 2008; 111:S18.
- Díaz-Feijoo B, Gil-Ibáñez B, Pérez-Benavente A, et al. Comparison of robotic-assisted vs conventional laparoscopy for extraperitoneal paraaortic lymphadenectomy. Gynecol Oncol 2014; 132:98.
- Magrina JF, Kho R, Montero RP, et al. Robotic extraperitoneal aortic lymphadenectomy: Development of a technique. Gynecol Oncol 2009; 113:32.
- James JA, Rakowski JA, Jeppson CN, et al. Robotic transperitoneal infra-renal aortic lymphadenectomy in early-stage endometrial cancer. Gynecol Oncol 2015; 136:285.
- Köhler C, Tozzi R, Klemm P, Schneider A. Laparoscopic paraaortic left-sided transperitoneal infrarenal lymphadenectomy in patients with gynecologic malignancies: technique and results. Gynecol Oncol 2003; 91:139.
- Dargent D, Ansquer Y, Mathevet P. Technical development and results of left extraperitoneal laparoscopic paraaortic lymphadenectomy for cervical cancer. Gynecol Oncol 2000; 77:87.
- Dowdy SC, Aletti G, Cliby WA, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy--a prospective cohort study of 293 patients with endometrial cancer. Gynecol Oncol 2008; 111:418.
- Childers JM, Brzechffa PR, Hatch KD, Surwit EA. Laparoscopically assisted surgical staging (LASS) of endometrial cancer. Gynecol Oncol 1993; 51:33.
- Kavallaris A, Kalogiannidis I, Chalvatzas N, et al. Standardized technique of laparoscopic pelvic and para-aortic lymphadenectomy in gynecologic cancer optimizes the perioperative outcomes. Arch Gynecol Obstet 2011; 283:1373.
- Weiser EB, Bundy BN, Hoskins WJ, et al. Extraperitoneal versus transperitoneal selective paraaortic lymphadenectomy in the pretreatment surgical staging of advanced cervical carcinoma (a Gynecologic Oncology Group study). Gynecol Oncol 1989; 33:283.
- Chen MD, Teigen GA, Reynolds HT, et al. Laparoscopy versus laparotomy: an evaluation of adhesion formation after pelvic and paraaortic lymphadenectomy in a porcine model. Am J Obstet Gynecol 1998; 178:499.
- Lanvin D, Elhage A, Henry B, et al. Accuracy and safety of laparoscopic lymphadenectomy: an experimental prospective randomized study. Gynecol Oncol 1997; 67:83.
- Bogani G, Ditto A, Martinelli F, et al. Extraperitoneal Robotic-Assisted Para-Aortic Lymphadenectomy in Gynecologic Cancer Staging: Current Evidence. J Minim Invasive Gynecol 2016; 23:489.
- Vergote I, Pouseele B, Van Gorp T, et al. Robotic retroperitoneal lower para-aortic lymphadenectomy in cervical carcinoma: first report on the technique used in 5 patients. Acta Obstet Gynecol Scand 2008; 87:783.
- Lowe MP, Tillmanns T. Outpatient laparoscopic extraperitoneal aortic nodal dissection for locally advanced cervical carcinoma. Gynecol Oncol 2008; 111:S24.
- Ramirez PT, Jhingran A, Macapinlac HA, et al. Laparoscopic extraperitoneal para-aortic lymphadenectomy in locally advanced cervical cancer: a prospective correlation of surgical findings with positron emission tomography/computed tomography findings. Cancer 2011; 117:1928.
- Seamon LG, Cohn DE, Henretta MS, et al. Minimally invasive comprehensive surgical staging for endometrial cancer: Robotics or laparoscopy? Gynecol Oncol 2009; 113:36.
- Lim PC, Kang E, Park DH. A comparative detail analysis of the learning curve and surgical outcome for robotic hysterectomy with lymphadenectomy versus laparoscopic hysterectomy with lymphadenectomy in treatment of endometrial cancer: a case-matched controlled study of the first one hundred twenty two patients. Gynecol Oncol 2011; 120:413.
- Charoenkwan K, Kietpeerakool C. Retroperitoneal drainage versus no drainage after pelvic lymphadenectomy for the prevention of lymphocyst formation in patients with gynaecological malignancies. Cochrane Database Syst Rev 2014; :CD007387.
- Medeiros LR, Rosa DD, Bozzetti MC, et al. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database Syst Rev 2009; :CD004751.
- Galaal K, Bryant A, Fisher AD, et al. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database Syst Rev 2012; :CD006655.
- Lawrie TA, Medeiros LR, Rosa DD, et al. Laparoscopy versus laparotomy for FIGO stage I ovarian cancer. Cochrane Database Syst Rev 2013; :CD005344.
- Orr JW. Surgical staging of endometrial cancer: does the patient benefit? Gynecol Oncol 1998; 71:335.
- Walker JL, Piedmonte MR, Spirtos NM, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol 2009; 27:5331.
- Backes FJ, Brudie LA, Farrell MR, et al. Short- and long-term morbidity and outcomes after robotic surgery for comprehensive endometrial cancer staging. Gynecol Oncol 2012; 125:546.
- Kumar S, Al-Wahab Z, Sarangi S, et al. Risk of postoperative venous thromboembolism after minimally invasive surgery for endometrial and cervical cancer is low: a multi-institutional study. Gynecol Oncol 2013; 130:207.
- Matsuura Y, Kawagoe T, Toki N, et al. Long-standing complications after treatment for cancer of the uterine cervix--clinical significance of medical examination at 5 years after treatment. Int J Gynecol Cancer 2006; 16:294.
- Todo Y, Yamamoto R, Minobe S, et al. Risk factors for postoperative lower-extremity lymphedema in endometrial cancer survivors who had treatment including lymphadenectomy. Gynecol Oncol 2010; 119:60.
- Salani R, Preston MM, Hade EM, et al. Swelling among women who need education about leg lymphedema: a descriptive study of lymphedema in women undergoing surgery for endometrial cancer. Int J Gynecol Cancer 2014; 24:1507.
- Rowlands IJ, Beesley VL, Janda M, et al. Quality of life of women with lower limb swelling or lymphedema 3-5 years following endometrial cancer. Gynecol Oncol 2014; 133:314.
- Mihara M, Hara H, Tsubaki H, et al. Combined conservative treatment and lymphatic venous anastomosis for severe lower limb lymphedema with recurrent cellulitis. Ann Vasc Surg 2015; 29:1318.e11.
- Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg 2013; 132:1305.
- Campisi C, Bellini C, Campisi C, et al. Microsurgery for lymphedema: clinical research and long-term results. Microsurgery 2010; 30:256.
- Zikan M, Fischerova D, Pinkavova I, et al. A prospective study examining the incidence of asymptomatic and symptomatic lymphoceles following lymphadenectomy in patients with gynecological cancer. Gynecol Oncol 2015; 137:291.
- Ghezzi F, Uccella S, Cromi A, et al. Lymphoceles, lymphorrhea, and lymphedema after laparoscopic and open endometrial cancer staging. Ann Surg Oncol 2012; 19:259.
- Mahrer A, Ramchandani P, Trerotola SO, et al. Sclerotherapy in the management of postoperative lymphocele. J Vasc Interv Radiol 2010; 21:1050.
- Khoder WY, Becker AJ, Seitz M, et al. Modified laparoscopic lymphocele marsupialization for the treatment of lymphoceles after radical prostatectomy: first results. J Laparoendosc Adv Surg Tech A 2011; 21:145.
- Solmaz U, Turan V, Mat E, et al. Chylous ascites following retroperitoneal lymphadenectomy in gynecologic malignancies: incidence, risk factors and management. Int J Surg 2015; 16:88.
- Kim EA, Park H, Jeong SG, et al. Octreotide therapy for the management of refractory chylous ascites after a staging operation for endometrial adenocarcinoma. J Obstet Gynaecol Res 2014; 40:622.
- Zhao Y, Hu W, Hou X, Zhou Q. Chylous ascites after laparoscopic lymph node dissection in gynecologic malignancies. J Minim Invasive Gynecol 2014; 21:90.
- Nakayama G, Morioka D, Murakami T, et al. Chylous ascites occurring after low anterior resection of the rectum successfully treated with an oral fat-free elemental diet (Elental(®)). Clin J Gastroenterol 2012; 5:216.
- Han D, Wu X, Li J, Ke G. Postoperative chylous ascites in patients with gynecologic malignancies. Int J Gynecol Cancer 2012; 22:186.
- Var T, Güngor T, Tonguc E, et al. The conservative treatment of postoperative chylous ascites in gynecologic cancers: four case reports. Arch Gynecol Obstet 2012; 285:849.
- Favero G, Lanowska M, Schneider A, et al. Laparoscopic approach for correction of chylous fistula after pelvic and paraaortic lymphadenectomy. J Minim Invasive Gynecol 2010; 17:262.
- Giovannini I, Giuliante F, Chiarla C, et al. External lymphatic fistula after intra-abdominal lymphadenectomy for cancer. Treatment with total parenteral nutrition and somatostatin. Nutrition 2008; 24:1220.
- Retroperitoneal space
- Lymphatic system
- - Pelvic lymph nodes
- - Paraaortic lymph nodes
- Extent of lymph node evaluation
- TUMOR SITES
- Cervical cancer
- Endometrial cancer
- Ovarian cancer
- PREOPERATIVE PREPARATION
- Preoperative evaluation
- Prophylactic antibiotics
- LYMPHADENECTOMY PROCEDURE
- Surgical access
- - Laparoscopy
- Robotic laparoscopy
- Conventional laparoscopy
- - Laparotomy
- - Transperitoneal versus extraperitoneal
- Pelvic lymphadenectomy
- Paraaortic lymphadenectomy
- - Extraperitoneal laparoscopic access
- - Procedure
- Left side
- Right side
- Infrarenal nodes
- SENTINEL NODE EVALUATION
- POSTOPERATIVE CARE
- Lymph node drainage issues
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS