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
- Professor of Gynecologic Oncology
- University of Washington
- 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.
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- 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
- SUMMARY AND RECOMMENDATIONS