Systematic (complete) para-aortic lymphadenectomy: description of a novel surgical classification with technical and anatomical considerations

Improvements and challenges in intraperitoneal laparoscopic para-aortic lymphadenectomy: The novel "tent-pitching" antegrade approach and vascular anatomical variations in the para-aortic region

INTRODUCTION

This study introduces and compares a new intraperitoneal laparoscopic para-aortic lymphadenectomy method to reach the level of the renal vein, the "tent-pitching" antegrade approach with the retrograde approach in gynecological malignancy surgeries in terms of success rate, complication incidence, and the number of lymph nodes removed. It focuses on the feasibility, safety, and effectiveness. Meanwhile, this article reports on the vascular anatomical variations discovered in the para-aortic region to enhance surgical safety.

MATERIAL AND METHODS

This was a retrospective cohort study including patients undergone laparoscopic para-aortic lymphadenectomy at a single center from January 2020 to December 2023 for high-risk endometrial and early-stage ovarian cancer. Patient charts were reviewed for mode of operation, perioperative complications, operative details, and histopathology. The patients were divided into anterograde group and retrograde group according to the operation mode. The two groups were further compared based on the success rate of lymph node clearance at the renal vein level, perioperative complications, and the number of removed lymph nodes. Quantitative data were analyzed using the t-test, non-normally distributed data using the rank-sum test, and categorical data using Fisher's exact test and the chi-square test, with statistical significance defined as P < 0.05.

RESULTS

Among 173 patients, the antegrade group showed higher surgery success (97.5% vs 68.82%), more lymph nodes removed (median 14 vs 7), and less median blood loss. The operation time was shorter in the antegrade group. Postoperative complications like lymphocele and venous thrombosis were lower in the antegrade group. Vascular abnormalities were found in 28.9% of patients, with accessory lumbar vein routing anomaly and accessory renal arteries being most common.

CONCLUSIONS

The antegrade approach is feasible, safe, and effective, improving surgical exposure, reducing difficulty without additional instruments or puncture sites, and minimizing organ damage risk. It is effective in achieving better access to the renal vein and removing more para-aortic lymph nodes than the retrograde method. Recognizing and carefully managing the diverse vascular abnormalities in the para-aortic area, including variations in renal arteries, veins, and the inferior vena cava, is essential to reduce intraoperative bleeding and the likelihood of converting to open surgery.

Vascular and Urinary Tract Anatomic Variants Relevant to Para-Aortic Lymphadenectomy in Women with Gynecological Cancers

BACKGROUND

Para-aortic lymphadenectomy is an essential part of gynecologic oncologic surgical treatment. The surgeon should be aware of the complex usual anatomy and its common variants.

METHODS

Between January 2021 and May 2023, 58 women underwent para-aortic lymphadenectomy for gynecologic malignancies.

RESULTS

Vascular and urinary tract anatomic variants were retrospectively reviewed from the prospective institutional database and results were compared with preoperative contrast-enhanced abdominal CT. Of these 58 women, 47 women had no vascular or urinary tract variants. One woman had a double inferior vena cava, two patients were found to have a retro-aortic left renal vein, four had accessory renal arteries, two had a double left ureter, one had a ptotic kidney in the iliac fossa, and one patient had bilateral kidney malrotation. Anatomic variants in the preoperative CT were described by a radiologist in only two patients, and additional vascular and urinary tract variants were found incidentally at the time of surgery.

CONCLUSIONS

Acknowledgment of vascular and urinary tract variants is helpful for the surgeon to establish an appropriate surgical plan and to avoid iatrogenic surgical trauma.

Paraaortic Lymphadenectomy in Gynecologic Oncology—Significance of Vessels Variations

Lymphadenectomy has been an essential part of the surgical treatment in surgical oncology, as the lymphatic channels and nodes are the main dissemination pathway for most of the gynecological cancers. Pelvic and paraaortic lymphadenectomy are frequent surgical procedures in gynecologic oncology. Paraaortic lymph node dissection facilitates staging, prognosis, surgical and postoperative management of patients. It is one of the most challenging retroperitoneal surgeries. A comprehensive knowledge of the paraaortic region is mandatory. Intraoperative bleeding is the most common complication during lymphadenectomy due to direct vascular injury, poor tissue handling, exuberant retraction and possible anatomical variations of the vessels in the paraaortic region. Approximately, one-third of women will have at least one anatomic variation in the paraaortic region. It must be stressed that anomalous vessels may be encountered in every woman who will undergo surgery. Consequently, detailed knowledge of anatomical vessels variations is required in order to prevent iatrogenic vessel injury. The importance of these variations is well described in urology, vascular and general surgery. Conversely, in oncogynecological surgery, there are few articles, which described some of the vessels variations in the paraaortic region. The present article aims to propose a surgical classification and to describe the majority of vessels variation, which could be encountered during paraaortic lymphadenectomy in gynecologic oncology. Moreover, surgical considerations in order to prevent anomalous vessels injury are well described.

Role of systematic pelvic and para-aortic lymphadenectomy in delayed debulking surgery after six neoadjuvant chemotherapy cycles for high-grade serous ovarian carcinoma

INTRODUCTION

We analyzed the role of systematic pelvic and para-aortic lymphadenectomy in delayed debulking surgery after six neoadjuvant chemotherapy (NACT) cycles for advanced high-grade serous ovarian carcinoma.

MATERIALS AND METHODS

We retrospectively reviewed patients with advanced ovarian carcinoma who underwent NACT with carboplatin-paclitaxel between 2008 and 2016. Patients were included only if they had FIGO IIIC-IVB high-grade serous carcinoma with clinically negative lymph nodes after six NACT cycles (carboplatin-paclitaxel) and underwent complete or near complete cytoreduction. Patients with partial lymphadenectomy or bulky nodes were excluded. Patients who underwent systematic pelvic and aortic lymphadenectomy and those who did not undergo lymph node dissection were compared. Progression-free and overall survivals were analyzed using the Kaplan-Meier method.

RESULTS

Totally, 132 patients with FIGO IIIC-IVB epithelial ovarian carcinoma were surgically treated after NACT. Sixty patients were included (39 and 21 in the lymphadenectomy and nonlymphadenectomy group, respectively); 40% had suspicious lymph nodes before NACT. Patient characteristics, blood transfusion numbers, and complication incidence were similar between the groups. In the lymphadenectomy group, 12 patients (30.8%) had histologically positive lymph nodes and the surgical time was longer (229 vs. 164 min). The median overall survival in the lymphadenectomy and nonlymphadenectomy groups, respectively, was 56.7 (95% CI 43.4-70.1) and 61.2 (21.4-101.0) months (p = 0.934); the corresponding disease-free survival was 8.1 (6.2-10.1) and 8.3 (5.1-11.6) months (p = 0.878). Six patients exclusively presented with lymph node recurrence.

CONCLUSIONS

Systematic lymphadenectomy after six NACT cycles may have no influence on survival.

A modified technique to perform para-aortic lymphadenectomy up to the renal vein

OBJECTIVE

To investigate the safety and feasibility of our modified technique to perform lymph node excision up to the renal vein in cases of gynecological cancer.

MATERIALS AND METHODS

87 patients with endometrial or ovarian neoplasms underwent laparoscopic para-aortic lymphadenectomy (LPAL) up to the left renal vein were enrolled prospectively. During surgery, the surgeon was positioned to the right side of the patient and an additional trocar was introduced into the upper right abdomen. The laparoscopic video screen was placed to the side of the patient's head. Three-fan retractor forceps were used to hold up the duodenum and small bowel. The rest of the procedure was the same as conventional LPAL.

RESULTS

The median operating time for LPAL was 72 min (range: 40-115 min) and the median estimated blood loss was 45 ml (range: 15-1000 mL). There were two cases of intra-operative vascular injury. The median number of retrieved para-aortic lymph nodes (PALNs) was 18 (range: 10-37). Of the 87 patients, 11 patients had positive PALNs. None of the cases required laparotomy.

CONCLUSION

Our findings demonstrate that our modified LPAL technique is feasible, reproducible, can achieve good exposure and reduces surgical difficulty.

Challenges Posed by Embryonic and Anatomical Factors in Systematic Lymphadenectomy for Endometrial Cancer

Lymph node involvement has been shown to be one of the most relevant prognostic factors in a variety of malignancies; this is also true of endometrial cancer. The determination of the lymph node status is crucial in order to establish the tumor stage, and to consider adjuvant treatment. A wide range of surgical staging practices are currently used for the treatment of endometrial cancer. The necessity and extent of lymph node dissection is an ongoing controversial issue in gynecological oncology. Lymph node surgery in endometrial cancer is technically challenging, and can be time consuming because of the topographic complexity of lymphatic drainage as such, and the fact that the lymph nodes are directly adjacent to both blood vessels and nerves. Therefore, profound and exact knowledge of the anatomy is essential. Sentinel lymph node mapping was recently introduced in surgical staging with the aim of reducing morbidity, whilst also obtaining useful prognostic information from a patient's lymph node status. The present review summarizes the current evidence on the role of lymph node surgery in endometrial cancer, focusing on the embryological, anatomical, and technical aspects.

Systemic Laparoscopic Para-Aortic Lymphadenectomy to the Left Renal Vein

Background

No large-scale clinical study has been done to show the standard surgical boundary and efficacy of laparoscopic para-aortic lymphadenectomy (LPAL).

Objectives

Therfore, this study aimed to evaluate the feasibility, efficacy, and standard surgical boundary of LPAL performed up to the left renal vein level in gynecological malignancies.

Methods

Medical records of 333 patients were retrospectively reviewed. All cases had gynecologic malignancies and had an operation including LPAL by a single surgical team between November 2003 and May 2018.

Results

Three hundred twenty-six patients underwent LPAL as part of their staging, restaging, or debulking surgery. Seven patients with isolated para-aortic lymph node recurrence underwent a repeat LPAL. The median age and body mass index were 54 years (range, 28-81 years) and 26.0 kg/m² (range, 20.3-37.2 kg/m²), respectively. The median operating time was 60 minutes (range, 24-135 minutes), and the median number of harvested para-aortic lymph nodes was 12 (range, 6-49). There were 11 cases of complications: 5 of major vessel injuries (3 inferior vena cava, 1 aorta, and 1 common iliac vein), 2 lymphocysts, 2 cases of chylous ascites, a cisterna chyli rupture, and 1 case of ureteric injury. There were 2 conversions to laparotomy: 1 left common iliac vein laceration that needed to be repaired and removal of an enlarged para-aortic lymph node completely.

Conclusion

It is feasible and efficient to perform LPAL to the left renal vein level for women with gynecologic malignancies by well-trained gynecologic oncology surgeons according to our suggested standard surgical boundary.

A deadly trap for para-aortic lymph node dissection in patients with horseshoe kidney as a complication: a case report

Horseshoe kidney is a rare congenital renal dysplasia. It is often associated with various anatomical abnormalities, including renal vessel and ureter variability, which increase unpredictable surgical risks. This current report describes the case of a 42-year-old woman diagnosed as having cervical squamous cell carcinoma complicated by horseshoe kidney. She underwent laparoscopic radical hysterectomy, bilateral oophorectomy and lymph node dissection, including dissection of the pelvic, presacral and para-aortic lymph nodes. The surgery was challenging, but no serious complications occurred. Postoperative multi-slice computed tomography angiography confirmed the anatomical variation of the renal location, ureter and renal vessels. To our knowledge, this is the first reported case of cervical carcinoma complicated with horseshoe kidney.

Impact of perioperative care on the post-operative recovery of women undergoing surgery for gynaecological tumours

To assess perioperative care in patients undergoing abdominal surgery for gynaecological tumours and how it relates to post-operative (PO) complications and oral PO feeding. Ninety-one women undergoing major abdominal surgery for gynaecological tumours were enrolled. Data included mechanical bowel preparation (MBP), prescribed diet, length of fast, start date of oral diet and progression of food consistency, anaesthetic technique, use of opioids and intravenous hydration (IH). Outcomes evaluated were nausea, vomiting and abdominal distension. The median pre-operative length of fast was 11.4 h. PO digestive complications occurred in 46.2% of the patients. Median intraoperative total IH and crystalloids were significantly higher in patients with abdominal distension during the first and second PO day. MBP with mannitol implied greater intraoperative IH and was significantly associated with a higher incidence of immediate PO nausea. Post-operative IH was also associated with gastrointestinal complications. The best cut-off point for the cumulative fluid load PO for determining a longer PO hospital stay was 4 L. Performing MBP before surgery and excessive IH are factors related to major digestive complications in our study population. Changes in pre-operative fasting time and PO refeeding should be considered to reduce the gastrointestinal complications and PO recovery time.

[Morbidity of pelvic lymphadenectomy and para-aortic lymphadenectomy in endometrial cancer]

The aim of this study was to evaluate the complication rate of pelvic and para-aortic lymphadenectomy in the management of endometrial cancer following the changes to the recommendations of INCa 2010. This is a retrospective study of 208 patients operated for endometrial cancer between July 2010 and March 2014 in two referral centers. Eighty lymphadenectomy were performed, 65 with hysterectomy and bilateral annexectomy and 18 lymphadenectomy were performed for restaging. Complications assessment is based on the Dindo Clavien classification. We report 17 severe complications (grade 3a and over) (P<0.001), including 14 among patients receiving lymphadenectomy. Morbidity increases with the number of lymphnodes removed and their positivity (P<0.001). The para-aortic lymphadenectomy is primarily responsible for complications (P <0.001). We describe 7 lower limbs lymphedema, 12 nerve injuries, 8 ileus, 5 venous or arterial thromboembolism, 17 blood transfusions, 13 lymphoceles including 9 infected. The rate of intraoperative complications on a first lymphadenectomy is 8% while it reached 22% for restaging. Restaging is significantly more at risk of serious complications (P=0.03) with two deaths. Twenty-four chronic disorders with impaired quality of life (2 without lymphadenectomy) are reported. They are present in 50% of restaging (P=0.033 compared to first lymphadenectomy). Lymphadenectomy is a source of severe morbidity (17.5%) with 2.5% mortality. The benefit of this surgery should probably be discussed again.

[The place of para-aortic lymphadenectomy in gynaecological malignancies. An old debate]

There is a lack of prospective randomized trial and scientific evidence for the use of para-aortic lymphadenectomy in gynaecological malignancies. This results in variations between countries for its utility. Based on the recommandations of the French Institute of Cancer (INCa), we open the debate of the place of para-aortic lymphadenectomy.