Laparoscopic Debulking of Enlarged Pelvic Nodes during Surgical Para-aortic Staging in Locally Advanced Cervical Cancer: A Retrospective Comparative Cohort Study

Study ObjectiveTo evaluate laparoscopic pelvic lymph node debulking during extraperitoneal aortic lymphadenectomy in diagnosis, therapeutic planning, and prognosis of patients with locally advanced cervical cancer and enlarged lymph nodes on imaging before chemoradiotherapy.DesignRetrospective, multicenter, comparative cohort study.SettingThe study was carried out at 11 hospitals with specialized gynecologic oncology units in Spain.PatientsTotal of 381 women with locally advanced cervical cancer and International Federation of Gynecology and Obstetrics 2018 stage IIIC 1r (radiologic) and higher who received primary treatment with chemoradiotherapy.InterventionsPatients underwent pelvic lymph node debulking and para-aortic lymphadenectomy (group 1), only para-aortic lymphadenectomy (group 2), or no lymph node surgical staging (group 3). On the basis of pelvic node histology, group 1 was subdivided as negative (group 1A) or positive (group 1B).Measurements and Main ResultsFalse positives and negatives of imaging tests, disease-free survival, overall survival, and postoperative complications were evaluated.In group 1, pelvic lymph node involvement was 43.3% (71 of 164), and aortic involvement was 24.4% (40 of 164). In group 2, aortic nodes were positive in 29.7% (33 of 111). Disease-free survival and overall survival were similar in the 3 groups (p = .95) and in groups 1A and 1B (p = .25). No differences were found between groups 1 and 2 in intraoperative (3.7% vs 2.7%, p = .744), early postoperative (8.0% vs 6.3%, p = .776), or late postoperative complications (6.1% vs 2.7%, p = .252). Fewer early and late complications were attributed to radiotherapy in group 1A than in the others (p = .022).ConclusionLaparoscopic pelvic lymph node debulking during para-aortic staging surgery in patients with locally advanced cervical cancer with suspicious nodes allows for the confirmation of metastatic lymph nodes without affecting survival or increasing surgical complications. This information improves the selection of patients requiring boost irradiation, thus avoiding overtreatment of patients with negative nodes.     

Para-aortic and Right Obturator Lymphadenectomy for Surgical Staging of Advanced Cervical Cancer through the TU-LESS Extraperitoneal Approach

ObjectiveTo present an innovative transumbilical laparoendoscopic single-site (TU-LESS) extraperitoneal approach for lymphadenectomy in a patient with advanced cervical carcinoma.DesignDemonstration of the novel technique through video.SettingIn advanced cervical cancer, determining the status of the para-aortic lymph nodes is essential because extended-field radiologic therapy is recommended for a patient with positive para-aortic lymph nodes [1]. Nonetheless, the sensitivity and specificity of currently available imaging workup for positive lymph nodes are limited. Surgical staging enables precise evaluation. However, laparotomy has potential wound complications and leads to treatment delay. Multiport laparoscopic transperitoneal and extraperitoneal approaches limit surgeons’ ability to reach the para-aortic area or obturator fossa in the same operation [2]. Thus, we take full use of these approaches’ advantages and avoid their disadvantages to design a promising minimally invasive surgery approach [3].InterventionsPara-aortic and obturator lymphadenectomy through the TU-LESS extraperitoneal approach was successfully performed without complications. The patient recovered quickly and received subsequent concurrent chemoradiation on schedule.ConclusionTU-LESS extraperitoneal para-aortic lymphadenectomy provides satisfactory exposure and easy access to both the para-aortic area and obturator fossa. In addition, the bowels are uplifted by an extraperitoneal air cushion to achieve excellent exposure and reduce the risk of bowel injury. With quick recovery, the patient could start accurate radiation treatment promptly.     

Upper margin of para-aortic lymphadenectomy in cervical cancer

Patients with early stage cervical cancer routinely undergo pelvic lymphadenectomy. A para-aortic lymphadenectomy is only performed in the setting of grossly enlarged lymph nodes. In patients with locally advanced disease, a para-aortic lymphadenectomy is indicated particularly when pelvic nodes are suspicious for disease on preoperative imaging. There is no consensus about the extent of para-aortic lymph node dissection in these patients. We reviewed relevant literature to determine the extension of para-aortic lymphadenectomy in patients with cervical cancer in order to establish whether lymph node dissection up to the inferior mesenteric artery or higher to the level of renal vessels should be performed. We performed a systematic search (PubMed; up to June 2011) to review systematic complete para-aortic lymphadenectomy. According to our search, eight women (1.09%) had isolated para-aortic node metastases, of which two had only lymph node metastases above the inferior mesenteric artery.     

The role of laparoscopic lymphadenectomy in the management of cervical carcinoma.

Laparoscopic lymphadenectomy was performed on 18 patients with invasive carcinoma of the cervix prior to definitive radiation therapy and/or radical hysterectomy. Ten patients underwent pelvic and para-aortic lymphadenectomies prior to planned radiotherapy. Two of these patients had grossly positive pelvic nodes, and one had a microscopically positive para-aortic node. Eight patients with early disease were considered candidates for radical hysterectomy and underwent laparoscopic lymphadenectomy. Three of these patients were found to have positive pelvic lymph nodes and the hysterectomy was abandoned. Five patients underwent radical hysterectomies immediately following their laparoscopic procedures. The average number of lymph nodes removed laparoscopically in these patients was 31.4; the average number of additional lymph nodes resected at laparotomy with the radical hysterectomy was 2.8. A single microscopically positive parametrial lymph node was found on permanent section in 1 patient with radical hysterectomy. No significant complications were associated with the laparoscopic lymphadenectomies. Nine of the 13 patients who underwent laparoscopic procedures only were discharged on Postoperative Day 1. The ability to perform pelvic and para-aortic lymphadenectomy allows for complete surgical staging of carcinoma of the cervix laparoscopically.     

Stadification ganglionnaire des cancers du col utérin avancé

Lymph node staging in patients with locally advanced cervical cancer is the most important prognostic factor and also leads to adjuvant treatment choice. Because of the lymphadenectomy associated morbidity and delay in the beginning of adjuvant therapy, noninvasive approaches were developed during the last decennia. Recently, positron emission tomography employing a glucose analogue (FDG-PET) has been shown to be more sensitive and more specific than magnetic resonance imaging or than computed tomography usually used in diagnosis of pelvic and para-aortic lymph node metastases. Even if recent studies have reported promising results, surgical pelvic and para-aortic staging remains actually the most accurate procedure for evaluating lymph node metastases. This procedure should be accomplished by transperitoneal or extraperitoneal laparoscopy, with the benefits of minimal morbidity, shorter length of hospital stay and no significant increase of complications comparing to laparotomy approach. Laparoscopy also allows an early start of adjuvant treatment, this delay constituting an important prognostic factor for patients with locally advanced cancer. However, the survival benefit of lymph node dissection is still controversial and should be proved in randomised studies.     

Laparoscopic surgery in women with endometrial cancer: the learning curve

OBJECTIVE: The aim of this study was to assess the effect of increasing surgeons's experience in the laparoscopic surgery of women with endometrial cancer (EC) on the surgical outcome of these patients. STUDY DESIGN: Data were obtained from a prospectively collected database of 108 patients two oncolaparoscopic centers in Czech Republic who underwent laparoscopically assisted surgical staging (LASS) from April 1996 to March 2001. Patients were arranged in chronological order and divided into three groups, based on the date of their surgery. The three groups were compared in patient characteristics and surgical outcome using one-way analysis of variance (ANOVA) and Wilcoxon rank sum test. SETTING: Department of Obstetrics and Gynecology, Endoscopic Training Center, Baby Friendly Hospital Kladno, Czech Republic. RESULTS: The three groups were similar in patient characteristics. Operative times for laparoscopic staging with pelvic lymphadenectomy (LN) decreased significantly from mean of 156.3 min for group 1 to 142.8 min for group 3 (P < 0.05). In cases LASS with pelvic lymphadenectomy was significant increase in the number lymph nodes harvested (12.4 for group 1, 13.9 for group 2, and 15.4 for group 3, P < 0.05). In cases LASS without lymphadenectomy was not significant difference in operating time, estimated blood loss, rate of conversion to laparotomy, operative complications, and length of hospital stay among the compared groups. The number of patients who underwent para-aortic lymphadanectomy was too small (n = 22), and their distribution was asymmetrical for comparison. CONCLUSION: A learning curve is demonstrated in the LASS of women with endometrial cancer. With increasing surgeon's team experience, there is significant decrease in operative time for staging with pelvic lymph node dissection and increase in the number of pelvic lymph nodes removed. The para-aortic lymphadenectomy (PALN) was found to be more challenging than pelvic lymphadenectomy.     

Extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of fallopian tube carcinoma

The endoscopic retroperitoneal approach is a minimally invasive method for surgical staging of cervical cancer. A 57-year-old woman had an intraoperative diagnosis of carcinoma of the left fallopian tube and undergone a retroperitoneal pelvic and para-aortic lymphadenectomy with no peritonization during surgical staging. Small suspicious nodes in the serous membrane of the sigmoid colon and peritoneal washings were positive for malignancy. A total of 12 nodes were obtained, all of which were negative. She received six cycles of paclitaxel and platinum-based chemotherapy and showed a complete clinical response. Thirty-two months after surgery, the abdominal computed tomography scan showed a left para-aortic lymph node, 19 mm in diameter, which was successfully removed through an extraperitoneal laparoscopic approach. The extraperitoneal laparoscopic approach of the para-aortic region is a feasible procedure after previous transperitoneal lymphadenectomy and chemotherapy.     

Efficacy of systematic lymphadenectomy and adjuvant radiotherapy in node-positive endometrial cancer patients

OBJECTIVE: To assess the efficacy of systematic lymphadenectomy and adjuvant radiotherapy in minimizing pelvic sidewall and para-aortic failures. METHODS: Between January 1984 and December 2001, a total of 146 patients with stage III and IV endometrial cancer and lymph node metastases were treated at our institution. Adequate pelvic lymphadenectomy was defined as the removal of more than 10 pelvic lymph nodes, and adequate para-aortic lymphadenectomy was defined as removal of 5 or more para-aortic lymph nodes. The 24 patients who received adjuvant chemotherapy were excluded. We assessed the ability of adequate pelvic and para-aortic lymphadenectomy, together with radiotherapy, to prevent pelvic and para-aortic recurrences. RESULTS: Of the 122 patients studied, 94 (77%) had adequate pelvic lymphadenectomy and 47 (39%) had adequate para-aortic lymphadenectomy. Pelvic radiotherapy was administered to 78% and para-aortic radiotherapy to 29% of patients. Median follow-up of censored patients was 56 months. Twenty-five percent of patients had pelvic sidewall failure at 5 years. Pelvic sidewall failures at 5 years occurred in 57% of patients who had inadequate node dissection and/or no radiotherapy, compared with 10% for those having both adequate lymphadenectomy and radiotherapy (P < 0.001). After risk factor assessment in a regression model, only treatment with adequate lymphadenectomy and radiotherapy was a significant independent predictor of pelvic control (P = 0.03). The performance of definitive pelvic lymphadenectomy may have increased treatment-related morbidity in the subgroup of patients who had postoperative radiotherapy. For the 41 patients with positive para-aortic lymph nodes, the 5-year para-aortic failure rate was 34% after adequate lymphadenectomy but without adjuvant para-aortic radiotherapy. Likewise, 69% failed in the para-aortic area when adjuvant para-aortic radiotherapy was administered to patients not having adequate para-aortic lymphadenectomy; however, none of the 11 patients failed in the para-aortic area after adequate lymphadenectomy and para-aortic radiotherapy (P = 0.08). CONCLUSIONS: Adequate (pelvic and para-aortic) lymphadenectomy and adjuvant radiotherapy appear complementary in reducing failures in both the pelvis and para-aortic areas in patients with node-positive endometrial cancer.     

Surgical Outcome of Extraperitoneal Paraaortic Lymph Node Dissections Compared With Transperitoneal Approach in Gynecologic Cancer Patients

Study ObjectiveTo evaluate the surgical outcome of extraperitoneal paraaortic lymph node dissection compared with the traditional transperitoneal approach.DesignRetrospective review (Canadian Task Force classification III).SettingUniversity hospital.PatientsWomen with gynecologic malignancies admitted to our hospital between 2007 and 2011 who underwent laparoscopic paraaortic lymphadenectomy.InterventionsIndication, diagnosis, and outcome according to type of surgery were evaluated.Measurements and Main ResultsOf 47 patients who underwent laparoscopic paraaortic lymphadenectomy because of gynecologic indications, 28 patients underwent extraperitoneal paraaortic lymph node dissection and 19 underwent the same procedure via the classic transperitoneal technique. The most frequent indication for extraperitoneal lymph node dissection was cervical cancer (71.4%), and for the transperitoneal technique was endometrial cancer (47.4%). The mean (SD) duration of surgery was 211 (38) minutes in the transperitoneal approach group, and 173 (51) minutes in the extraperitoneal lymphadenectomy group (p = .009). No significant differences between groups were found in the number of lymph nodes removed (15 [5.9] nodes in the extraperitoneal group vs 17.4 [8.6] in the transperitoneal group; p = .25). However, a higher rate of positive nodes was observed in the extraperitoneal group than in the transperitoneal group (42.8% vs 36.2%, respectively [p = .001]), and a significantly shorter stay in the intensive care unit in the extraperitoneal group (0.59 [0.5] vs 1.1 [0.5] days, respectively; p = .02). No significant differences in complication rate were found between groups.ConclusionsExtraperitoneal paraaortic lymph node dissection is a minimally invasive procedure that is an excellent and safe approach to the paraaortic area, with a low complication rate, sufficient number of lymph nodes, and short hospital stay. It seems to be a good alternative to the classic transperitoneal approach.     

A comparison of extraperitoneal versus transperitoneal laparoscopic or robotic para-aortic lymphadenectomy for staging of endometrial carcinoma

Objective

The optimal surgical approach for complete lymphadenectomy in patients with endometrial cancer is controversial. The objective of our study was to compare the surgical outcomes of extraperitoneal laparoscopic, transperitoneal laparoscopic, and robotic transperitoneal para-aortic lymphadenectomy in endometrial cancer staging.

Methods

A retrospective review was performed on patients who underwent extraperitoneal or transperitoneal para-aortic lymphadenectomy for endometrial cancer staging from January 2007 to November 2012. Three patient groups were compared: extraperitoneal laparoscopic para-aortic lymphadenectomy, robotic hysterectomy and pelvic lymphadenectomy (“extraperitoneal group”; N = 34); laparoscopic hysterectomy and transperitoneal pelvic and para-aortic lymphadenectomy (“transperitoneal laparoscopic group”; N = 108); and robotic hysterectomy and transperitoneal pelvic and para-aortic lymphadenectomy (“transperitoneal robotic group”; N = 52). Fisher's exact test and Kruskal–Wallis test were used for statistical analysis, and statistical significance was defined as P < 0.05.

Results

The median number of para-aortic lymph nodes obtained was higher in the extraperitoneal group than in the transperitoneal laparoscopic and robotic groups (10, 5, and 4.5 nodes, respectively; P < 0.001). BMI was higher in the extraperitoneal group (median, 35.1 kg/m²) than in the transperitoneal groups but did not differ between the transperitoneal laparoscopic group (median, 28.4 kg/m²) and the transperitoneal robotic group (median, 30.2 kg/m²). Among patients with a BMI < 35 kg/m², the median number of para-aortic nodes harvested was higher in the extraperitoneal group than in the transperitoneal laparoscopic and robotic groups (9, 4, and 5 nodes, respectively; P < 0.01). The same pattern was observed among patients with a BMI ≥ 35 kg/m² (10, 6, and 3 nodes, respectively), but only the extraperitoneal group and the transperitoneal robotic group were significantly different (P = 0.001). There was no significant difference in median estimated blood loss between the extraperitoneal group and either the transperitoneal laparoscopic group (100 vs. 112.5 mL; P = 0.06) or the transperitoneal robotic group (100 vs. 67.5 mL; P = 0.23). The median operative time was longer in the extraperitoneal group (339.5 min; range, 242–453 min) than in the transperitoneal laparoscopic group (286 min; range, 101–480 min) and the transperitoneal robotic group (297.5 min, range 182–633 min) (P < 0.01).

Conclusion

Extraperitoneal laparoscopic para-aortic lymphadenectomy resulted in a higher number of para-aortic lymph nodes removed than transperitoneal laparoscopic or robotic lymphadenectomy. The extraperitoneal approach should be considered for endometrial cancer staging.     

宫颈癌淋巴结切除适应证和争议

NCCN和FIGO指南对淋巴结切除适应证做出推荐,但就宫颈癌淋巴结切除仍存在争议点。对于局部晚期宫颈癌行手术分期是安全可行的。前哨淋巴结切除术目前尚不能替代系统性淋巴结切除术。对于ⅠA2~ⅡA2期宫颈癌,建议行腹主动脉旁淋巴结取样术,上界达肠系膜下动脉水平足够。有转移肿大的淋巴结建议手术切除。     

Pattern and clinical predictors of lymph node metastases in epithelial ovarian cancer

Para-aortic lymphadenectomy is part of staging in early epithelial ovarian cancer (EOC) and could be part of therapy in advanced EOC. However, only a minority of patients receive therapy according to guidelines or have attendance to a specialized unit. We analyzed pattern of lymphatic spread of EOC and evaluated if clinical factors and intraoperative findings reliably could predict lymph node involvement, in order to evaluate if patients could be identified in whom lymphadenectomy could be omitted and who should not be referred to a center with capacity of performing extensive gynecological operations. Retrospective analysis was carried out of all patients with EOC who had systematic pelvic and para-aortic lymphadenectomy during primary cytoreductive surgery. One hundred ninety-five patients underwent systematic pelvic and para-aortic lymphadenectomy. Histologic lymph node metastases were found in 53%. The highest frequency was found in the upper left para-aortic region (32% of all patients) and between vena cava inferior and abdominal aorta (36%). Neither intraoperative clinical diagnosis nor frozen section of pelvic nodes could reliably predict para-aortic lymph node metastasis. The pathologic diagnosis of the pelvic nodes, if used as diagnostic tool for para-aortic lymph nodes, showed a sensitivity of only 50% in ovarian cancer confined to the pelvis and 73% in more advanced disease. We could not detect any intraoperative tool that could reliably predict pathologic status of para-aortic lymph nodes. Systematic pelvic and para-aortic lymphadenectomy remains part of staging in EOC. Patients with EOC should be offered the opportunity to receive state-of-the-art treatment including surgery.     

Feasibility of extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy

OBJECTIVE: The aim of this study is to evaluate the feasibility of extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy for cervical and endometrial carcinoma. METHODS: Seventy-six patients underwent extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy between February 1999 and September 2005. The lymph nodes dissected with the laparoscopic procedure included the inframesenteric para-aortic lymph nodes, the sacral lymph nodes, and the bilateral common iliac lymph nodes. The extraperitoneal laparoscopic operation was performed with pelvic open surgery using Lap Disc to ensure the safety of patients. RESULTS: The number of patients with cervical and endometrial carcinoma was 36 and 40, respectively. The median age of patients was 51 years (range 24-75 years). Conversion to open surgery was necessary in 8 patients. These include 3 patients who encountered blood loss of 400, 136 and 128 ml; 2 extremely obese women; and 3 patients who had peritoneal tears causing CO2 gas leakage. Among the remaining 68 patients, the median operating time for extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy was 75 min (range 45-145 min), and the median estimated blood loss was 5 ml (range 5-138 ml). The median total number of resected nodes was 14 (range 2-31), and 4 patients had lymph node metastasis. No patient encountered postoperative complications attributable to extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy. CONCLUSIONS: Extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy with pelvic open surgery using Lap Disc is a feasible procedure, particularly in the surgeons learning phase.     

盆腹腔淋巴取样术在子宫内膜癌手术中的临床意义

目的探讨盆腹腔淋巴取样术在子宫内膜癌的临床意义。方法分析2000年1月-2007年12月上海同济大学附属第一妇婴保健院手术治疗的213例子宫内膜癌患者,其中,86例行盆腹腔淋巴取样术,127例行淋巴结切除术。手术方式根据手术切除淋巴结的情况分为两组。①取样组：淋巴取样术,筋膜外全子宫双附件切除/次广泛子宫切除术＋盆腔/腹主动脉旁淋巴结取样术86例;②切除组：次广泛/广泛子宫切除术＋盆腔淋巴结切除/腹主动脉旁淋巴结切除术127例。结果取样组：切除淋巴结中位数18枚,淋巴结的转移10例。切除组：切除淋巴结中位数32枚,淋巴结转移11例。5年生存率分别为94.2%和94.5%。取样组无病发症发生,淋巴结切除组中有9例,分别是1例术中大出血（〉2000ml）,淋巴囊肿感染6例,淋巴漏2例。结论在子宫内膜癌中淋巴结取样术可准确了解淋巴结的转移情况,适宜手术分期,并不影响生存率,是避免过度手术减少并发症发生的有效方法。     

宫颈癌手术盆腹腔淋巴结切除相关问题

盆腹腔淋巴结切除是宫颈癌手术治疗的重要组成部分。如何评判盆腔淋巴结切除是否彻底？哪些患者需要腹主动脉旁淋巴结切除？前哨淋巴结在宫颈癌治疗中的作用？这些是当今宫颈癌淋巴结切除面临的问题,文章就以上问题进行讨论。     

Laparoscopic Approach for Correction of Chylous Fistula after Pelvic and Paraaortic Lymphadenectomy

Chylous fistula is an uncommon but challenging complication after lymphadenectomy for treatment of gynecologic cancers. Its presence contributes substantially to increased morbidity and may retard the onset of adjuvant therapies. Treatment options include dietary modifications or surgical intervention. A 68-year-old woman with renal insufficiency developed chylous ascites after pelvic und para-aortic laparoscopic lymph node dissection followed by chemoradiation for treatment of class IIb cervical cancer. Conservative treatment failed, and the patient underwent laparoscopic exploration. The leakage was identified near the cisterna chyle, and was closed with sutures. There was no evidence of recurrence after 2-month follow-up. This case demonstrates successful laparoscopic management of chylous ascites after para-aortic lymphadenectomy and chemoradiation, using suturing.     

Endometrium- und Zervixkarzinom

Laparoscopic management of gynaecologic cancer has been controversial for decades. Much technical progress has however been achieved, enabling experienced endoscopic surgeons to perform most gynaeco-oncologic procedures such as hysterectomy, omentectomy, and pelvic and para-aortic lymph node dissection. Although the oncologic value of laparoscopy with respect to safety and patient outcome has not yet been shown in prospective randomized clinical trials, many studies with thousands of patients have revealed similar oncologic results and its feasibility when compared to laparotomy. Especially the lymph node yield has been shown to be similar with both laparoscopic and open surgical methods. This approach has therefore become well accepted for cervical and endometrial carcinomas, especially in early stages. In addition, a staging laparoscopy including pelvic and paraaortic lymph node sampling and debulking contributes to accurately stage advanced cervical cancer cases in order to achieve the adequate treatment.     

Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies

OBJECTIVE: Lymphadenectomy is an integral part of staging and treatment of gynecologic malignancies. We evaluated the feasibility and oncologic value of laparoscopic transperitoneal pelvic and paraaortic lymphadenectomy in correlation to complication rate and body mass index. METHODS: Between August 1994 and September 2003, pelvic and/or paraaortic transperitoneal laparoscopic lymphadenectomy was performed in 650 patients at the Department of Gynecology of the Friedrich-Schiller University of Jena. Retrospective and prospective data collection and evaluation of videotapes were possible in 606 patients. Laparoscopic lymphadenectomy was part of the following surgical procedures: staging laparoscopy in patients with advanced cervical cancer (n = 133) or early ovarian cancer (n = 44), trachelectomy in patients with early cervical cancer (n = 42), laparoscopic-assisted radical vaginal hysterectomy in patients with cervical cancer (n = 221), laparoscopy before exenteration in patients with pelvic recurrence (n = 20), laparoscopic-assisted vaginal hysterectomy or laparoscopic-assisted radical vaginal hysterectomy in patients with endometrial cancer (n = 112), and operative procedures for other indications (n = 34). RESULTS: After a learning period of approximately 20 procedures, a constant number of pelvic lymph nodes (16.9-21.9) was removed over the years. Pelvic lymphadenectomy took 28 min, and parametric lymphadenectomy took 18 min for each side. The number of removed paraaortic lymph nodes increased continuously over the years from 5.5 to 18.5. Right-sided paraaortic, left-sided inframesenteric and left-sided infrarenal lymphadenectomy took an average of 36, 28, and 62 min, respectively. The number of removed lymph nodes was independent from the body mass index of the patient. Duration of pelvic lymphadenectomy was independent of body mass index, but right-sided paraaortic lymphadenectomy lasted significantly longer in obese women (35 vs. 41 min, P = 0,011). The overall complication rate was 8.7% with 2.9% intraoperative (vessel or bowel injury) and 5.8% postoperative complications. No major intraoperative complication was encountered during the last 5 years of the study. CONCLUSION: By transperitoneal laparoscopic lymphadenectomy, an adequate number of lymph nodes can be removed in an adequate time and independent from body mass index. The complication rate is low and can be minimized by standardization of the procedure.     

Single-port laparoscopy and extraperitoneal para-aortic lymphadenectomy: about fourteen consecutive cases

Objective

To report the feasibility and reproducibility of single port extraperitoneal para-aortic lymphadenectomy in locally advanced cervical cancer.

Methods

The same single port was used for the transperitoneal step and the extraperitoneal approach used thereafter (in the absence of peritoneal disease) for the lymphadenectomy. Para-aortic lymphadenectomy was performed via a left-sided extraperitoneal approach.

Results

Fourteen consecutive patients with cervical cancer underwent a laparoscopic staging procedure (3 stage IB2, 10 IIB and 1 stage IVA). No patient had para-aortic FDG uptake on PET/CT. In one case lymphadenectomy was unfeasible because of vascular anomalies of the renal vessels (low insertion of 2 left renal arteries). The median operative time was 190 min (range, 135–250). The median number of lymph nodes removed was 14 [range, 2–23]. The definitive pathological analysis revealed that three patients had metastatic disease. No conversion to conventional multiport laparoscopy was necessary.

Conclusions

This series reports that para-aortic lymphadenectomy technique via the extraperitoneal approach with a multichannel single port is feasible and reproducible.     

根治性同步放化疗前淋巴结清扫在局部晚期宫颈癌诊疗中的意义

宫颈癌是威胁女性健康的第四大肿瘤,分期主要基于临床检查。2018年10月国际妇产科联盟(FIGO对宫颈癌分期进行了修改,强调了盆腔及腹主动脉旁淋巴结的转移情况。对于根治性同步放化疗的患者,淋巴结转移与放疗肿瘤控制率密切相关。由于腹主动脉旁淋巴结转移的情况决定了是否扩大放疗照射野,放疗对于较大的淋巴结控制效果不理想,因此在根治性放化疗前手术评估淋巴结情况、切除增大的淋巴结,有助于分期及减瘤,进行个体化的治疗。但手术分期为有创操作,存在相关风险,可能推迟放疗起始时间,缺乏前瞻性的随机对照研究,此治疗方式并未被广泛认可。综述根治性放化疗前手术清扫淋巴结分期的相关文献。