Key Words and Terms: Extraperitoneal para-aortic lymph node dissection (EPLND), Retroperitoneal Lymph Node Dissection, gynaecological cancers, cervical carcinoma, Testicular Cancer
Because lymph node dissection in the staging and diagnosis of cancer is a leading cause of secondary lymphedema, we have included pages on axillary node biopsy, Sentinel Node Biopsy, Small Needle Biopsy and Lymphoscintigraphy
Here is information on a less heard of procedure, presently being used/targeted towards cervical cancer and testicular cancer. It is called Extraperitoneal para-aortic lymph node dissection. We have included information also about the procedure called Retroperitoneal Lymph Node Dissection
Because the procedure is new and just now being more widely used, the statistics on lymphedema do not exist. Secondary lymphedema resulting from it would presumably be leg lymphedema and even male genital lymphedema male. Or female genital lymphedema female lymphedema. Since anyone undergoing the removal of lymph nodes is at risk. patients underoing the procedure need to be advised of the warning signs of lymphedema and therisk factors for lymphedema.
Clinical studies indicate that between 30% to 40% of cancer survivors will develop lymphedema at some time in their life as a direct result of diagnosing, testing and treatment of cancer.
In March 2006, NICE (the National Institute for Health and Clinical Excellence) looked at the evidence for using 'keyhole surgery' to remove abdominal lymph nodes after testicular cancer. This is called laparoscopic retroperitoneal lymph node dissection. With this type of operation, the surgeon makes 4 or 5 small cuts (incisions). He or she puts a type of telescope through into the abdomen, called a laparoscope. The laparoscope has an eye piece and hand controls for surgical instruments. The surgeon can see inside the body and carry out the operation while looking down the eye piece of the laparoscope. Generally, you recover more quickly after keyhole surgery because you are not having such a big operation. In the studies NICE looked at, hospital stay was around 3 or 4 days after keyhole surgery and about 10 days after open surgery.
RPLND has evolved considerably since the early 1900s when the technique was first performed. Bilateral dissections, which became standard therapy for low-stage testicular cancer in the 1950s and '60s, gave way, in the 1980s and '90s, to less extensive, template and nerve-sparing techniques. Currently, the type of dissection performed varies, depending on which disease stage is being treated.
This dissection is performed in patients with no clinical signs of spread to the retroperitoneum and no surgically visible disease, ie, clinical stage I disease. The surgical technique employed is either the template or nerve-sparing technique. In the modified template technique, the dissection is complete above the level of the inferior mesenteric artery but is limited to the ipsilateral side below the level of the inferior mesenteric. In the nerve-sparing RPLND, the lumbar sympathetic nerves are prospectively identified and preserved, and the node-bearing tissues around these nerves are then removed. Both techniques preserve ejaculation in the vast majority of patients.
This is performed in patients with low-volume, clinically demonstrable disease or with visible disease at surgery, ie, clinical stage IIA or IIB disease. The surgical boundaries are generally wider than in RPLND-I, are usually bilateral above the inferior mesenteric artery, and, in most cases, are bilateral below the inferior mesenteric artery as well. The lumbar sympathetic nerves and the hypogastric plexus are carefully preserved, resulting in preservation of ejaculation in over 95% of patients when the procedure is done by experienced surgeons.
This is a cytoreductive procedure performed after chemotherapy. Only in highly selected cases are nerve-sparing boundaries utilized. Up to 30% to 50% of patients may have preservation of ejaculation following this procedure. From: Current Role of Retroperitoneal Lymph Node Dissection in Testicular Cancer
Steven A. Vasilev M.D., FACS, FACOG b, a, 1 and Kathryn F. McGonigle M.D., FACOGb, a a Department of Gynecology, Division of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, California, 91010 b Division of Gynecologic Oncology, University of California, Irvine, School of Medicine, Irvine, California Received 15 February 1995. Available online 29 April 2002.
Extraperitoneal cervical cancer “staging” is considered superior to a transperitoneal approach. We developed an entirely extraperitoneal laparoscopic technique for para-aortic lymph node dissection in a pig model, followed by human subject application. Using latex balloon dissection technology, the technique is as follows. A retroperitoneal space is created via a 15-mm left flank incision. The collapsed balloon trochar is inserted and the balloon is inflated under direct visualization. Subsequently, a CO2pneumoretroperitoneum is established with 12–15 mm Hg and dissection is carried out using a total of three to four left flank port sites. For initial technique development and improvement, four pigs were used. Excellent bilateral retroperitoneal exposure was achieved. A complete dissection was performed from the renal to the iliac vessels. Subsequently, a bilateral sampling procedure from the level of the inferior mesenteric artery to the iliac vessels was performed in four human subjects. A mean of 5 nodes (range 1–9) was removed with an EBL of <50 cc. Operative times were 120–140 min. There were no intra- or postoperative complications. This initial experience demonstrates that laparoscopic extraperitoneal para-aortic access and node sampling is feasible. Further study is ongoing to determine the extent of dissection possible using this approach. However, since this approach mimics the extraperitoneal laparotomy technique, it may have all the advantages of adhesion avoidance combined with an outpatient procedure.
*1 Presented at the 26th Annual Meeting of the Society of Gynecologic Oncologists, San Francisco, CA, February 19–22, 1995. 1 To whom reprint requests should be addressed. Fax: (818) 301-8260. E-mail: firstname.lastname@example.org.
Gynecol Oncol. 2008
Moore KN, Gold MA, McMeekin DS, Walker JL, Rutledge T, Zorn KK. University of Oklahoma, Division of Gynecologic Oncology, 920 SL Young Boulevard, Oklahoma City, OK, USA.
Keywords Cervical cancer; Extraperitoneal lymph node; Technique Presented as Oral Plenary at the Western Association of Gynecologic Oncologists, Santa Fe, NM 2005 and as a poster at the Society of Gynecologic Oncologists Annual Meeting, Palm Springs, CA 2006.
OBJECTIVE: To examine surgico-pathologic outcomes following extraperitoneal para-aortic lymph node dissection (EPLND) via pfannenstiel compared to paramedian incision prior to radiation in patients with cervical cancer.
METHODS: At our institution, patients with locally advanced cervical cancer undergo, EPLND. From 1990 to 2000, EPLND was performed via paramedian incision (PM) primarily to identify positive para-aortic lymph nodes (PALN). From 2000 to present, a complete pelvic and para-aortic lymphadenectomy was performed via pfannenstiel incision (PF). Records for all patients undergoing EPLND were reviewed. Pathologic findings, post-operative complications, and time to initiation of radiation (TRT) were abstracted.
RESULTS: 93 patients underwent EPLND, 48 via PF and 45 via PM incision. The mean age and body mass index did not differ between the two groups. Stage distribution was similar: IB2 8 vs. 0%; IIB 44 vs. 44%; IIIA/B 35 vs. 44%; IVA 13 vs. 11%, respectively. Positive PALN were identified in 44% of PF patients and 29% of PM patients (p=ns). TRT was not significantly different at 36.4 vs. 28.8 days, respectively. There were more complications among the PF group including cellulitis and lymphocyst formation. Pre-treatment computed tomography (CT) scan had positive and negative predictive values of only 86 and 66% for evaluation of PALN involvement.
CONCLUSIONS: We present an extraperitoneal method for removal of the pelvic and para-aortic lymph nodes with acceptable complications and no significant delay to initiate chemoradiation. Accurate assessment of lymphatic metastases results in modification of the radiation field, which, along with surgical debulking, may impact overall survival.
Gynecol Oncol. 2007 Aug
Tillmanns T, Lowe MP. The West Clinic Center for Gynecologic Oncology, 100 North Humphreys Boulevard, Memphis, TN 38120, USA. Keywords: Laparoscopic extraperitoneal aortic lymph node dissection; Outpatient surgery; Minimally invasive surgery; Cervical cancer; CT scan; MRI scan; PET scan
Corresponding author. Fax: +1 312 926 2188.
OBJECTIVE: To report on the safety, feasibility, and costs of outpatient laparoscopic extraperitoneal aortic lymph node dissection (LEPSS) for locally advanced cervical carcinoma.
METHODS: A retrospective analysis of all outpatient LEPSS procedures performed at our institution between August 2005 and February 2007 was performed. All patients with clinical stage IIB-IVA cervical carcinoma with no evidence of bulky aortic lymphadenopathy (>1.0 cm) on pre-operative computed tomography were offered the procedure. If present, pelvic nodal disease could not exceed greater than 1.5 cm. Records were reviewed for demographics, operative findings, complications, length of stay, and CT scan aortic nodal status. As a comparison, the average costs for outpatient LEPSS and outpatient CT, MRI, and PET scan at our institution were calculated.
RESULTS: A total of eighteen outpatient LEPSS procedures were identified. The median age was 49 (22-72). The median BMI was 29 (18-51). The median operative time was 108 min (60-135 min). The median aortic nodal count was 10 (5-20 nodes). The median blood loss was 25 ml (10-50 ml). There were no intraoperative complications. There was no conversion from a retroperitoneal to a transperitoneal approach. No patient required overnight hospitalization. One patient experienced a lymphocyst postoperatively. There was no delay in the initiation of chemoradiation for any of the patients with a median onset of 10 days from the date of surgery. At least 20% of the patients had one or more medical co-morbidities such as obesity, diabetes, hypertension, or a prior abdominal surgery. Occult aortic nodal metastasis was detected in 11% of the patients with a negative pre-operative CT scan. The average calculated costs at our institution for outpatient LEPSS was $5233 dollars versus $1520 dollars for CT scan, $4830 dollars for MRI and $5494 dollars for a PET scan.
CONCLUSIONS: To our knowledge this is the first reported experience of outpatient laparoscopic extraperitoneal aortic lymph node dissection for locally advanced cervical cancer. Outpatient LEPSS appears to be a safe and feasible procedure in the hands of an experienced surgeon, however further study is warranted. From a cost analysis perspective, outpatient LEPSS appears equivalent to PET scan and MRI, but is more expensive than CT scan.
Acta Obstet Gynecol Scand. 2007
Sanjuán A, Illa M, Torné A, Román SM, Jurado M, Lejarcegui JA, Pahisa J. Department of Gynecology and Obstetrics, Hospital Clínic i Provincial, University of Barcelona, Spain. email@example.com
Keywords: Extraperitoneal laparoscopy; paraaortic lymphadenectomy; recurrence
OBJECTIVE: The aim of this study was to evaluate the feasibility of extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of gynecological cancers.
METHODS: Seven patients underwent extraperitoneal laparoscopic para-aortic lymphadenectomies for suspected lymph node recurrence, detected by magnetic resonance image or CT scan. The suspicious nodes were removed through an extraperitoneal laparoscopic approach.
RESULTS: The median age of patients was 51 years (range: 39-67). The median operating time was 207 min (range 120-300). There were no intraoperative or postoperative complications. The median nodal yield was 7.3 (range: 1-15). The median hospital stay was 2.5 days (range: 2-3). Histological examination revealed metastasis in 6 of the 7 patients.
CONCLUSION: The extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of gynecological cancers is a safe and feasible procedure which should be considered in the case of possible recurrence.
Gynecol Oncol. 2005 Dec
Marnitz S, Köhler C, Roth C, Füller J, Hinkelbein W, Schneider A. Department of Radiooncology, Charite Universitaetsmedizin, Berlin, Germany.
Keywords: Cervical cancer; Laparoscopic staging; Primary chemoradiation; Lymph node debulking; Skip metastasis Corresponding author. Fax: +49 30 84454477.
OBJECTIVE: At present, cervical cancer remains the only gynecologic tumor, which is staged by clinical examination according to FIGO. This is associated with a high percentage of over- and understaging of tumor extent. With the operative, especially laparoscopic staging, exact information about intraabdominal tumor spread, lymph node metastases, and involvement of adjacent organs is possible. However, the advantage of operative staging is still discussed controversially. The aim of this study is to describe the laparoscopic transperitoneal staging procedure in patients with cervical cancer and their oncologic outcome after primary chemoradiation.
METHODS: From November 1994 to October 2003, 456 consecutive patients with histologically confirmed primary cervical cancer were admitted to the Department of Gynecology of the Friedrich-Schiller-University Jena, Germany. Out of these, 84 patients with locally advanced tumor (tumor size>or=4 cm) and/or lymph node involvement and/or tumor infiltration to bladder or rectum were selected by a standardized laparoscopic staging procedure for primary chemoradiation. Data of surgery, chemoradiation, and follow-up were analyzed retrospectively for these patients.
RESULTS: The mean age of the patients was 54 years (26-80), and the mean body-mass-index was 24.8 (17.9-42.2). Preoperative clinical evaluation showed a stage distribution according to FIGO with stage IB1 in 15.5%, IB2 in 15.5%, IIA in 8.3%, IIB in 23.8%, IIIA in 8.3%, IIIB in 21.4%, IVA in 6%, and IVB in 1.2%. In 15 out of 84 (17.8%) patients, intraabdominal tumor spread was diagnosed by laparascopy. In 24 out of 84 (28.5%) patients, invasion of bladder and/or rectum was proven histologically after biopsy. In 60 out of 84 (71%) patients, lymph node metastases were confirmed histologically. In 2 out of 13 patients with FIGO-stage Ib1, skip metastases in infrarenal paraaortic lymph nodes were seen. Removal of more than 5 pelvic and/or more than 5 positive paraaortic lymph nodes was associated with significant improvement of overall survival. According to the histological findings following laparoscopic staging in 36 out of 84 (43%) patients, a higher tumor stage was diagnosed. If tumor involvement of lymph nodes is also included, an upstaging in 73/84 (87%) of patients has to be noted down. Downstaging was not necessary in any patient following laparoscopic evaluation.
CONCLUSION: Only operative staging gives exact information about tumor extension in patients with locally advanced and/or nodal positive cervical cancer and allows individual treatment planning. This can be done successfully by a transperitoneal laparoscopic approach without serious adverse effects delaying chemoradiation. Debulking of tumor-involved lymph nodes significantly improves overall survival and should be performed prior to primary chemoradiation. Laparoscopic staging should be the basis for all treatment studies in order to group patients according to true tumor extent.
Gynecol Obstet Fertil. 2007 Oct
ichez A, Lamblin G, Mathevet P. Service de gynécologie, pavillon L, hôpital Edouard-Herriot, 5, place d'Arsonval, 69437 Lyon cedex 03, France. firstname.lastname@example.org
Keywords: Cervical cancer; Para-aortic lymph nodes; Laparoscopy; Extraperitoneal approach; Surgical staging
OBJECTIVE: Description of the morbidity and the learning curve of the left extraperitoneal laparoscopic paraaortic lymphadenectomy in patients with gynecologic cancers.
PATIENTS AND METHODS: Retrospective study of patients treated with the left extraperitoneal laparoscopic paraaortic lymphadenectomy between August 1999 and January 2005. Duration of surgery, per and post-operative complications, duration of the hospital stay, number of retrieved nodes, and pathologic results were studied. A comparative analysis of the results was performed between trained and training surgeons.
RESULTS: Eighty-one patients were planned for the left extraperitoneal laparoscopic paraaortic lymphadenectomy. The major indication (90% of cases) was advanced cervical carcinomas (stage IB2 and more). The median number of retrieved nodes was 14, with a mean operative time of 109 minutes. The median hospital stay was 3 days. Two major complications related to the surgical technique were observed: a laceration of the inferior vena cava and an acute abdominal syndrome. Seven lymphocysts (8.6%) were observed (with associated symptoms in 2 cases). Trained surgeons to the technique displayed higher success rate of this surgical technique and higher number of retrieved lymph nodes.
DISCUSSION AND CONCLUSIONS: The left extraperitoneal laparoscopic paraaortic lymphadenectomy allows the accurate staging and management of patients with gynecologic cancers and mainly women affected by advanced cervical carcinoma. The surgical technique is safe and reproducible when performed by trained surgeons.
Keywords: Para-aortic lymphadenectomy; Laparoscopy; Cervical cancer; Single-port
This study is currently recruiting participants. Verified on August 2011 by M.D. Anderson Cancer Center