PELVIC AND AORTIC LYMPHADENECTOMY

Lymphatics are the main pathway for distant spread of gynecologic tumors. The node groups most commonly involved are located along the iliac and retroperitoneal vessels. Therefore, pelvic and aortic lymphadenectomy are performed for staging and therapeutic purposes. In both cases, strict indications and well-defined boundaries of dissection should be set, and a sufficient number of nodes should be removed if the best prognostic information and the maximum therapeutic benefit are to be gained from the procedure (Table 1).2, 6, 11

In this article, node nomenclature according to Benedetti-Panici et al¹⁵ is adopted. This classification includes eight pelvic and eight aortic groups (Tables 2 and 3). The pelvic groups are external iliac, superficial obturator, deep obturator, common iliac, superficial internal iliac, deep internal iliac, presacral, and parametrial. The aortic groups are precaval, paracaval, superficial intercavoaortic, deep intercavoaortic, preaortic, paraaortic, retrocaval, and retroaortic.

Adequate perioperative management and proper surgical technique,12, 13, 14 avoidance of retroperitoneal drains,⁵ and awareness of the vascular and urinary anomalies most commonly encountered¹⁰ are all of utmost importance to decrease perioperative complications, blood loss, operative time, and postoperative stay of patients referred for lymphadenectomy for gynecologic malignancies. Perioperative management includes mechanical bowel preparation, deep venous thrombosis prophylaxis with subcutaneous heparin, leg stockings and early mobilization, short-term antibiotic prophylaxis, and early feeding.²⁴ In the past years, thanks to the improvements in perioperative care and advances in anesthesia and surgical technique, a remarkable improvement has occurred in postoperative recovery after systematic lymphadenectomy. Most patients that the authors treat are now being discharged, on average, on the postoperative day 5 or 6, without significant morbidity. At the same time, having reached the plateau of the learning curve, a substantial reduction of operating time has been achieved, with the procedure lasting less than 1 hour in most patients.