Complete Pelvic Node Dissection
Kenneth D. Hatch
Achim Schneider
GENERAL PRINCIPLES
Definition
A complete pelvic node dissection is performed in the treatment of early cervical cancer for both curable intent and to identify patients who may need postoperative radiation and/or chemotherapy.
Prior to the introduction of linear accelerators and image-modulated radiation therapy, external beam radiation therapy was given with cobalt 60 and led to significant toxicity of bowel and urinary tract. This encouraged surgeons to do complete node dissections and offer radiation therapy only for multiple positive nodes.
With the introduction of modern radiotherapy, the complications from postoperative RT diminished and it became standard practice to give External Beam Radiotherapy (EBRT) to node-positive patients.
In 1999, the results of a Gynecologic Oncology Group (GOG) study randomizing node-negative patients with high-risk factors of size of tumor greater than 4 cm, lymphovascular space invasion, and greater than one-third stromal invasion to EBRT or observation were published. This showed a survival advantage to the EBRT-treated patients. As a result, the rate of postoperative EBRT given to patients after radical hysterectomy is up to 40%.
Anatomic Considerations
The anatomic boundaries for complete pelvic node dissection for cervical cancer are the following: the common iliac bifurcation cephalad, the deep iliac circumflex vein caudad, the psoas muscle lateral, the ureter medial, and below the obturator nerve dorsally.
The lumbosacral region is between the psoas muscle and the external and common iliac vessels.
The obturator region is below the external iliac vein and dorsal to the obturator nerve.
The external iliac region is medial to the external iliac vessels.
The internal iliac region is along the internal iliac artery and vein and the sacrum.
IMAGING AND OTHER DIAGNOSTICS
Computed tomography (CT) has an overall accuracy for detection of metastatic disease of 84.4%. The false-positive rate is of 21% and false-negative rate of 13%.
MRI is more accurate than CT in assessing size of tumor, depth of invasion, and parametrial extension but is not superior in detecting metastatic disease (86%).
PET/CT has the potential to identify metastasis in normalsized nodes; however, in early-stage disease, the sensitivity is reported from 32% to 83% and the positive predictive value from 69% to 91%. Thus, it cannot be relied on to detect microscopic disease.
PREOPERATIVE PLANNING
Complete pelvic lymphadenectomy is most often performed for early-stage disease when the intent is for cure. Women who have stage 1B2 disease will have a 15% rate of lymph node metastasis. If the gynecologic oncologist plans to abort the radical hysterectomy when positive nodes are found, the patient should be advised of the plan. Thorough explanation before the surgery will reduce the disappointment of awakening to find the uterus has not been removed.
There is no upper age limit at which the patient is not eligible for the node dissection.
Obesity is not a contraindication as the pelvic dissection is not affected by adipose as are the paraaortic nodes.
Preparation of the bowel varies with the experience of the surgeon. At a minimum, the patient should have clear liquids the day before the surgery. Some surgeons will order an oral cathartic the afternoon before surgery. Some surgeons will have the patient place an enema the morning of surgery.
SURGICAL MANAGEMENT
Positioning
The patient is paced in the low lithotomy position with the legs in adjustable Yellofins or Allen stirrups. The patient should be secured to the table on gel pads or some similar system to prevent sliding while in Trendelenburg position. Padded shoulder stops are recommended for morbidly obese patients.
Compression devices are on the calf for DVT prophylaxis.
Antibiotics are given prior to the incision (see Chapter 11, Laparoscopic Hysterectomy with Pelvic and Paraaortic Node Dissection, for additional details).
Approach
Placement of the trocars is discussed in Chapter 11, Laparoscopic Hysterectomy with Pelvic and Paraaortic Node Dissection.
PROCEDURES AND TECHNIQUES
Complete Pelvic Node Dissection (Videos 20.1 and 20.2) 
Open the pelvic retroperitoneal space
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