Laparoscopic Paraaortic Node Dissection for Cervical Cancer



Laparoscopic Paraaortic Node Dissection for Cervical Cancer


Kenneth D. Hatch

Achim Schneider



GENERAL PRINCIPLES



Definition



  • Paraaortic node dissection in women who have cervical cancer is indicated for diagnostic (staging) or therapeutic reasons.


  • Women with stage 1B2 or 2A disease who are candidates for radical hysterectomy have a 6% to 12% risk of paraaortic node positivity. These women will benefit from paraaortic node dissection to eliminate the radical hysterectomy and allow the radiation therapist to cover all positive fields.


  • Women with stage 2B or above with negative nodes on PET/CT have up to a 35% chance of positive paraaortic nodes at the time of surgical staging.


  • Women who have resection of microscopic (less than 5 mm in size) metastatic paraaortic nodes followed by extended field radiation have a survival equal to women who have negative paraaortic nodes.


  • Staging and resection of nodes by laparotomy has been used since the 1970s; however, radiation-induced intestinal complications diminished its therapeutic advantage.


  • The development of laparoscopic techniques has markedly decreased these complications and has led to many institutions to perform standard surgical staging.


Anatomic Considerations



  • Laparoscopic paraaortic node dissection can be performed by either transperitoneal or extraperitoneal techniques.


  • The anatomic boundaries have been described in chapters 9 and 14.


IMAGING AND OTHER DIAGNOSTICS



  • Clinical staging of cervical cancer is accurate in 85% of stage 1B but drops to 35% in stage 2A, and to 21% in stage 2B.


  • Imaging with MRI is the most accurate means of detecting the size of the lesion, depth of invasion, parametrial invasion, and extension to the uterus.


  • PET/CT is most accurate in detecting nodal or other metastatic diseases.


  • Early-stage cervical cancer stage 1A2 and 1B1 have such a low rate of detectable metastases that pretreatment PET/CT is not indicated.


  • Patients with locally advanced cervical cancer defined as stage 1B2 through stage 4 may benefit from PET/CT if metabolically active enlarged nodes are identified.


  • When PET/CT is compared with surgical staging, the falsenegative rate is 12%.


  • Surgical staging has found paraaortic node positivity in 6% of stage 1B, 12% of stage 2A, 19% of stage 2B, 33% of stage 3A, 29% of stage 3B, and 30% of stage 4.


PREOPERATIVE PLANNING



  • The results of any images need to be reviewed and discussed with the patient. The goal of the surgery and the subsequent impact on the radiation will be discussed.


  • The images will indicate if there are enlarged nodes and where they are located so the surgeon will specifically look at those locations.


  • If no nodes are suspicious, then a standard node dissection will be planned.


SURGICAL MANAGEMENT



  • Obese patients will benefit from an extraperitoneal node dissection since the bowel will not be in the way.


Positioning



  • Those patients who will have a transperitoneal laparoscopic node dissection will be in the standard lithotomy position shown in other chapters.


  • The patient who will have a retroperitoneal dissection will be in the supine position with the left arm out. This will allow the trocars to be placed along the left flank. A tucked arm would be in the way of the surgery.




PROCEDURES AND TECHNIQUES


Transperitoneal Laparoscopic Node Dissection

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May 7, 2019 | Posted by in GYNECOLOGY | Comments Off on Laparoscopic Paraaortic Node Dissection for Cervical Cancer

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