High Alert Zones in Nerve-Sparing Retroperitoneal Lymph Node Dissection in Gynecologic Cancers: A Precise Anatomy and Safe Surgical Technique

Abstract

Background:

Retroperitoneal lymph node dissection (RPLND) is one of the most commonly performed surgical procedures in advanced gynecologic cancers such as carcinoma ovary, carcinoma endometrium, carcinosarcoma uterus, and ovarian growing teratoma syndrome. RPLND is a reliable method to identify nodal micro/macrometastasis and is a standard of care for the staging of cancer. It helps in determining the prognosis of the disease. Nerve-sparing RPLND (NS RPLND) is the gold standard to prevent bowel, bladder, and sexual dysfunction. The incidence of these dysfunctions is as high as 40%–60% as compared with the NS approach.

Materials and Methods:

This is a prospective observational study. We had performed 225 NS RPLNDs for various gynecologic cancers, especially in advanced carcinoma ovary and carcinoma endometrium. Out of 225 NS RPLNDs, we performed it in 124 patients after neoadjuvant chemotherapy (NACT). Upfront NS RPLNDs were done in other 101 patients. We did these procedures with the concept of the high alert zone. Approved has been taken by the “institutional ethics committee, AIIMS, New Delhi, India” vide reference no: IEC-592/03.11.2017, AA-3/29.

Results:

In our technique, we explored the meticulous anatomy of this area and did the lymph nodal dissection in a stepwise manner, safeguarding the sympathetic nerves and its plexus throughout the course. With the current technique, we divided the field of dissections into five zones. Two hundred twenty-five gynecologic cancer patients underwent surgery. The most common malignancies are ovarian carcinoma (upfront: 76 and post-NACT: 95 patients) and uterine carcinoma (n = 31). NS RPLNDs were done in 14 ovarian germ cell tumors, 5 ovarian granulosa cell tumors, and 4 endometrial stromal sarcoma patients. We experienced more technical challenges in post-NACT NS RPLNDs than in upfront NS RPLNDs.

Conclusions:

NS RPLND is a procedure of choice for patients with gynecologic malignancies in whom surgical intervention for retroperitoneal lymph nodes is warranted. These procedures might have been associated with fewer surgical morbidities such as improved bowel, bladder, and sexual dysfunction in almost all patients with the low-burden disease and selected patients with advanced disease upfront or post-NACT settings. High alert zones are vulnerable areas of vital structures damage. Our NS RPLND technique in gynecologic cancer is feasible and reproducible without any extra surgical morbidities.