• Cervical Cancer
• Laparoscopy
• Cervix Uteri
• SLN and Lymphadenectomy

The role of lymph node assessment in patients with locally advanced cervical cancer and the impact of the discovery and removal of occult nodal disease is still debated.

The value of surgical staging prior to chemoradiation in international guidelines is contradictory, since results published in the literature are controversial,1 and even the PET scan has a high false-negative rate for metastatic lymph nodes involvement.

Marnitz et al published a randomized trial in 2020 (Uterus-11 study)2 processing this question. Minimally invasive surgical staging in patients with locally advanced cervical cancer has demonstrated upstaging rates between 22% and 43% compared with clinical staging.

Studies that specifically search the debulking of macroscopically enlarged lymph nodes show better outcomes for patients in whom enlarged lymph nodes can be removed. The potential oncologic benefit of removing bulky pelvic and para-aortic lymph node metastases prior to primary chemoradiation, from a radiobiological point of view, is to provide higher loco-regional control and it allows adaptation of the extent of irradiation fields.3

The optimal surgical approach for para-aortic lymphadenectomy in gynecologic cancers using minimally invasive surgery is controversial.

In our institution, a team trained in gynecologic oncologic surgery performs systematically transperitoneal laparoscopic staging of patients with bulky or locally advanced cervical carcinoma, without significantly increasing treatment-related morbidity or mortality and without delaying chemoradiotherapy treatment.4 When performing debulking surgery, it is important to use a procedure with a low complication rate to avoid delaying the chemoradiation, which is the definitive oncologic treatment for these patients.

Conclusions

• Debulking surgery, prior to chemoradiation treatment, allows the extent of disease to be confirmed, which might not be seen with complementary imaging techniques or with clinical staging.

• Removal of larger lymph nodes has a potential oncologic benefit, providing higher loco-regional control prior to primary chemoradiation.

• We recommend performing a well-planned lymphadenectomy, with an accurate pre-operative plan and following key surgical steps and dissection landmarks.

• Laparoscopic debulking of enlarged para-aortic nodes in patients with locally advanced cervical cancer is a feasible technique, performed by teams trained in gynecologic oncologic surgery.

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Figure 1

Laparoscopic transperitoneal para-aortic approach in advanced cervical carcinoma.

Video 1 Laparoscopic transperitoneal surgery in cervical cancer is today a standardized procedure, previously considered to be at high risk of complications. Nevertheless, with pre-operative analysis and well-planned surgery, it is feasible to perform in the hands of trained gynecologic oncologic surgeons.