Introduction/Background Lymph node metastasis significantly impairs the prognosis in cervical cancer. Patients with nodal metastases have a 3-year survival rate of 64%, compared to 94% in nodal-negative patients. It is postulated that bulky lymph node metastases are at a substantial risk of treatment failure due to the inverse relationship between tissue radiosensitivity and tumor deposit volume. Therefore, it is rational to hypothesize that pre-treatment lymph node debulking may optimize the response to radiotherapy, provided that the procedure is safe and does not delay the main treatment.
Methodology The illustrative case is of a 29-year-old patient with squamous cell carcinoma of the cervix stage T2bN1M0, treated with upfront chemoradiotherapy and brachytherapy, achieving a complete clinical response but experiencing retroperitoneal lymph node recurrence after a 8-month disease-free interval. Intraoperative evaluation identified para-aortic, intercaval, retro, and paracaval lymph node conglomerates measuring up to 5.0 cm.
The robotic surgical technique and tactics used for retroperitoneal lymph node debulking are described for didactics to perform it safely and effectively.
Results After accessing the retroperitoneal space, surgical thread is used to traction the peritoneal fold anteriorly. The acquisition of the surgical field provides wider freedom of movement for robotic forceps. Sharp dissection of great vessels allows the safety and radicality needed. The use of metal clips helps define the anatomical limits and the radiotherapy field, and prevents lymphorrhea. Surgical gauzes could be used as landmarks while lateralizing and protecting the ureters. The vessel-loop promotes the lateral and anterior vena cava mobilization during retrocaval space dissection, exposing the lumbar vessels.
Conclusion The benefits of this procedure are unproven and should not delay the sequential radiotherapy and systemic treatment. This video shows the strategies to achieve the desired success and avoid intraoperative complications. The standardized surgical steps and adequate training could make this complex surgical procedure easier and lead to satisfactory results.
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