Paraaortic Lymphadenectomy in Gynecologic Oncology—Significance of Vessels Variations

Abstract

Lymphadenectomy has been an essential part of the surgical treatment in surgical oncology, as the lymphatic channels and nodes are the main dissemination pathway for most of the gynecological cancers. Pelvic and paraaortic lymphadenectomy are frequent surgical procedures in gynecologic oncology. Paraaortic lymph node dissection facilitates staging, prognosis, surgical and postoperative management of patients. It is one of the most challenging retroperitoneal surgeries. A comprehensive knowledge of the paraaortic region is mandatory. Intraoperative bleeding is the most common complication during lymphadenectomy due to direct vascular injury, poor tissue handling, exuberant retraction and possible anatomical variations of the vessels in the paraaortic region. Approximately, one-third of women will have at least one anatomic variation in the paraaortic region. It must be stressed that anomalous vessels may be encountered in every woman who will undergo surgery. Consequently, detailed knowledge of anatomical vessels variations is required in order to prevent iatrogenic vessel injury. The importance of these variations is well described in urology, vascular and general surgery. Conversely, in oncogynecological surgery, there are few articles, which described some of the vessels variations in the paraaortic region. The present article aims to propose a surgical classification and to describe the majority of vessels variation, which could be encountered during paraaortic lymphadenectomy in gynecologic oncology. Moreover, surgical considerations in order to prevent anomalous vessels injury are well described.

Vascular and Urinary Tract Anatomic Variants Relevant to Para-Aortic Lymphadenectomy in Women with Gynecological Cancers

“…The prevalence of retroaortic left renal veins is 2.1% in the literature [29]. When the left renal vein is retro-aortic, the upper ventral border of para-aortic lymph node dissection may be missed, and the superior mesenteric artery or left renal artery may be injured during dissection [30].…”

A report on accessory renal arteries incidence in Slovak adults: Cadaveric study and surgical correlation

“…Intraoperative bleeding is the most common complication during lymphadenectomy. Anomalous vessels may be encountered in every patient who undergoes surgery in the aorto-caval region (30).…”

Laparoscopic transperitoneal para-aortic lymphadenectomy in double inferior vena cava vascular anomalies

“…These variants can be silent, diagnosed as an incidental finding after pre-operative imaging studies, or have hemodynamic repercussion. They can be a risk factor for deep vein thrombosis (predisposing to venous stasis even in the presence of a compensatory collateral system) and sometimes they are associated with congenital malformations (cardiac, splenic, renal) 2 3…”