Treatment of Early-Stage Gynecological Cancer-Related Lower Limb Lymphedema by Lymphaticovenular Anastomosis—The Triple Incision Approach

Abstract

Background and Objectives: Lower extremity lymphedema (LEL) is one of the most relevant chronic and disabling sequelae after gynecological cancer therapy involving pelvic lymphadenectomy (PL). Supermicrosurgical lymphaticovenular anastomosis (LVA) is a safe and effective procedure to treat LEL, particularly indicated in early-stage cases when conservative therapies are insufficient to control the swelling. Usually, preoperative assessment of these patients shows patent and peristaltic lymphatic vessels that can be mapped throughout the limb to plan the sites of skin incision to perform LVA. The aim of this study is to report the efficacy of our approach based on planning LVA in three areas of the lower limb in improving early-stage gynecological cancer-related lymphedema (GCRL) secondary to PL. Materials and Methods: We retrospectively reviewed the data of patients who underwent LVA for the treatment of early-stage GCRL following PL. Patients who had undergone groin dissection were excluded. Our preoperative study based on indocyanine green lymphography (ICG-L) and color doppler ultrasound (CDU) planned three incision sites located in the groin, in the medial surface of the distal third of the thigh, and in the upper half of the leg, to perform LVA. The primary outcome measure was the variation of the mean circumference of the limb after surgery. The changes between preoperative and postoperative limbs’ measures were analyzed by Student’s t-test. p values < 0.05 were considered significant. Results: Thirty-three patients were included. In every patient, three incision sites were employed to perform LVA. A total of 119 LVA were established, with an average of 3.6 for each patient. The mean circumference of the operated limb showed a significant reduction after surgery, decreasing from 37 cm ± 4.1 cm to 36.1 cm ± 4.4 (p < 0.01). Conclusions: Our results suggest that in patients affected by early-stage GCRL secondary to PL, the placement of incision sites in all the anatomical subunits of the lower limb is one of the key factors in achieving good results after LVA.

Local Perineal Capillary Perforator Flaps: A Minimally Invasive Technique for the Correction of Vulvar Stenosis

“…The perineum has a dense network of perforating blood vessels that originate from the obturator artery and the internal and external pudendal arteries and are interconnected by anastomoses and choke vessels. CDU is considered by many to be a useful and versatile tool for identifying and mapping the superficial subcutaneous structures in the female genital region, such as perforating vessels, lymphatic vessels, and lymph nodes [ 34 , 35 , 36 , 37 , 38 , 39 , 40 ]. In this study, CDU enabled the visualization and mapping of perineal capillary perforators, ensuring safer flap harvesting.…”

Indocyanine green fluorescence applied to gynecologic oncology: beyond sentinel lymph node

“…Caretto et al . 18 performed LVA in 33 patients who had previously undergone pelvic lymphadenectomy for gynecological malignancies. Preoperative ICG was used to assess leg lymphatic drainage and plan incision sites for performing the anastomosis, resulting in a significant reduction in limb circumference after surgery.…”

Secondary post-oncologic vulvar reconstruction – a simplified algorithm

“…Postoperative wound complications remain one of the biggest problems in the care of these patients, with an incidence of 26%-85% (7), causing enormous physical and psychosocial problems, prolonged hospital stays, delays in the beginning of adjuvant therapies that can worsen oncologic outcome, as well as high healthcare costs. The most common postoperative short-term complications reported in the literature are wound breakdown, infection, lymphatic leakage, perineal disunion or cutaneous necrosis, and hematoma (8)(9)(10). Diabetes, jaundice, chronic renal failure, poor physical condition, advanced age, alcoholism, smoking, obesity, poor nutrition, and previous radiotherapy or chemotherapy are considered patient-related risk factors for short-term complications (11)(12)(13)(14).…”