Extraperitoneal endosurgical aortic and common iliac dissection in the staging of bulky or advanced cervical carcinomas

Abstract

A pilot study of a new surgical technique for aortic dissection, combining the advantages of extraperitoneal surgery and minimal invasive surgery, was conducted. Fifty-three patients underwent infrarenal aortic and common iliac dissection for the staging of bulky or advanced cervical carcinomas. The indication for extended lymph node staging was bulky early stage in 33 patients, International Federation of Gynecology and Obstetrics distal Stage IIB or higher in 14 patients, nonbulky early stage with microscopic positive pelvic lymph nodes in 1 patient, and central recurrence in 5 patients. The lymph node dissection template included the common iliac lymph nodes, the inframesenteric lymph nodes, and the preaortic and lateroaortic infrarenal lymph nodes. The operation was performed using endoscopic techniques with CO(2) insufflation of the extraperitoneal space. The procedure failed in two patients. Nine patients had lymph node biopsy or selective removal of macroscopically positive lymph nodes. For the 42 remaining patients, the average duration of the operation was 125.9 +/- 31.8 minutes and the average number of lymph nodes was 20.7. Overall, 17 patients had positive lymph nodes, in whom disease was macroscopic in 9 patients and microscopic in 8. Overall, the positivity rate was 32%. Five complications occurred, four of them related to the extraperitoneal dissection technique. An intraoperative complication occurred in one patient, in whom a lateral injury to a fixed and dilated ureter was managed by stenting. A postoperative complication occurred in another patient, in whom a retroperitoneal hematoma causing ileus and compression of the upper ureter was managed conservatively. Two symptomatic lymphocysts occurred; one of them required drainage under ultrasound guidance. All patients but one had external radiation therapy tailored according to the aortic lymph node status. After an average follow-up of 18.9 months, 60% of lymph node positive patients and 15% of lymph node negative patients died. Distant recurrence occurred in 53% of lymph node positive patients and 9% of lymph node negative patients. No patient had recurrence in the aortic or common iliac area. Two patients developed radiation enteritis. This new technique deserves to be used as a tool to identify lymph node positive patients who require extended-field radiation and/or chemotherapy.