Abstract
Simple SummaryOne of the most frequent complications of the systematic lymph node dissection (SLND) is the injury of autonomic nervous system in the para-aortal region during the procedure. These injuries are supposed to be responsible for some of the postoperative bladder, bowel, and sexual dysfunctions. The poor anatomical understanding of the sympathetic nerves within the boundaries of an infra-renal bilateral template has limited the promulgation of a precise nerve-sparing surgery during such SLND. Therefore, the principal goal of the present study was to provide the first ever-comprehensive exposition of the anatomy of the female aortic plexus and superior hypogastric plexus and their variations. This exposition was achieved by strategic dissection of 19 human female cadavers and extrapolating the findings to develop a precise surgical technique for more accurate navigation into these structures during nerve-sparing SLND in 15 cervical cancer patients and 48 ovarian cancer patients.Whilst systematic lymph node dissection has been less prevalent in gynaecological cancer cases in the last few years, there is still a good number of cases that mandate a systematic lymph node dissection for diagnostic and therapeutic purposes. In all of these cases, it is crucial to perform the procedure as a nerve-sparing technique with utmost exactitude, which can be achieved optimally only by isolating and sparing all components of the aortic plexus and superior hypogastric plexus. To meet this purpose, it is essential to provide a comprehensive characterization of the specific anatomy of the human female aortic plexus and its variations. The anatomic dissections of two fresh and 17 formalin-fixed female cadavers were utilized to study, understand, and decipher the hitherto ambiguously annotated anatomy of the autonomic nervous system in the retroperitoneal para-aortic region. This study describes the precise anatomy of aortic and superior hypogastric plexus and provides the surgical maneuvers to dissect, highlight, and spare them during systematic lymph node dissection for gynaecological malignancies. The study also confirms the utility and feasibility of this surgery in gynaecological oncology.
Highlights
Dissection evaluation of pelvic and para-aortic lymph nodes has been an integral component of the surgical staging protocol for several gynaecologic malignancies for over a century [1,2]
The significance of the prognostic value of the para-aortic lymph node status in locally advanced cervical cancer has been accentuated again in the new International Federation of Gynaecology and Obstetrics (FIGO) staging system for cervical cancer that classifies patients with a para-aortic lymph node involvement in stage FIGO IIIC2 [6]. These developments in surgical management of gynaecological malignancies have given rise to austere diagnostic restrictions for a systematic lymph node dissection in such cases. Taking these facts and the potential additional treatment burden of a systematic lymph node dissection into account, all contentions are in place to avoid the complications of a lymph node dissection
One of the most frequent and vital complications of the para-aortic lymph node dissection that has perhaps never descended into the cognitive focus of many gynaecologic oncologists is the injury of autonomic nervous system in the para-aortal region during the procedure
Summary
Dissection evaluation of pelvic and para-aortic lymph nodes has been an integral component of the surgical staging protocol for several gynaecologic malignancies for over a century [1,2]. The significance of the prognostic value of the para-aortic lymph node status in locally advanced cervical cancer has been accentuated again in the new International Federation of Gynaecology and Obstetrics (FIGO) staging system for cervical cancer that classifies patients with a para-aortic lymph node involvement in stage FIGO IIIC2 [6]. These developments in surgical management of gynaecological malignancies have given rise to austere diagnostic restrictions for a systematic lymph node dissection in such cases. The present study supposes that these nerve injuries are responsible for some of the postoperative bladder, bowel, and sexual dysfunctions
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