Infrarenal lymphadenectomy for gynecological malignancies: two laparoscopic approaches.

Objective: Compare two approaches for laparoscopic infrarenal lymphadenectomy.

Methods: Retrospective chart review. Statistical analyses with SPSS.

Patients: 4 stage II/III cervical carcinoma, 75 clinical stage I/II endometrial carcinoma, 36 clinically stage I/II tubal/ovarian cancer. 36 transperitoneal approaches; 79 extraperitoneal approaches. Both groups had similar age, 58years (range 29-80), BMI of 25 (range 18-41), blood loss, 150cm(3) (range 25-1500), and hospital stay, 1day (range 1-6). The extraperitoneal surgery took longer (240 v 202min; p=.001); yielded more nodes (50 v 41; p=.004). Extraperitoneal approach yielded more inframesenteric (14 v 10; p=.036), and infrarenal nodes (14 v 9; p=.001). 25% of cervical, 19% of endometrial and 14% of ovarian cancer patients had metastases in radiographically negative infrarenal nodes. 50% of cervical, 33% of endometrial and 17% of ovarian cancer patients had therapy altered by aortic lymphadenectomy. When the inframesenteric nodes were positive, 63% of endometrial and 80% of ovarian cancer patients had infrarenal metastases. More metastases were identified with increasing aortic node count. Extraperitoneal lymphadenectomy had no learning curve (p=0.320), while transperitoneal lymphadenectomy did (p=0.016). Higher BMI patients had lower aortic node yields by transperitoneal (p=.057) but not extraperitoneal approach (p=.578). Among the 14 patients whose BMI was 35-41, mean extraperitoneal total aortic nodal yield was 30; transperitoneal yield was 6.

Conclusions: Infrarenal aortic lymphadenectomy may offer higher aortic nodal yields, even in patients with BMI's of 45. Larger prospective studies are needed to confirm whether this dissection in high-risk patients ensures more accurate therapy, and possibly improves cure rates.