Lateral Pelvic Lymph Node Dissection LPLD Technical Notes Indications Results and Complications

LPLD consists of a complete dissection of the endopelvic fascia together with the rectum and mesorectum [9]; the first phase is represented by the complete removal of the para-aortic and paracaval tissues, from the left renal vein, up to the aorto-caval bifurcation. Starting then from the aorto-caval bifurcation, and using ureters as lateral dissection limits, all lymph nodes as well as the lymphatic-cellular tissue are removed medially to the common and internal iliac vessels [5, 9]. Moreover, the clearance of the obturator region is performed preserving the nerve [9]. In case of metastatic, or suspected lymph nodes located down the iliac vessels and in the obturator foramen, some surgeons remove the hypogastric vessels completely, preserving the superior vesical artery and the obturator nerve [2].

The likelihood of rectal cancer hitting the lymphatic system depends on its stage and it may reach 70% in the case of complete parietal penetration or of infiltration of nearby organs. It is these patients having parietal extension (u)T3 and (u)T4, and stage III TNM who are mostly likely to undergo an LPLD [2,9].

Pre-operative selection is based on combined information given by pelvic TAC and RNM, and by rectal endosonography. In a perspective evaluation of lateral pelvic lymphadenopathy there is a critical diagnostic limit for lymph nodes of <5 mm [2], and moreover it must be taken into account that the lymph nodal intraoperative staging performed by the surgeon is not very accurate [25].

Sauer and Bacon [24], Stearns and Deddish [27] and St. Mark's Hospital's surgeons [28] were the first to apply LPLD but without any remarkable results in terms of local relapses and survival. Enker et al. [29] renewed interest in LPLD, managing to improve the survival of patients having Dukes C stage in comparison with those who underwent ordinary surgery.

One of the best documented experiences was proven at the National Cancer Center Hospital in Tokyo [3,16], where LPLD results were considerably higher than results obtained performing ordinary lymphadenectomy surgery both regarding long-term survival (88% 5-year Dukes B and 61% Dukes C vs. 74% and 43%) and regarding local relapse control (6.3% Dukes B and 23.6% Dukes C vs. 21.8% and 32.9%).

Moriya et al. [2] consider LPLD to be particularly effective in the treatment of Dukes C stage (55% 5-year survival free of illness, 16% pelvic relapses) and presented a remarkable 5-year survival of 43% in patients presenting with lateral lymph nodal metastasis, especially if compared with curability percentages lower than 10% in former experiences [3].

Suzuki et al. [13] emphasise that the extension of lymphadenectomy is a decisive factor in preventing local relapses.

Surgical mortality in LPLD is low, ranging from 0.7 to 2.1% [2, 16, 29], but there is an increase of intraoperative blood loss [16, 29], of complications, and a serious problem with genito-urinary function ality [16, 25]. Eighty per cent of patients complain of post-surgery bladder disorders, 40% complain of lack of a bladder kick sensation and 76% complain of impotency; these percentages are twice as high as those of patients who underwent ordinary surgery [16]. This is the consequence of sacrificing pelvic autonomic nerve structures [30].

With the aim of reconciling radical needs with an appropriate lifestyle, Japanese surgeons developed extended lymphadenectomies by preserving pelvic nerve structures (LPLD-nerve sparing - NS) [30, 31]. The extent of the preservation of nerve structures may be total or partial (complete or partial sparing of the contralateral hypogastric nerve, or of the pelvic plexus, performed on one side or on both) [30, 31] and depends on where the tumour is located, its grading and stage [32].

Although some histopathologic reports discuss the opportunity to perform nerve-sparing operations because of the possibility of a perineural invasion of the pelvic plexuses [33, 34], clinical experiences are rather favourable. Five-year survival is 74-91.7% in Dukes B patients, and 56.7-67.3% in Dukes C patients [31, 35]; local relapses are about 4.8-7.9% [30, 31, 35].

As for functional results, after a (partial or total) LPLD-NS, appropriate urinary function is maintained by 78.6-93.2% of patients, effective potency is maintained by 31.2-71.3% of patients and an ability to ejaculate is maintained by 6.5-53% of the cases [30].

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