Pelvic and retroperitoneal lymphadenectomy
What is it?
Lymphadenectomy (pelvic or retroperitoneal) consists in the removal of lymph nodes, a necessary procedure when diagnostic-radiological findings suggest a high risk of their involvement by neoplastic disease. Lymph nodes are small organelles with the function of filtering fluids and proteins from all over the body.
When is this procedure indicated?
When an organ becomes diseased with cancer, it is possible for some cancer cells to leave the confines of the organ and be captured by the nearest lymph nodes. For this reason, in some patients with pelvic urologic tumors such as prostate or bladder cancer, lymph node removal is performed in order to obtain a more precise staging of the disease. In addition, removing sites of metastasis can have an effect on the natural history of the disease by maximizing oncologic control and reducing the risk of recurrence.
How is it performed?
The intervention is performed under general anesthesia. The classic procedure generally involves a mid-abdominal, supra- or sub-umbilical incision, depending on where the lymph nodes involved in the disease are located (pelvis or retroperitoneum). In case the lymph nodes involved by the disease are located at the retroperitoneal level, the intervention initially provides access to the abdominal cavity by transperitoneal route and derotation of the intestinal skein to access the retroperitoneum.
Step 1
The lymph nodes, which are located near the large retroperitoneal blood vessels, the aorta and vena cava, are then removed. The procedure provides, where the stage of lymph node involvement allows it, the sparing of the nerves of the sympathetic system chain responsible for ejaculation.
Step 2
Once the lymph nodes have been removed, 1-2 small drainage tubes are placed in the retroperitoneum, which allows monitoring for any blood or lymph leakage. In case the lymph nodes involved by the disease are located in the pelvis, the surgery starts with an incision of the abdominal wall that generally starts just below the navel and extends to the pubis.
Step 3
We then enter the pelvis where the lymph nodes draining the prostate and bladder are located.
Step 4
We then proceed to remove the lymph nodes themselves, which are located near the iliac and obturator vessel.
Step 5
One or two drainage tubes are then placed in the pelvic excavation, which will exit the skin lateral to the midline wound. A bladder catheter is placed during both procedures to monitor diuresis.
Step 6
In addition, both types of surgery at our Institute can be performed using robot-assisted technology (with the Da Vinci® system).
Recovery
Recovery is usually rapid; generally, from the first day after surgery the patient can resume walking and eating, thus promoting bowel movement and circulation. Drainage tubes will be removed as soon as the amount of drained fluid becomes small. Discharge from the hospital occurs after about 4 days of hospitalization, the patient will return after about 7-10 days to the outpatient clinic for a check of the surgical wound and removal of the bladder catheter.
Short-term complications
Short-term complications include infection (approximately 10% of cases), wound-related issues (approximately 5% of cases), issues due to injury to large blood vessels (hemorrhage), issues due to peripheral nerve injury (painful neuropathy, motor and sensory deficits in specific areas of the pelvis and lower extremities), and finally issues due to immobilization, such as thrombosis (approximately 1% of cases). In some cases, there may be a collection of lymph (lymphocele) that becomes infected leading to fever and requires percutaneous drainage and antibiotic therapy.
Long-term complications
Long-term complications include incisional hernias and lymph accumulation in the lower extremities (lymphedema) and external genitalia; finally, absence of ejaculation if retroperitoneal lymph nodes are removed.
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