Laparoscopic pelvic lymphadenectomy was introduced in 1989 by Querleu5
and laparoscopic inframensenteric para-aortic lymphadenectomy was introduced in 1992 by Netzhat.6
With the rapid development of laparoscopic operative techniques and instruments, laparoscopic lymphadenectomy has become a common procedure for the treatment of gynecologic malignancies. Laparoscopic surgery for advanced cervical cancer provides not only radical treatment but also the chance, by implementing staging, to benefit patients by adjusting treatment modalities according to the exact field of radiation and debulking nodal metastasis.7
A recent advance has been robotic transperitoneal infrarenal aortic lymphadenectomy, which can be performed adequately and safely with the robotic column.8
A previous report described the increased survival in patients with macroscopic lymph node resected.9
Another study also reported increased survival in patients without residual lymph nodes.10
Marnitz et al11
found that removal of more than 5 pelvic and/or 5 positive para-aortic lymph nodes was associated with significant improvement in overall survival. However, Goff et al12
mentioned that without a randomized trial, it would not be possible to verify that surgical excision of grossly involved nodes provides a surgical advantage.
In this study, when the laparoscopic transperitoneal radical hysterectomy with lymphadenectomy procedure was first performed, the surgeon was still in the learning phase, and lymphadenectomy was not performed up to the level of the renal vessel. As time progressed, an infrarenal aortic lymphadenectomy was performed.13
When the 2 groups were compared, the differences were only in the intra- and postoperative transfusions, and harvested lymph nodes. Transfusions occurred frequently in the initial learning phase, and the larger number of harvested lymph nodes is considered a result of the more extended lymphadenectomy in group I. To examine the changes in surgical results relative to the increasing cases, a regression analysis was performed. The results showed there was no change over time with respect to blood loss, total harvested lymph nodes, and operative time; thus, the bias between the 2 groups can be minimized.
When considering the clinical and surgical results of this study, it was expected that the survival outcome would be poorer in group II, but the survival analysis showed the opposite results. Although there were limitations in comparison due to the small number of cases, the disease-free survival rate had a statistically significant decrease in group I.
Among the reported cases of cervical cancer, sufficient data on the results of infrarenal para-aortic lymphadenectomy are not available. Altintas et al14
reported positive infrarenal lymph nodes in 5 of 103 cervical cancer patients (4.8%) and showed that omitting upper para-aortic lymph node dissection in the absence of malignant findings in the inferior para-aortic lymph node at frozen section must be considered. Köhler et al15
reported positive infrarenal lymph nodes in 1 of 11 patients (9%). Michel et al16
reported positive infrarenal lymph nodes in 20 of 421 stage Ib-IIb cervical cancer patients (4.7%), 8 of whom (1.9%) showed isolated positive infrarenal lymph nodes. This finding suggests that para-aortic lymphadenectomy should include removal of all of the left para-aortic chain and should be performed up to the level of the left renal vein. Michel et al16
also recommended that because of the low frequency of para-aortic involvement when tumor size is <2 cm, such a procedure could be avoided in patients with small tumors. When the current and previous studies are comprehensively considered, the positive infrarenal lymph node rate is 4.7% (26/547), and the isolated lymph node rate is 1.4% (8/547). Of the aforementioned studies, laparoscopic lymphadenectomy was performed in our study and by Köhler et al,15
whereas laparotomy lymphadenectomy was performed by Altintas et al14
and Michel et al.16
No data are available for isolated infrarenal para-aortic lymph node recurrence after definitive therapy (staging procedure or radiation). The incidence, after definitive therapy for invasive cervical carcinoma, of radiographically detected isolated disease recurrence in para-aortic lymph node varies from 1.7% to 12%. In 2 larger series, with a combined total of 2087 patients, the incidence of isolated para-aortic recurrence was approximately 2%.17–19
The 3-year survival rates after recurrence were 34%, 28%, and 5% for patients with para-aortic lymph node relapse alone, supraclavicular lymph node relapse with or without para-aortic lymph node relapse, and relapse other than para-aortic and supraclavicular lymph nodes. Of the patients with para-aortic lymph node relapse alone, 27% survived >5 years.20
It was suggested that isolated para-aortic lymph node recurrence after primary irradiation due to cervical carcinoma is a curable disease. If diagnosed early with a normal SCC level or an SCC level <4 ng/mL, and no clinical symptoms or signs, the 5-year survival rate with concurrent chemoradiation was 51.2%.18
The isolated para-aortic lymph node recurrence is very low and can be salvaged with concurrent chemoradiation after early detection.