Extraperitoneal Lymphadenectomy in the Management of Gynecologic Cancer

The role of lymphadenectomy in the management of gynecologic malignancies has evolved as we have come to better understand the limitations of our current diagnostic tests and treatment paradigms for node-positive disease. The optimal surgical approach to lymphadenectomy is one that minimizes operative morbidity, permits rapid postoperative recovery, and leads to prompt initiation of adjuvant therapy without compromising oncologic outcomes. Initially, node status was assessed using a transperitoneal approach by laparotomy. However, the high complication rate associated with this procedure, particularly in combination with extended field radiation, led to the development of extraperitoneal approaches to lymphadenectomy. With the innovation and refinement of minimally invasive surgery, the effectiveness of laparoscopic and robotic extraperitoneal lymphadenectomy has now been established. This review describes the execution of the various extraperitoneal approaches to lymphadenectomy in gynecologic oncology surgical practice. The data comparing the adequacy and sensitivity of these and transperitoneal approaches for the assessment of nodal involvement are also presented. Further, the unique advantages of and complications associated with the extraperitoneal lymphadenectomy are discussed. Lastly, this review will highlight what we have learned about the diagnostic and therapeutic value of lymphadenectomy in the management of gynecologic malignancies as the extraperitoneal approach has been critically evaluated over time. Presently, the first phase III randomized controlled trials investigating these endpoints with consideration given to the various approaches to lymphadenectomy are ongoing.