Aortic utero-ovarian sentinel nodes and left infrarenal aortic lymph node dissection by ICG supported navigation.

•Visualization of paraaortic sentinel compartments in endometrial cancer•Nerve sparing dissection of left paraaortic infrarenal lymph compartment•Educational video may be basis for standardization of paraaortic sentinel node dissection.

Abstract

Lymphatic spread in endometrial cancer occurs along two major pathways: the uterine vascular mesometrium to the pelvic iliac lymph compartment and via the ovarian mesonephric pathway (infundibulopelvic ligament) to the paraaortic nodes visualized in (Kimmig et al., 2016a, Kimmig et al., 2016b). However, it could be shown that in pelvic negative nodes following pelvic lymphadenectomy and even pelvic sentinel node excision the incidence of positive paraaortics is as low as 1–2% (Abu-Rustum et al., 2009, Kim et al., 2016, Holloway et al., 2016, Zahl Eriksson et al., 2016). Thus, it could be reasonable to omit paraaortic and even pelvic systematic lymphadenectomy in patients with negative sentinels to reduce morbidity (Tschernichovsky et al., 2016). However, in patients with pT1b/G2 and 3 tumors percentage of isolated positive paraaortic nodes may be significantly higher (Kumar et al., 2014): paraaortic sentinel node resection may be useful to identify their risk correctly. In addition, ICG-guided navigation could also support the resection of the complete paraaortic compartment in case of proven positive nodes. In this video, the visualization of the lymphatic paraaortic drainage of the uterine corpus has been achieved by application of 4 × 0.5 ml of a 1.66 mg/ml solution of indocyanine green (ICG Pulsion®) intracorporal into the uterine fundus and midcorporal, right and left. It was injected via an Iowa-trumpet transcervically in about 0.5 cm myometrial depth, each.

The video defines the technique of “en bloc” resection of paraaortic nodes together with the connecting ovarian lymph vessels isolated from their attachment to the colonic mesentery and preserving the inferior mesenteric plexus. It will also be basis for identification of paraaortic sentinel nodes in an international multicenter study under consideration (Kimmig et al., unpublished data).