The lymphatic drainage of the uterine cervix in adult fresh cadavers: Anatomy and surgical implications

Abstract

Objective: To investigate the differences of the amount of paracervical lymphatic structures removed when performing classical type III, modified type II and nerve-sparing radical hysterectomy (RH). Material and Methods: Open macroscopic or laparoscopic pelvic dissections in 18 fresh adult female cadavers after lymphatic channels and nodes staining by Lipiodol dye solution injection of the uterine cervix. Results: We distinguished three different lymphatic pathways: 1) the supraureteral paracervical pathway (vascular portion of paracervix-uterine artery and superficial uterine vein), identified in 96% of cases, and removed in all types of RH, 2) the infraureteral paracervical pathway (vascular portion of paracervix-deep uterine vein), identified in 22% of cases, and removed by type III and nerve-sparing RH, and 3) the neural paracervical pathway (nervous portion of paracervix), identified in 7% of cases, and removable only by type III RH. No evidence of stained lymphatic structures running into the vesicouterine and uterosacral ligaments was found. Conclusion: Nerve-sparing RH offers the most effective ratio between oncological safety and surgical-related complications, and would be particularly useful in patients with high risk of paracervical involvement while our results suggest caution in the use of modified type II RH in patients at low-moderate risk of paracervical involvement, unless the use of adjuvant radiotherapy, because of the large amount of potentially lymph-bearing paracervical tissue leaved in situ. Classical type III RH affords the complete resection of all paracervical lymphatic pathways potentially draining the cervix, however this procedure implies a high risk of lesions of the autonomous nerves of pelvic organs.

Optimization of Near-Infrared Fluorescent Sentinel Lymph Node Mapping in Cervical Cancer Patients

“…The location of the NIR fluorescent SLNs was in concordance with formerly published drainage patterns (11). Furthermore, bilateral SLNs were found in 8 of 9 patients.…”

Lymphatic vessels around the uterus: D2-40 (podoplandin) immunohistochemistry using elderly cadavers

“…Smith et al [24] reported laparoscopic skeletonisation of the uterine artery for conservative management of cervical carcinoma. In their excellent injection study using fresh cadavers, Ercoli et al [3] demonstrated the supraureteric lymphatic route along the uterine artery and superficial uterine vein plays a major and critical role in cancer metastasis from the uterine cervix. However, because of the tight entrapment of LVs close to the artery and vein, as shown in the present study, preservation of the uterine artery during complete removal of the lymphatic route would seem to be difficult.…”

“…Using cross-sectional histology with D2-40 immunohistochemistry, we took photos at hot spots of LVs [32] in each of the sections to allow compari- Mean ± standard deviation (% in 6 mm 2 including accumulation of lymphatic vessels); 1 Along and around the uterine artery and its branches; 2 Along and around the superior vesical arteries and veins; 3 In the subperitoneal tissue in the broad ligament of the uterus; 4 In the paracolpium or paravaginal tissue 3-4 cm below the uterine cervix; 5 In smooth muscles of the bladder or ureter.…”

“…Recently, however, in an excellent injection study using fresh adult cadavers, Ercoli et al [3] demonstrated that the supraureteric lymphatic route along the uterine artery and superficial uterine vein plays a major and critical role in metastasis of cancer from the uterine cervix, in contrast to the infraureteric route along the deep uterine vein as well as the neural paracervical route in the nerve-rich deep part of the cardinal ligament. In fact, using D2-40 immunohistochemistry of cardinal ligament specimens removed from cervical cancer patients, Hoffman et al [8] demonstrated discontinuous micrometastases in the soft tissue around the uterine artery and superficial uterine vein and a cluster of carcinoma cells in a lymphatic vessel adjacent to the uterine artery.…”

“…Recently, Weber et al [31] confirmed similar micrometastasis in LVs in patients with endometrial cancer. Surprisingly, the injection study by Ercoli et al [3] using adult cadavers was the first of its kind and rather limited in scope. This situation is clearly different from other viscera, such as the lung and oesophagus [20], mammary gland [26] and stomach [16,23].…”