Lateral Pelvic Lymph Node Dissection for Low Locally Advanced Rectal Cancer: A Review

Lateral pelvic lymph node dissection (LPLND) for advanced low rectal cancer has generated much discussion in the literature in the last few years. Whilst it is still being debated as to whether it constitutes a locoregional disease amenable to surgery or whether it features distant metastases requiring neoadjuvant therapy, what is clear is that patients with enlarged LPLNs have higher rate of recurrence. In this review, we analyzed the current evidence and recommendations for LPLN dissection. In the case of advanced low rectal cancer (stage II-III) below the peritoneal reflection, the decision to perform LPLND depends on (1) size of the node on MRI (>5 mm) prior to neoadjuvant chemoradiotherapy and (2) non-responsive node after CRT (LPLN >5 mm before and after CRT). LPLN does prolong the operating time and cause greater blood loss, but is not associated with any greater morbidity. Preservation of the neurovascular structures, including the obturator nerves, hypogastric nerves, and the inferior vesical arteries, is essential. We also described the key steps in performing LPLND.