Pelvic lymphedema: Truth or fiction?

Summary

Pelvis is a functional shell-like unit consisting of the pelvic floor and perineum. The patients, who underwent a radical operation of the pelvis due to an oncological disease, often develop pelvic disorders. These disorders do not depend on the type of surgery or any presence of postoperative treatment (radio- and chemotherapy). The reason for this is still mostly unknown. These disorders without an appropriate treatment of rehabilitation always result in the following symptoms: fatty tissue hypertrophy and fibrosis as well as functional chronic disorders. Lymphedema is described as a progressive pathological condition with retention of protein-rich liquid in the interstitial space, fatty tissue hypertrophy and fibrosis. It is possible to assume that lymphadenectomy related to pelvic surgery results in a localized lymphedema in the pelvis developing disorders of perineum and pelvic floor: a pelvic lymphedema, or rather a blind lymphedema, i.e. with symptoms but with no signs. The clinical evidence shows that the lymphatic vessels play a relevant role in the pathology of the pelvic floor and perineum. The study of pelvic lymphedema could be the key when choosing the therapies for pelvic disorders resulting from surgery.

Introduction

The increasingly higher availability of technical and scientific expertise allowed reaching excellent results in the oncological surgery, especially in pelvic surgery. In the past the evident need to cure the patient has led to impair the psycho–physical integrity of the patient performing heavy mutilations. The progresses reached with the use of new technologies in addition to the recent acquisitions in the anatomo–pathological field, allowed respecting more the physical and social function of the patient. Despite the oncological progresses obtained with the conservative techniques, a concomitant improvement in the functional aspects has not been observed [1]. A certain number of patients should cope with symptoms of functional type to avoid radical operations. These disorders do not significantly differ from the symptoms caused by the primary pelvic disease and the patient does not benefit functionally from the surgery.

Despite all the efforts performed, there is no clear evidence of the damage related to the surgery but only theory: Neuronal damage, reduced organ capacity and compliance, loss of the normal sphincter sensitivity [2]. To simplify we can state that the patient always develops a chronic pathology of the pelvic floor or perineum in the postoperative period. However, this disorder not always shows clinically detectable characteristics. Two different disorders can be currently identified: the pelvic floor syndrome for radical operations of urologic, gynaecological and proctologic type and the syndrome of anterior resection for conservative surgery of coloproctological type [1], [3]. These disorders do not seem to be related to the presence of radical or conservative surgery even in absence of concomitant medical treatments, such as radiation and chemotherapy. These problems persist for at least one year, even when the test parameters will be within the normal range [2]. The patients respond to biofeedback for the rehabilitation of the pelvic floor even with no further psychotherapy. Contrary to everybody’s belief, it is evident that, pelvis disorders in the postoperative period are a symptom and not a diagnosis! [4]. Considering the incidence of pelvis oncological disease, the related functional disorders take impressive proportions from social and economical points of view, requiring urgent answer to how and why this damage is determined. In the literature a number of hypotheses have risen in the recent years without finding any common element to which these disorders can be led. The high prevalence of frequently overlapped syndrome led me to view the existence of one unifying syndrome: Pelvic lymphedema.