Intraoperative identification and management of renovascular anatomical variations during paraaortic lymphadenectomy: An illustrated surgical experience

Intraoperative identification and management of renovascular anatomical variations during paraaortic lymphadenectomy: An illustrated surgical experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Intraoperative identification and management of renovascular anatomical variations during paraaortic lymphadenectomy: An illustrated surgical experience Özgün Ceylan, Tuba Zengin Aksel This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8590126/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Feb, 2026 Read the published version in BMC Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose Renovascular anatomical variations pose potential surgical challenges during paraaortic lymphadenectomy (PaLA) in gynecologic oncology. This study aimed to document the prevalence and intraoperative characteristics of renovascular variations encountered during PaLA, and to describe their management through detailed photographic documentation. Methods This retrospective single-center observational study included 42 patients with gynecologic malignancies (24 endometrial, 16 ovarian, 2 cervical cancers) who underwent PaLA at Ankara, Türkiye, between February 2024 and February 2025. Procedures were performed laparoscopically (n = 20, 47.6%) or via laparotomy (n = 22, 52.4%). Patients underwent preoperative contrast-enhanced abdominal CT (slice thickness ≤ 3 mm). Renovascular variations were identified intraoperatively, photographed, and classified anatomically. Results Renovascular variations were identified in 9 patients (21.4%). Inferior polar renal arteries occurred in 5 patients (11.9%): 2 bilateral, 3 unilateral right-sided. Retroaortic left renal vein was encountered in 4 patients (9.5%). Preoperative imaging identified variations in 8 of 9 cases (88.9%), with one small-caliber artery missed on imaging. No vascular injuries occurred in cases with recognized variations. All laparoscopic cases with variations (n = 4) were completed without conversion. Conclusion Renovascular variations occurred in one-fifth of patients undergoing PaLA in this series. While preoperative imaging identified most variations, intraoperative vigilance remains essential. With careful surgical technique and anatomical awareness, these variations can be safely managed, though the small sample size limits generalizability. This series provides educational documentation for gynecologic oncologists. gynecologic oncology paraaortic lymphadenectomy polar artery retroaortic vein vascular variations Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 1. Introduction Para-aortic lymphadenectomy (PaLA) is a critical surgical procedure in the management of gynecologic malignancies, particularly for endometrial, ovarian, and selected cervical cancers. The anatomical boundaries of para-aortic lymph nodes are defined caudally by the aortic bifurcation, cranially by the left renal vein, laterally on the left by the ureter and gonadal vein, and on the right by the ureter and Gerota fascia ( 1 ). Renovascular anatomical variations (RVs) within this surgical field can significantly impact procedural safety and surgical planning. Most studies of RVs derive from autopsy series, renal transplant evaluations, or radiological analyses ( 2 – 4 ), with the classical single renal artery and vein per kidney observed in only approximately 70% of individuals ( 5 , 6 ). Renovascular variations include multiple renal veins, circumaortic left renal vein, and retroaortic left renal vein (RLRV), with prevalence ranging from 2% to 30% depending on the specific variant ( 3 , 7 – 9 ). Accessory renal arteries, including polar arteries that enter directly at the renal poles, occur in approximately 20% of cases ( 10 ). These variations, when unrecognized, may lead to inadvertent vascular injury, hemorrhage, or incomplete lymph node dissection. Despite extensive anatomical documentation, detailed intraoperative descriptions with photographic documentation in the context of gynecologic oncology surgery remain limited. This study aims to document the prevalence, anatomical characteristics, and intraoperative management of RVs encountered during PaLA in gynecologic oncology patients. Through detailed photographic documentation and descriptive analysis, we seek to enhance anatomical awareness among gynecologic oncologists and provide a visual reference for surgical planning. This single-center retrospective series represents our institutional experience and is presented with recognition of its inherent limitations in sample size and generalizability. 2. Methods 2.1. Study Design and Patient Population This retrospective, single-center, observational study was conducted at Etlik City Hospital, Ankara, Türkiye, between February 2024 and February 2025. Forty-two consecutive patients with gynecologic malignancies who underwent PaLA were included: 24 (57.1%) with high-risk endometrial cancer, 16 (38.1%) with ovarian cancer, and 2 (4.8%) with inoperable cervical cancer undergoing staging prior to chemoradiotherapy. The cervical cancer patients underwent PaLA only, without concurrent hysterectomy, resulting in shorter operative times. All procedures were performed by a single gynecologic oncology team via laparoscopy (n = 20, 47.6%) or laparotomy (n = 22, 52.4%). Surgical approach selection was based on clinical and radiological assessment and was not randomized. This study was approved by the Etlik City Hospital Ethics Committee (approval number: 02/09/2025-AEŞH-BADEK2-2025-396). All patients provided informed consent. 2.2.Preoperative Imaging Assessment All patients underwent preoperative contrast-enhanced multidetector computed tomography (MDCT) with arterial and venous phases (slice thickness ≤ 3 mm) as part of routine staging. For this study, CT images were retrospectively reviewed by two experienced radiologists (> 10 years of abdominal imaging experience) who were blinded to intraoperative findings. Each radiologist independently assessed RVs, with discrepancies resolved by consensus. The retrospective design introduces potential observer bias and may overestimate imaging sensitivity. Renovascular variations were classified using established anatomical criteria: accessory renal arteries (vessels arising from the aorta separate from the main renal artery, entering the hilum or renal poles) and RLRV (left renal vein coursing posterior to the aorta before draining into the inferior vena cava). 2.3.Intraoperative Documentation and Surgical Technique During all procedures, RVs were identified through direct visualization, preserved when feasible, and photographed using standardized protocols. The surgical technique for PaLA was standardized regardless of approach. Following bowel mobilization and peritoneal incision, dissection extended to the level of the left renal vein (or 3–4 cm above the inferior mesenteric artery when retroaortic left renal vein was suspected). Key anatomical landmarks (left renal vein, gonadal vessels, inferior mesenteric artery) were identified before lymph node dissection, with particular attention to potential polar arteries traversing the dissection field. 2.4.Statistical Analysis Given the descriptive nature of this study and the small number of patients with renovascular variations (n = 9), formal statistical hypothesis testing was not performed. Continuous variables are presented as mean ± standard deviation or median (interquartile range) as appropriate. Categorical variables are presented as frequencies and percentages. No comparative analysis between laparoscopic and open surgical approaches was conducted, as this was not a primary objective of the study and the sample size was insufficient for meaningful subgroup analysis. 3. Results 3.1. Patient Demographics and Anatomical Variations A total of 42 patients underwent PaLA during the study period. The overall median age was 60 years (range: 33–78), and median body mass index was 30 kg/m² (range: 23–45). Renovascular anatomical variations were identified in 9 patients (21.4%), comprising 5 cases (11.9%) with accessory inferior polar renal arteries and 4 cases (9.5%) with RLRV. No patient exhibited multiple concomitant variations. Patient characteristics, histologic diagnoses, surgical approaches, and identified variations are summarized in Table 1 . Table 1 Patient Characteristics and Renovascular Variations Identified During Paraaortic Lymphadenectomy Patient Age (yr) BMI (kg/m²) Histology Approach Variation Type Pt1 61 25 Serous carcinoma, uterine Lpt Inferior polar arteries, bilateral Pt2 78 31 Carcinosarcoma, uterine Ls Inferior polar arteries, bilateral Pt3 41 27 Micropapillary serous borderline, ovarian Lpt Inferior polar artery, right Pt4 57 29 Endometrioid carcinoma grade 2, endometrial Ls Inferior polar artery, right Pt5 63 32 Microinvasive seromucinous borderline, ovarian Ls Inferior polar artery, right Pt6 51 36 Endometrioid carcinoma grade 1, ovarian Lpt Retroaortic renal vein Pt7 62 30 Serous carcinoma, uterine Lpt Retroaortic renal vein Pt8 49 28 Endometrioid carcinoma grade 2, endometrial Ls Retroaortic renal vein Pt9 67 29 Serous carcinoma, uterine Lpt Retroaortic renal vein Median (Range) 61 (41–78) 29 (25–36) †. Pt:patient, Lpt: laparotomy, Ls:laparoscopy, BMI = body mass index. 3.2.Preoperative Imaging Detection Preoperative contrast-enhanced CT identified RVs in 8 of 9 cases (88.9%). One small-caliber right inferior polar artery (< 2 mm diameter) was not detected on preoperative imaging but was identified intraoperatively and preserved without injury. Among the 33 patients without RVs on imaging, no unexpected variations were encountered during surgery. Given the small sample size and retrospective design, these imaging performance metrics should be interpreted with caution. 3.3.Inferior Polar Renal Arteries Inferior polar renal arteries were observed in 5 patients (11.9%), with bilateral involvement in 2 cases and unilateral right-sided variations in 3 cases ( Figs. 1 – 5 ). The vessels originated from the anterolateral aorta below the main renal arteries and above the inferior mesenteric artery, traversing directly through the lymphadenectomy dissection field. All accessory polar arteries were successfully preserved without injury. No patient experienced postoperative renal dysfunction. 3.4.Retroaortic Left Renal Vein Retroaortic left renal vein was encountered in 4 patients (9.5%) ( Figs. 6 – 9 ). In each case, the vein coursed posterior to the aorta before draining into the inferior vena cava, typically at or below the level of the inferior mesenteric artery. In 2 cases, associated venous variants were noted: the left gonadal vein draining into the RLRV ( Fig. 7 ) and the left suprarenal vein draining into the main renal vein proximal to its retroaortic course ( Fig. 9 ). All RLRVs were successfully preserved without injury. 3.5.Perioperative Outcomes Perioperative outcomes stratified by presence of RVs are presented in Table 2 . No statistical testing was performed due to small sample size (n = 9 with variations). Table 2 Perioperative Outcomes Stratified by Presence of Renovascular Variations Parameter With RVs (n = 9) Without RVs (n = 33) Demographics Age, years 61 (41–78) 59 (33–71) BMI, kg/m² 29 (25–36) 31 (23–45) Surgical Approach Laparoscopy, n (%) 4 (44.4) 16 (48.5) Laparotomy, n (%) 5 (55.6) 17 (51.5) Operative Outcomes Total operative time, min 206.7 ± 25.0 183.6 ± 25.4 Estimated blood loss, mL 374.4 ± 90.2 344.1 ± 74.1 Para-aortic LNs removed, n 19.3 ± 3.9 17.4 ± 6.1 Intraoperative Events Vascular injury, n (%) 0 (0) 0 (0)ᵃ Conversion to laparotomy, n (%) 0 (0) 1 (3.0)ᵃ Postoperative Outcomes Hospital stay, days 4.3 ± 1.0 4.2 ± 1.2 Complications, n (%) 0 (0) 1 (3.0)ᵇ 30-day readmission, n (%) 0 (0) 1 (3.0) Data presented as median (range) for age and BMI, mean ± standard deviation for continuous outcomes, or n (%) for categorical variables. LN = lymph node; RV = renovascular variation. ᵃ One patient without RV experienced inferior vena cava injury during laparoscopic lymph node dissection, requiring conversion to laparotomy for vascular repair. ᵇ One patient without RV developed a wound infection (Clavien-Dindo grade II) requiring 30-day readmission for antibiotic therapy. c Two patients in the non-RV group underwent paraaortic lymphadenectomy only for inoperable cervical cancer staging (operative times: 110 and 120 minutes), without concurrent hysterectomy or oophorectomy. When these patients were excluded, the mean operative time in the non-RV group was 188.1 ¬± 18.7 minutes (n = 31). Mean operative time was 206.7 ± 25.0 minutes in patients with RVs versus 183.6 ± 25.4 minutes in those without (difference: 23.1 min). Two patients in the non-variation group underwent PaLA only for inoperable cervical cancer (operative times: 110 and 120 min); excluding these cases, mean operative time was 188.1 ± 18.7 minutes (n = 31, difference: 18.6 min). Mean estimated blood loss was 374.4 ± 90.2 mL versus 344.1 ± 74.1 mL (difference: 30.3 mL). Mean lymph nodes removed was 19.3 ± 3.9 versus 17.4 ± 6.1 (difference: 1.9 nodes). Mean hospital stay was 4.3 ± 1.0 versus 4.2 ± 1.2 days. No vascular injuries occurred in the 9 patients with recognized RVs. All completed their intended procedures (4 laparoscopic, 5 open) without conversion, achieving complete lymphadenectomy in all cases. One patient without variation experienced an inferior vena cava injury during laparoscopy, requiring conversion and vascular repair, with uneventful recovery. No postoperative complications occurred in the variation group. One patient without variation developed a wound infection (Clavien-Dindo grade II) requiring 30-day readmission for antibiotic therapy. 4. Discussion Paraaortic lymphadenectomy remains a cornerstone procedure in gynecologic oncology, yet RVs within the surgical field present significant technical challenges. While these variations are well-documented in anatomical and radiological literature, detailed intraoperative descriptions with photographic documentation in gynecologic oncology remain limited ( 2 , 3 ). This study provides practical documentation of RVs encountered during systematic PaLA, with emphasis on preoperative recognition and surgical management strategies. Renovascular variations were identified in 21.4% of patients, including retroaortic left renal vein in 9.5% and inferior polar renal arteries in 11.9%. Our RLRV prevalence exceeds the 3% pooled estimate from recent meta-analyses ( 2 , 3 ), likely reflecting small sample size and potential differences between surgical cohorts and autopsy-based series. Inferior polar artery prevalence aligns with reported ranges of 4–22% ( 4 , 11 ). These vessels function as end arteries without collateral circulation; injury may cause segmental renal ischemia ( 4 ). In our series, all polar arteries traversed the lymphadenectomy field, requiring careful identification and preservation to avoid vascular compromise. Preoperative contrast-enhanced CT identified 88.9% of RVs in our cohort. One small-caliber polar artery (< 2 mm) was missed, likely due to vessel size and overlapping lumbar vessels. These findings highlight inherent limitations of current imaging protocols. Emerging techniques such as three-dimensional CT angiographic reconstruction may improve detection rates, though cost-effectiveness and clinical utility require validation in larger studies. While preoperative imaging identified most variations, intraoperative vigilance remains essential, as imaging is not infallible. No vascular injuries occurred in patients with recognized RVs, contrasting with previous reports of significantly higher injury rates in patients with unidentified variants (44.4% vs 7.1%, p = 0.022 ) ( 12 ). This outcome likely reflects several protective factors: systematic exposure of anatomical landmarks before dissection (left renal vein, gonadal vessels, inferior mesenteric artery), routine modification of dissection planes when variations were encountered, preoperative imaging awareness when available, and low threshold for conversion when necessary. All procedures were performed by an experienced gynecologic oncology team; these findings cannot be extrapolated to suggest universal safety, particularly for less experienced surgeons or centers without routine preoperative imaging. This study has several important limitations. First, the small sample size (n = 42 total, n = 9 with variations) limits generalizability and precludes statistical comparison between groups. Second, the retrospective imaging review introduces potential observer bias and may overestimate diagnostic accuracy. Third, the single-center, single-team design limits applicability to broader surgical practice. Fourth, heterogeneity in surgical procedures (two patients underwent isolated PaLA for cervical cancer staging without concurrent hysterectomy) introduces confounding when comparing operative outcomes. Fifth, one vascular variation was missed on preoperative imaging, demonstrating that current protocols have inherent limitations. Finally, the descriptive nature precludes definitive conclusions about comparative safety between laparoscopic and open approaches or between patients with and without variations. Despite these limitations, our findings provide practical insights for gynecologic oncologists. Renovascular variations are encountered in approximately one-fifth of patients undergoing PaLA. Preoperative imaging can identify most but not all variations, and intraoperative vigilance remains essential. With careful surgical technique and anatomical awareness, these variations can be managed safely, though larger studies are needed to establish definitive safety benchmarks. The detailed photographic documentation provided in this series may serve as a visual reference for surgical planning and intraoperative recognition of common renovascular patterns encountered during gynecologic oncology procedures. Declarations Ethics approval and consent to participate This study was approved by the Etlik City Hospital Ethics Committee (approval number: 02/09/2025-AEŞH-BADEK2-2025-396). All patients provided written informed consent for surgical procedures and use of anonymized clinical data for research purposes. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. Consent for publication All patients provided informed consent for the publication of anonymized clinical data and de-identified intraoperative photographs for educational purposes. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Competing interests The authors declare that they have no competing interests. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Author Contribution Ö Ceylan: Project development, Data collection, Manuscript writing. TZ Aksel: Data collection Clinical trial number: not applicable References Selçuk İ, Öz M, Toyran A, Tatar İ, Engin Üstün Y, Demiryurek D. Para-aortic lymphadenectomy: step by step surgical education video. J Turkish German Gynecol Assoc. 01 Eylül 2021;22(3):253-4. Valenzuela Fuenzalida JJ, Vera-Tapia K, Urzúa-Márquez C, Yáñez-Castillo J, Trujillo-Riveros M, Koscina Z, vd. Anatomical Variants of the Renal Veins and Their Relationship with Morphofunctional Alterations of the Kidney: A Systematic Review and Meta-Analysis of Prevalence. JCM. 25 Haziran 2024;13(13):3689. Hostiuc S, Rusu MC, Negoi I, Dorobanțu B, Grigoriu M. Anatomical variants of renal veins: A meta-analysis of prevalence. Sci Rep. 25 Temmuz 2019;9(1):10802. 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Ocak 2024;251:152170. Türkvatan A, Özdemir M, Cumhur T, Ölçer T. Multidetector CT angiography of renal vasculature: normal anatomy and variants. Eur Radiol. Ocak 2009;19(1):236-44. Gulas E, Wysiadecki G, Cecot T, Majos A, Stefańczyk L, Topol M, vd. Accessory (multiple) renal arteries–Differences in frequency according to population, visualizing techniques and stage of morphological development. Vascular. 2016;24(5):531-7. Boggess JF, Gehrig PA, Cantrell L, Shafer A, Ridgway M, Skinner EN, vd. A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: robotic assistance, laparoscopy, laparotomy. American Journal of Obstetrics and Gynecology. Ekim 2008;199(4):360.e1-360.e9. Gyimadu A, Salman MC, Karcaaltincaba M, Yuce K. Retroperitoneal vascular aberrations increase the risk of vascular injury during lymphadenectomy in gynecologic cancers. Arch Gynecol Obstet. Ağustos 2012;286(2):449-55. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Feb, 2026 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 30 Jan, 2026 Reviews received at journal 29 Jan, 2026 Reviews received at journal 25 Jan, 2026 Reviewers agreed at journal 24 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers invited by journal 22 Jan, 2026 Editor invited by journal 20 Jan, 2026 Editor assigned by journal 17 Jan, 2026 Submission checks completed at journal 17 Jan, 2026 First submitted to journal 13 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8590126","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":577716818,"identity":"eee20c36-8c0e-44b7-95f6-b3a60a6940bb","order_by":0,"name":"Özgün 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11:29:10","extension":"png","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":392706,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/00f02570ab239e06ff3801c0.png"},{"id":100778881,"identity":"ba125bda-0cb4-490b-8930-f00eccb11797","added_by":"auto","created_at":"2026-01-21 11:29:21","extension":"png","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":465092,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/aa428aeb2ad09f1b274c40cc.png"},{"id":100779009,"identity":"b87f2961-83f6-4507-88ff-664b9fd05f77","added_by":"auto","created_at":"2026-01-21 11:31:46","extension":"png","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":286433,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/bb97ef706ea6a092c102d090.png"},{"id":100779270,"identity":"8bf38b73-2af6-4989-b240-15e30709ab7d","added_by":"auto","created_at":"2026-01-21 11:35:08","extension":"png","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":388186,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/08762e6b20625f0173657e8f.png"},{"id":100778646,"identity":"94b374e2-4963-4621-85e7-1313688f9996","added_by":"auto","created_at":"2026-01-21 11:26:52","extension":"xml","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":65236,"visible":true,"origin":"","legend":"","description":"","filename":"5847a85b9d7b4fdb8a41c9b29e0d326f1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/421f884ca7cef5d8d2f5b087.xml"},{"id":100779144,"identity":"2203ecff-f153-470f-b464-88df91ec51df","added_by":"auto","created_at":"2026-01-21 11:34:02","extension":"html","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75904,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/1caeebd82f5aa5048417c1ca.html"},{"id":100778811,"identity":"a3e66186-fc6d-4e0f-9dd9-9d9ee88ce9a2","added_by":"auto","created_at":"2026-01-21 11:28:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":939665,"visible":true,"origin":"","legend":"\u003cp\u003eBilateral inferior polar renal arteries in Pt1. A) Preoperative contrast-enhanced abdominal CT demonstrating bilateral inferior polar arteries, B) Intraoperative view during laparotomy.\u003c/p\u003e\n\u003cp\u003eAA: abdominal aorta, IVC: inferior vena cava, IMA: inferior mesenteric artery, LRV: left renal vein, LRA: left renal artery, LCIA: left common iliac artery, RCIA: right common iliac artery, LPA: left polar artery, RPA: right polar artery, Ur: ureter\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/a4f422c78e60bbae3a4e0485.png"},{"id":100778963,"identity":"2ec21b31-654c-4bca-9b87-3bf77252c6e9","added_by":"auto","created_at":"2026-01-21 11:30:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":532050,"visible":true,"origin":"","legend":"\u003cp\u003eBilateral inferior polar renal arteries in Pt2. A-C) Preoperative contrast-enhanced abdominal CT demonstrating bilateral inferior polar arteries, B) Intraoperative view during laparoscopy.\u003c/p\u003e\n\u003cp\u003eAA: abdominal aorta, IVC: inferior vena cava, IMA: inferior mesenteric artery, LRA: left renal artery, RRV: right renal vein, LPA: left polar artery, RPA: right polar artery, RK: right kidney, LK: left kidney\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/b5424b8258f627523c50e615.png"},{"id":100778889,"identity":"b4b62482-992c-4506-a712-91fd571f84ed","added_by":"auto","created_at":"2026-01-21 11:29:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":906683,"visible":true,"origin":"","legend":"\u003cp\u003eRight inferior polar renal artery in Pt3. A) Preoperative contrast-enhanced abdominal CT demonstrating right inferior polar artery, B) Intraoperative view during laparotomy.\u003c/p\u003e\n\u003cp\u003eAA: abdominal aorta, IVC: inferior vena cava, IMA: inferior mesenteric artery, LRV: left renal vein, CLT: common lumbar trunk, RPA: right polar artery, LCIA: left common iliac artery, RCIA: right common iliac artery, Ur: ureter\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/0bbbc56216c27e24276aeb19.png"},{"id":100778851,"identity":"b4155df9-21f6-474d-8fe1-53619ac7f769","added_by":"auto","created_at":"2026-01-21 11:28:54","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":682069,"visible":true,"origin":"","legend":"\u003cp\u003eRight inferior polar renal artery in Pt4. A) Preoperative contrast-enhanced abdominal MRI demonstrating right inferior polar artery, B) Intraoperative view during laparoscopy.\u003c/p\u003e\n\u003cp\u003eAA: abdominal aorta, IVC: inferior vena cava, IMA: inferior mesenteric artery, LRV: left renal vein, RRA: right renal artery, RPA: right polar artery, LCIA: left common iliac artery, RCIA: right common iliac artery\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/a4b5ed756e93630b3fdc9ba6.png"},{"id":100778893,"identity":"77418a36-4187-4c94-9bc7-d03a5a8dbd09","added_by":"auto","created_at":"2026-01-21 11:29:39","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":629300,"visible":true,"origin":"","legend":"\u003cp\u003eRight inferior polar renal artery in Pt5. A) Preoperative contrast-enhanced abdominal CT demonstrating right inferior polar artery, B) Intraoperative view during laparoscopy.\u003c/p\u003e\n\u003cp\u003eAA: abdominal aorta, IVC: inferior vena cava, IMA: inferior mesenteric artery, RPA: right polar artery, LCIA: left common iliac artery, RCIA: right common iliac artery\u003c/p\u003e","description":"","filename":"image5.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/8b23c2be503c32ce04733bca.png"},{"id":100778847,"identity":"e54c552d-39d2-49ba-99a9-dc14576d9183","added_by":"auto","created_at":"2026-01-21 11:28:40","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":940404,"visible":true,"origin":"","legend":"\u003cp\u003eRetroaortic left renal vein in Pt6. A) Preoperative contrast-enhanced abdominal CT demonstrating retroaortic renal vein, B) Intraoperative viewduring laparotomy.\u003c/p\u003e\n\u003cp\u003eAA: abdominal aorta, IVC: inferior vena cava, IMA: inferior mesenteric artery, LRV: left renal vein, LCIA: left common iliac artery, RCIA: right common iliac artery, RK: right kidney, LK: left kidney, Ur: ureter\u003c/p\u003e","description":"","filename":"image6.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/14c22cb08bd4be9211063a5b.png"},{"id":100778873,"identity":"04223ff2-4af7-4ea4-9e6c-8f383b8f7828","added_by":"auto","created_at":"2026-01-21 11:29:13","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":1061713,"visible":true,"origin":"","legend":"\u003cp\u003eRetroaortic left renal vein in Pt7. A) Preoperative contrast-enhanced abdominal CT demonstrating retroaortic renal vein, B) Intraoperative viewduring laparotomy.\u003c/p\u003e\n\u003cp\u003eAA: abdominal aorta, IVC: inferior vena cava, IMA: inferior mesenteric artery, LRV: left renal vein, LCIA: left common iliac artery, LCIV: left common iliac vein, RCIA: right common iliac artery, LGV: left gonadal vein, RK: right kidney, Ur: ureter\u003c/p\u003e","description":"","filename":"image7.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/f491b5d2731eaeb935eb9c14.png"},{"id":100778852,"identity":"a68de5ed-3808-4253-81e3-6fbd139d0161","added_by":"auto","created_at":"2026-01-21 11:28:55","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":591586,"visible":true,"origin":"","legend":"\u003cp\u003eRetroaortic left renal vein in Pt8. A) Preoperative contrast-enhanced abdominal CT demonstrating retroaortic renal vein, B) Intraoperative viewduring laparoscopy.\u003c/p\u003e\n\u003cp\u003eAA: abdominal aorta, IVC: inferior vena cava, IMA: inferior mesenteric artery, LRV: left renal vein\u003c/p\u003e","description":"","filename":"image8.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/6477277f41de88faa7117ef8.png"},{"id":100779142,"identity":"9a964983-0b67-470f-87ae-9c603e60d1a2","added_by":"auto","created_at":"2026-01-21 11:33:57","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":969340,"visible":true,"origin":"","legend":"\u003cp\u003eRetroaortic left renal vein in Pt9. A) Preoperative contrast-enhanced abdominal CT demonstrating retroaortic renal vein, B) Intraoperative viewduring laparotomy.\u003c/p\u003e\n\u003cp\u003eAA: abdominal aorta, IVC: inferior vena cava, IMA: inferior mesenteric artery, LRV: left renal vein, RRV: right renal vein, LGV: left gonadal vein, LRA: left renal artery, RRA: right renal artery, RK: right kidney, LK: left kidney, LSRV: left suprarenal vein\u003c/p\u003e","description":"","filename":"image9.png","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/4f24d8322cd3cac8bc473d9c.png"},{"id":103251233,"identity":"be7180d2-3cf0-4a8a-a6b0-82eea112d5d3","added_by":"auto","created_at":"2026-02-23 16:06:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":10026882,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8590126/v1/4272bea5-19a6-4646-8e50-4302dead6b4f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Intraoperative identification and management of renovascular anatomical variations during paraaortic lymphadenectomy: An illustrated surgical experience","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePara-aortic lymphadenectomy (PaLA) is a critical surgical procedure in the management of gynecologic malignancies, particularly for endometrial, ovarian, and selected cervical cancers. The anatomical boundaries of para-aortic lymph nodes are defined caudally by the aortic bifurcation, cranially by the left renal vein, laterally on the left by the ureter and gonadal vein, and on the right by the ureter and Gerota fascia (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Renovascular anatomical variations (RVs) within this surgical field can significantly impact procedural safety and surgical planning. Most studies of RVs derive from autopsy series, renal transplant evaluations, or radiological analyses (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), with the classical single renal artery and vein per kidney observed in only approximately 70% of individuals (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRenovascular variations include multiple renal veins, circumaortic left renal vein, and retroaortic left renal vein (RLRV), with prevalence ranging from 2% to 30% depending on the specific variant (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Accessory renal arteries, including polar arteries that enter directly at the renal poles, occur in approximately 20% of cases (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). These variations, when unrecognized, may lead to inadvertent vascular injury, hemorrhage, or incomplete lymph node dissection. Despite extensive anatomical documentation, detailed intraoperative descriptions with photographic documentation in the context of gynecologic oncology surgery remain limited.\u003c/p\u003e \u003cp\u003eThis study aims to document the prevalence, anatomical characteristics, and intraoperative management of RVs encountered during PaLA in gynecologic oncology patients. Through detailed photographic documentation and descriptive analysis, we seek to enhance anatomical awareness among gynecologic oncologists and provide a visual reference for surgical planning. This single-center retrospective series represents our institutional experience and is presented with recognition of its inherent limitations in sample size and generalizability.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study Design and Patient Population\u003c/h2\u003e \u003cp\u003eThis retrospective, single-center, observational study was conducted at Etlik City Hospital, Ankara, T\u0026uuml;rkiye, between February 2024 and February 2025. Forty-two consecutive patients with gynecologic malignancies who underwent PaLA were included: 24 (57.1%) with high-risk endometrial cancer, 16 (38.1%) with ovarian cancer, and 2 (4.8%) with inoperable cervical cancer undergoing staging prior to chemoradiotherapy. The cervical cancer patients underwent PaLA only, without concurrent hysterectomy, resulting in shorter operative times. All procedures were performed by a single gynecologic oncology team via laparoscopy (n\u0026thinsp;=\u0026thinsp;20, 47.6%) or laparotomy (n\u0026thinsp;=\u0026thinsp;22, 52.4%). Surgical approach selection was based on clinical and radiological assessment and was not randomized. This study was approved by the Etlik City Hospital Ethics Committee (approval number: 02/09/2025-AEŞH-BADEK2-2025-396). All patients provided informed consent.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2.Preoperative Imaging Assessment\u003c/h2\u003e \u003cp\u003eAll patients underwent preoperative contrast-enhanced multidetector computed tomography (MDCT) with arterial and venous phases (slice thickness\u0026thinsp;\u0026le;\u0026thinsp;3 mm) as part of routine staging. For this study, CT images were retrospectively reviewed by two experienced radiologists (\u0026gt;\u0026thinsp;10 years of abdominal imaging experience) who were blinded to intraoperative findings. Each radiologist independently assessed RVs, with discrepancies resolved by consensus. The retrospective design introduces potential observer bias and may overestimate imaging sensitivity. Renovascular variations were classified using established anatomical criteria: accessory renal arteries (vessels arising from the aorta separate from the main renal artery, entering the hilum or renal poles) and RLRV (left renal vein coursing posterior to the aorta before draining into the inferior vena cava).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3.Intraoperative Documentation and Surgical Technique\u003c/h2\u003e \u003cp\u003eDuring all procedures, RVs were identified through direct visualization, preserved when feasible, and photographed using standardized protocols. The surgical technique for PaLA was standardized regardless of approach. Following bowel mobilization and peritoneal incision, dissection extended to the level of the left renal vein (or 3\u0026ndash;4 cm above the inferior mesenteric artery when retroaortic left renal vein was suspected). Key anatomical landmarks (left renal vein, gonadal vessels, inferior mesenteric artery) were identified before lymph node dissection, with particular attention to potential polar arteries traversing the dissection field.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4.Statistical Analysis\u003c/h2\u003e \u003cp\u003eGiven the descriptive nature of this study and the small number of patients with renovascular variations (n\u0026thinsp;=\u0026thinsp;9), formal statistical hypothesis testing was not performed. Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (interquartile range) as appropriate. Categorical variables are presented as frequencies and percentages. No comparative analysis between laparoscopic and open surgical approaches was conducted, as this was not a primary objective of the study and the sample size was insufficient for meaningful subgroup analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Patient Demographics and Anatomical Variations\u003c/h2\u003e \u003cp\u003eA total of 42 patients underwent PaLA during the study period. The overall median age was 60 years (range: 33\u0026ndash;78), and median body mass index was 30 kg/m\u0026sup2; (range: 23\u0026ndash;45). Renovascular anatomical variations were identified in 9 patients (21.4%), comprising 5 cases (11.9%) with accessory inferior polar renal arteries and 4 cases (9.5%) with RLRV. No patient exhibited multiple concomitant variations. Patient characteristics, histologic diagnoses, surgical approaches, and identified variations are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Characteristics and Renovascular Variations Identified During Paraaortic Lymphadenectomy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge (yr)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHistology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eApproach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eVariation Type\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePt1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSerous\u0026nbsp;carcinoma, \u003cem\u003euterine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLpt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInferior polar arteries, \u003cem\u003ebilateral\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePt2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCarcinosarcoma, \u003cem\u003euterine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInferior polar arteries, \u003cem\u003ebilateral\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePt3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMicropapillary\u0026nbsp;serous\u003c/p\u003e \u003cp\u003eborderline, \u003cem\u003eovarian\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLpt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInferior polar artery, \u003cem\u003eright\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePt4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEndometrioid\u0026nbsp;carcinoma\u003c/p\u003e \u003cp\u003egrade 2, \u003cem\u003eendometrial\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInferior polar artery, \u003cem\u003eright\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePt5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMicroinvasive seromucinous\u003c/p\u003e \u003cp\u003eborderline,\u0026nbsp;\u003cem\u003eovarian\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInferior polar artery, \u003cem\u003eright\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePt6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEndometrioid carcinoma\u003c/p\u003e \u003cp\u003egrade 1, \u003cem\u003eovarian\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLpt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetroaortic renal vein\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePt7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSerous\u0026nbsp;carcinoma, \u003cem\u003euterine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLpt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetroaortic renal vein\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePt8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEndometrioid\u0026nbsp;carcinoma\u003c/p\u003e \u003cp\u003egrade 2, \u003cem\u003eendometrial\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetroaortic renal vein\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePt9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSerous\u0026nbsp;carcinoma, \u003cem\u003euterine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLpt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetroaortic renal vein\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian (Range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e61 (41\u0026ndash;78)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e29 (25\u0026ndash;36)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003e\u0026dagger;. Pt:patient, Lpt: laparotomy, Ls:laparoscopy, BMI\u0026thinsp;=\u0026thinsp;body mass index.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2.Preoperative Imaging Detection\u003c/h2\u003e \u003cp\u003ePreoperative contrast-enhanced CT identified RVs in 8 of 9 cases (88.9%). One small-caliber right inferior polar artery (\u0026lt;\u0026thinsp;2 mm diameter) was not detected on preoperative imaging but was identified intraoperatively and preserved without injury. Among the 33 patients without RVs on imaging, no unexpected variations were encountered during surgery. Given the small sample size and retrospective design, these imaging performance metrics should be interpreted with caution.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.3.Inferior Polar Renal Arteries\u003c/h2\u003e \u003cp\u003eInferior polar renal arteries were observed in 5 patients (11.9%), with bilateral involvement in 2 cases and unilateral right-sided variations in 3 cases \u003cb\u003e(\u003c/b\u003eFigs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e The vessels originated from the anterolateral aorta below the main renal arteries and above the inferior mesenteric artery, traversing directly through the lymphadenectomy dissection field. All accessory polar arteries were successfully preserved without injury. No patient experienced postoperative renal dysfunction.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.4.Retroaortic Left Renal Vein\u003c/h2\u003e \u003cp\u003eRetroaortic left renal vein was encountered in 4 patients (9.5%) \u003cb\u003e(\u003c/b\u003eFigs.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e In each case, the vein coursed posterior to the aorta before draining into the inferior vena cava, typically at or below the level of the inferior mesenteric artery. In 2 cases, associated venous variants were noted: the left gonadal vein draining into the RLRV \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e and the left suprarenal vein draining into the main renal vein proximal to its retroaortic course \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e All RLRVs were successfully preserved without injury.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.5.Perioperative Outcomes\u003c/h2\u003e \u003cp\u003ePerioperative outcomes stratified by presence of RVs are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. No statistical testing was performed due to small sample size (n\u0026thinsp;=\u0026thinsp;9 with variations).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative Outcomes Stratified by Presence of Renovascular Variations\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith RVs (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWithout RVs (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAge, years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (41\u0026ndash;78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (33\u0026ndash;71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBMI, kg/m\u0026sup2;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (25\u0026ndash;36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (23\u0026ndash;45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical Approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLaparoscopy, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (48.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLaparotomy, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (51.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative Outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTotal operative time, min\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e206.7\u0026thinsp;\u0026plusmn;\u0026thinsp;25.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e183.6\u0026thinsp;\u0026plusmn;\u0026thinsp;25.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEstimated blood loss, mL\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e374.4\u0026thinsp;\u0026plusmn;\u0026thinsp;90.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e344.1\u0026thinsp;\u0026plusmn;\u0026thinsp;74.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePara-aortic LNs removed, n\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative Events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVascular injury, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eConversion to laparotomy, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.0)ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHospital stay, days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eComplications, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.0)ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e30-day readmission, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eData presented as median (range) for age and BMI, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for continuous outcomes, or n (%) for categorical variables. LN\u0026thinsp;=\u0026thinsp;lymph node; RV\u0026thinsp;=\u0026thinsp;renovascular variation.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eᵃ One patient without RV experienced inferior vena cava injury during laparoscopic lymph node dissection, requiring conversion to laparotomy for vascular repair.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eᵇ One patient without RV developed a wound infection (Clavien-Dindo grade II) requiring 30-day readmission for antibiotic therapy.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003ec\u003c/sup\u003e \u003cem\u003eTwo patients in the non-RV group underwent paraaortic lymphadenectomy only for inoperable cervical cancer staging (operative times: 110 and 120 minutes), without concurrent hysterectomy or oophorectomy. When these patients were excluded, the mean operative time in the non-RV group was 188.1 \u0026not;\u0026plusmn; 18.7 minutes (n\u0026thinsp;=\u0026thinsp;31).\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMean operative time was 206.7\u0026thinsp;\u0026plusmn;\u0026thinsp;25.0 minutes in patients with RVs versus 183.6\u0026thinsp;\u0026plusmn;\u0026thinsp;25.4 minutes in those without (difference: 23.1 min). Two patients in the non-variation group underwent PaLA only for inoperable cervical cancer (operative times: 110 and 120 min); excluding these cases, mean operative time was 188.1\u0026thinsp;\u0026plusmn;\u0026thinsp;18.7 minutes (n\u0026thinsp;=\u0026thinsp;31, difference: 18.6 min). Mean estimated blood loss was 374.4\u0026thinsp;\u0026plusmn;\u0026thinsp;90.2 mL versus 344.1\u0026thinsp;\u0026plusmn;\u0026thinsp;74.1 mL (difference: 30.3 mL). Mean lymph nodes removed was 19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9 versus 17.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1 (difference: 1.9 nodes). Mean hospital stay was 4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 versus 4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 days.\u003c/p\u003e \u003cp\u003eNo vascular injuries occurred in the 9 patients with recognized RVs. All completed their intended procedures (4 laparoscopic, 5 open) without conversion, achieving complete lymphadenectomy in all cases. One patient without variation experienced an inferior vena cava injury during laparoscopy, requiring conversion and vascular repair, with uneventful recovery. No postoperative complications occurred in the variation group. One patient without variation developed a wound infection (Clavien-Dindo grade II) requiring 30-day readmission for antibiotic therapy.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eParaaortic lymphadenectomy remains a cornerstone procedure in gynecologic oncology, yet RVs within the surgical field present significant technical challenges. While these variations are well-documented in anatomical and radiological literature, detailed intraoperative descriptions with photographic documentation in gynecologic oncology remain limited (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This study provides practical documentation of RVs encountered during systematic PaLA, with emphasis on preoperative recognition and surgical management strategies.\u003c/p\u003e \u003cp\u003eRenovascular variations were identified in 21.4% of patients, including retroaortic left renal vein in 9.5% and inferior polar renal arteries in 11.9%. Our RLRV prevalence exceeds the 3% pooled estimate from recent meta-analyses (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), likely reflecting small sample size and potential differences between surgical cohorts and autopsy-based series. Inferior polar artery prevalence aligns with reported ranges of 4\u0026ndash;22% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). These vessels function as end arteries without collateral circulation; injury may cause segmental renal ischemia (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In our series, all polar arteries traversed the lymphadenectomy field, requiring careful identification and preservation to avoid vascular compromise.\u003c/p\u003e \u003cp\u003ePreoperative contrast-enhanced CT identified 88.9% of RVs in our cohort. One small-caliber polar artery (\u0026lt;\u0026thinsp;2 mm) was missed, likely due to vessel size and overlapping lumbar vessels. These findings highlight inherent limitations of current imaging protocols. Emerging techniques such as three-dimensional CT angiographic reconstruction may improve detection rates, though cost-effectiveness and clinical utility require validation in larger studies. While preoperative imaging identified most variations, intraoperative vigilance remains essential, as imaging is not infallible.\u003c/p\u003e \u003cp\u003eNo vascular injuries occurred in patients with recognized RVs, contrasting with previous reports of significantly higher injury rates in patients with unidentified variants (44.4% vs 7.1%, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.022\u003c/em\u003e) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This outcome likely reflects several protective factors: systematic exposure of anatomical landmarks before dissection (left renal vein, gonadal vessels, inferior mesenteric artery), routine modification of dissection planes when variations were encountered, preoperative imaging awareness when available, and low threshold for conversion when necessary. All procedures were performed by an experienced gynecologic oncology team; these findings cannot be extrapolated to suggest universal safety, particularly for less experienced surgeons or centers without routine preoperative imaging.\u003c/p\u003e \u003cp\u003eThis study has several important limitations. First, the small sample size (n\u0026thinsp;=\u0026thinsp;42 total, n\u0026thinsp;=\u0026thinsp;9 with variations) limits generalizability and precludes statistical comparison between groups. Second, the retrospective imaging review introduces potential observer bias and may overestimate diagnostic accuracy. Third, the single-center, single-team design limits applicability to broader surgical practice. Fourth, heterogeneity in surgical procedures (two patients underwent isolated PaLA for cervical cancer staging without concurrent hysterectomy) introduces confounding when comparing operative outcomes. Fifth, one vascular variation was missed on preoperative imaging, demonstrating that current protocols have inherent limitations. Finally, the descriptive nature precludes definitive conclusions about comparative safety between laparoscopic and open approaches or between patients with and without variations.\u003c/p\u003e \u003cp\u003eDespite these limitations, our findings provide practical insights for gynecologic oncologists. Renovascular variations are encountered in approximately one-fifth of patients undergoing PaLA. Preoperative imaging can identify most but not all variations, and intraoperative vigilance remains essential. With careful surgical technique and anatomical awareness, these variations can be managed safely, though larger studies are needed to establish definitive safety benchmarks. The detailed photographic documentation provided in this series may serve as a visual reference for surgical planning and intraoperative recognition of common renovascular patterns encountered during gynecologic oncology procedures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Etlik City Hospital Ethics Committee (approval number: 02/09/2025-AEŞH-BADEK2-2025-396). All patients provided written informed consent for surgical procedures and use of anonymized clinical data for research purposes. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients provided informed consent for the publication of anonymized clinical data and de-identified intraoperative photographs for educational purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026Ouml; Ceylan: Project development, Data collection, Manuscript writing. TZ Aksel: Data collection\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSel\u0026ccedil;uk İ, \u0026Ouml;z M, Toyran A, Tatar İ, Engin \u0026Uuml;st\u0026uuml;n Y, Demiryurek D. Para-aortic lymphadenectomy: step by step surgical education video. J Turkish German Gynecol Assoc. 01 Eyl\u0026uuml;l 2021;22(3):253-4. \u003c/li\u003e\n\u003cli\u003eValenzuela Fuenzalida JJ, Vera-Tapia K, Urz\u0026uacute;a-M\u0026aacute;rquez C, Y\u0026aacute;\u0026ntilde;ez-Castillo J, Trujillo-Riveros M, Koscina Z, vd. Anatomical Variants of the Renal Veins and Their Relationship with Morphofunctional Alterations of the Kidney: A Systematic Review and Meta-Analysis of Prevalence. JCM. 25 Haziran 2024;13(13):3689. \u003c/li\u003e\n\u003cli\u003eHostiuc S, Rusu MC, Negoi I, Dorobanțu B, Grigoriu M. Anatomical variants of renal veins: A meta-analysis of prevalence. Sci Rep. 25 Temmuz 2019;9(1):10802. \u003c/li\u003e\n\u003cli\u003eTardo DT, Briggs C, Ahern G, Pitman A, Sinha S. Anatomical variations of the renal arterial vasculature: An Australian perspective. J Med Imag Rad Onc. Ekim 2017;61(5):643-9. \u003c/li\u003e\n\u003cli\u003eStojadinovic D, Zivanovic-Macuzic I, Jakovcevski M, Jeremic D, Kovacevic M, Minic M. The Anatomy of Renal Arteries in Adults. Serbian Journal of Experimental and Clinical Research. 01 Haziran 2022;23(2):147-53. \u003c/li\u003e\n\u003cli\u003eSatyapal KS, Haffejee AA, Singh B, Ramsaroop L, Robbs JV, Kalideen JM. Additional renal arteries incidence and morphometry. Surg Radiol Anat. Nisan 2001;23(1):33-8. \u003c/li\u003e\n\u003cli\u003eHazirolan T, Oz M, Turkbey B, Karaosmanoglu AD, Sayan Oguz B, Canyigit M. CT angiography of the renal arteries and veins: normal anatomy and variants. Diagn Interv Radiol [İnternet]. 2009 [a.yer 21 Haziran 2025]; Erişim adresi: https://dirjournal.org/articles/doi/1305-3825.DIR.2902-09.1\u003c/li\u003e\n\u003cli\u003eDamen NS, Hostiuc S, Jianu AM, Manta BA, Rusu MC, Dobra MA. Anatomical variants of the retroaortic left renal vein. Annals of Anatomy - Anatomischer Anzeiger. Ocak 2024;251:152170. \u003c/li\u003e\n\u003cli\u003eT\u0026uuml;rkvatan A, \u0026Ouml;zdemir M, Cumhur T, \u0026Ouml;l\u0026ccedil;er T. Multidetector CT angiography of renal vasculature: normal anatomy and variants. Eur Radiol. Ocak 2009;19(1):236-44. \u003c/li\u003e\n\u003cli\u003eGulas E, Wysiadecki G, Cecot T, Majos A, Stefańczyk L, Topol M, vd. Accessory (multiple) renal arteries\u0026ndash;Differences in frequency according to population, visualizing techniques and stage of morphological development. Vascular. 2016;24(5):531-7. \u003c/li\u003e\n\u003cli\u003eBoggess JF, Gehrig PA, Cantrell L, Shafer A, Ridgway M, Skinner EN, vd. A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: robotic assistance, laparoscopy, laparotomy. American Journal of Obstetrics and Gynecology. Ekim 2008;199(4):360.e1-360.e9. \u003c/li\u003e\n\u003cli\u003eGyimadu A, Salman MC, Karcaaltincaba M, Yuce K. Retroperitoneal vascular aberrations increase the risk of vascular injury during lymphadenectomy in gynecologic cancers. Arch Gynecol Obstet. Ağustos 2012;286(2):449-55. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"gynecologic oncology, paraaortic lymphadenectomy, polar artery, retroaortic vein, vascular variations","lastPublishedDoi":"10.21203/rs.3.rs-8590126/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8590126/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eRenovascular anatomical variations pose potential surgical challenges during paraaortic lymphadenectomy (PaLA) in gynecologic oncology. This study aimed to document the prevalence and intraoperative characteristics of renovascular variations encountered during PaLA, and to describe their management through detailed photographic documentation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective single-center observational study included 42 patients with gynecologic malignancies (24 endometrial, 16 ovarian, 2 cervical cancers) who underwent PaLA at Ankara, T\u0026uuml;rkiye, between February 2024 and February 2025. Procedures were performed laparoscopically (n\u0026thinsp;=\u0026thinsp;20, 47.6%) or via laparotomy (n\u0026thinsp;=\u0026thinsp;22, 52.4%). Patients underwent preoperative contrast-enhanced abdominal CT (slice thickness\u0026thinsp;\u0026le;\u0026thinsp;3 mm). Renovascular variations were identified intraoperatively, photographed, and classified anatomically.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eRenovascular variations were identified in 9 patients (21.4%). Inferior polar renal arteries occurred in 5 patients (11.9%): 2 bilateral, 3 unilateral right-sided. Retroaortic left renal vein was encountered in 4 patients (9.5%). Preoperative imaging identified variations in 8 of 9 cases (88.9%), with one small-caliber artery missed on imaging. No vascular injuries occurred in cases with recognized variations. All laparoscopic cases with variations (n\u0026thinsp;=\u0026thinsp;4) were completed without conversion.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eRenovascular variations occurred in one-fifth of patients undergoing PaLA in this series. While preoperative imaging identified most variations, intraoperative vigilance remains essential. With careful surgical technique and anatomical awareness, these variations can be safely managed, though the small sample size limits generalizability. This series provides educational documentation for gynecologic oncologists.\u003c/p\u003e","manuscriptTitle":"Intraoperative identification and management of renovascular anatomical variations during paraaortic lymphadenectomy: An illustrated surgical experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-21 10:01:56","doi":"10.21203/rs.3.rs-8590126/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-30T05:46:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-29T22:08:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-25T22:48:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304611929319225992819037882070657941935","date":"2026-01-24T16:48:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204381320845609830552998813161561301846","date":"2026-01-23T12:34:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-23T04:58:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-20T20:18:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-17T06:28:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-17T06:28:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-01-13T09:19:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f525e2e3-09ac-4774-bc16-68a576ec82e1","owner":[],"postedDate":"January 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:03:40+00:00","versionOfRecord":{"articleIdentity":"rs-8590126","link":"https://doi.org/10.1186/s12893-026-03601-z","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-02-20 15:57:36","publishedOnDateReadable":"February 20th, 2026"},"versionCreatedAt":"2026-01-21 10:01:56","video":"","vorDoi":"10.1186/s12893-026-03601-z","vorDoiUrl":"https://doi.org/10.1186/s12893-026-03601-z","workflowStages":[]},"version":"v1","identity":"rs-8590126","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8590126","identity":"rs-8590126","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}