1641 A NEW MULTIMODALITY TECHNIQUE ACCURATELY MAPS THE PRIMARY LYMPHATIC LANDING SITES OF THE BLADDER

Abstract

You have accessJournal of UrologyBladder Cancer: Invasive/Metastatic Disease I1 Apr 20101641 A NEW MULTIMODALITY TECHNIQUE ACCURATELY MAPS THE PRIMARY LYMPHATIC LANDING SITES OF THE BLADDER Beat Roth, Michael P. Wissmeyer, Pascal Zehnder, Frédéric D. Birkhaeuser, George N. Thalmann, Thomas M. Krause, and Urs E. Studer Beat RothBeat Roth More articles by this author , Michael P. WissmeyerMichael P. Wissmeyer More articles by this author , Pascal ZehnderPascal Zehnder More articles by this author , Frédéric D. BirkhaeuserFrédéric D. Birkhaeuser More articles by this author , George N. ThalmannGeorge N. Thalmann More articles by this author , Thomas M. KrauseThomas M. Krause More articles by this author , and Urs E. StuderUrs E. Studer More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1443AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To map the primary lymphatic landing sites of the urinary bladder using a dual modality imaging approach of single photon emission computed tomography (SPECT) fused with computed tomography (CT) plus intraoperative verification by gamma probe. METHODS One day prior to surgery, flexible cystoscopy-guided injection of technetium nanocolloid into 1 of 6 defined non-tumor-bearing sites of the bladder was performed in 60 consecutive cystectomy patients under local anesthesia for preoperative detection of radioactive lymph nodes (LNs) with SPECT/CT followed by intraoperative verification with a gamma probe. Gamma probe-guided LN dissection was always followed by backup extended lymph node dissection (PLND) along the major pelvic vessels for ex vivo detection of possibly missed LNs. The SPECT/CT and intraoperative findings were used to generate a three dimensional projection of each LN site. RESULTS 284 radioactive LNs were identified (median 4 LNs per patient and site; range: 1-14). They were distributed as follows: external iliac n=86 (30%), of which 10 (12%) were situated in the fossa of Marcille; obturator fossa n=70 (25%); internal iliac n=74 (26%); common iliac n=42 (15%); para-aortic/paracaval n=11 (4%). 31 of the 74 internal iliac radioactive LNs (42%) were located medially to the internal iliac artery. 92% of all radioactive LNs were found distal and caudal to where the ureter crosses the common iliac arteries. 8% were found proximal to the uretero-iliac crossing, none without simultaneous detection of additional radioactive LNs within the ‘endopelvic' region. ‘Extended' PLND resected 92% of all primary lymphatic landing sites while ‘limited' PLND only resected 52%. CONCLUSIONS The multimodality technique with preoperative SPECT/CT plus intraoperative gamma probe detection accurately located the primary lymphatic landing sites of the bladder, showing their template to be larger than is often appreciated. PLND limited to the ventral portion of the external iliac vessels and obturator fossa removes only about 50% of all primary lymphatic landing sites, whereas ‘extended' PLND along the major pelvic vessels including the internal iliac, external iliac, obturator and common iliac region up to the uretero-iliac crossing removes about 90%. Resection cephalad to the retracted ureters appears unwarranted for reasons of both time and the unfavourable risk/benefit ratio. Bern, Switzerland© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e634 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Beat Roth More articles by this author Michael P. Wissmeyer More articles by this author Pascal Zehnder More articles by this author Frédéric D. Birkhaeuser More articles by this author George N. Thalmann More articles by this author Thomas M. Krause More articles by this author Urs E. Studer More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...