Abstract
PurposeTo determine the safety and feasibility of extraperitoneal laparoscopic extended lymph node dissection (LND) at the time of extraperitoneal laparoscopic radical nephroureterectomy (RNU).Materials and MethodsBetween May 2018 and March 2019, 39 patients with upper tract urothelial carcinoma (UTUC) received extraperitoneal laparoscopic RNU and concomitant extraperitoneal laparoscopic extended LND. All patients were followed for at least 90 days. Perioperative and pathological data including nodal status and perioperative complications were collected.ResultsAmong all 39 patients, 12 patients had pT1, 6 had pT2, 20 had pT3 disease, and 1 had T4 disease. The median (range) lymph node count was 10 (5–22), with 8 patients having pathologically proven lymph node metastasis. The median (range) operating time was 225 (165–430) min, and the median estimated blood loss was 200 (60–800) ml. The median postoperative hemoglobin loss was 1.6 (0–4.2) g/dl. The median (range) postoperative hospital stays were 6 (3–26) days. Overall, 7 patients experienced minor (Clavien Grade I–II) postoperative complications with five patients having Clavien Grade I complications and two patients having Clavien Grade II complications. No major complication (Clavien grade III–IV) occurred. With a median follow-up of 38 months, a total of 8 patients (20.5%) developed local or distant recurrence and no regional LNs where extended LND were performed had recurrence.ConclusionsThe present prospective study demonstrated that extraperitoneal laparoscopic extended LND during extraperitoneal laparoscopic RNU for UTUC is a feasible and safe procedure which provides minimal invasion, rapid recovery, and potentially lower risk of regional LN recurrence. Larger prospective clinical trials with survival endpoints are needed to further determine its potential therapeutic benefits.Trial RegistrationClinicalTrials.gov identifier NCT 03544437 www.clinicaltrials.gov
Highlights
Upper tract urothelial carcinoma (UTUC) is an uncommon but aggressive disease that accounts for approximately 5% to 10% of all urothelial neoplasms [1, 2]
While lymphadenectomy for UTUC has been debated with regard to its therapeutic effects, increasing evidence in literature has advocated the potential benefits of staging and treatment that retroperitoneal lymph node dissection (LND) brings to UTUCs, especially in patients with advanced UTUCs [14, 15]
It was shown that patients with clinical non-metastatic urothelial carcinoma in the renal pelvis undergoing complete lymphadenectomy could improve cancer-specific survival and recurrence-free survival compared to those with incomplete or no lymphadenectomy [18]
Summary
Upper tract urothelial carcinoma (UTUC) is an uncommon but aggressive disease that accounts for approximately 5% to 10% of all urothelial neoplasms [1, 2]. 60% of UTUCs are invasive at presentation, of which 15%–30% have involvement of regional lymph nodes at the time of surgery [2]. Lymph node metastasis is a powerful prognostic predictor for survival outcomes in UTUC [3]. It has been demonstrated that regular imaging is limited in accurately assessing nodal involvement in UTUC [4]. Standardized dissection templates of lymphadenectomy in UTUC have been inadequately defined and often left at the surgeon’s discretion in practice, which hinders the most accurate staging and brings great variation among studies exploring its benefits. Since vast lymphatic drainage routes and great variation of lymphatic spread exist in UTUC of different primary sites, extended lymphadenectomy may be needed for eradication of all potential metastasis [5, 6]. Thorough and extensive lymphadenectomy represents the most accurate staging method
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