Bilateral Extended Pelvic Lymph Node Research Articles

Unilateral Pelvic Lymph Node Dissection in Prostate Cancer Patients Diagnosed in the Era of Magnetic Resonance Imaging-targeted Biopsy: A Study That Challenges the Dogma.

Bilateral extended pelvic lymph node dissection at the time of radical prostatectomy is the current standard of care if pelvic lymph node dissection is indicated; often, however, pelvic lymph node dissection is performed in pN0 disease. With the more accurate staging achieved with magnetic resonance imaging-targeted biopsies for prostate cancer diagnosis, the indication for bilateral extended pelvic lymph node dissection may be revised. We aimed to assess the feasibility of unilateral extended pelvic lymph node dissection in the era of modern prostate cancer imaging. We analyzed a multi-institutional data set of men with cN0 disease diagnosed by magnetic resonance imaging-targeted biopsy who underwent prostatectomy and bilateral extended pelvic lymph node dissection. The outcome of the study was lymph node invasion contralateral to the prostatic lobe with worse disease features, ie, dominant lobe. Logistic regression to predict lymph node invasion contralateral to the dominant lobe was generated and internally validated. Overall, data from 2,253 patients were considered. Lymph node invasion was documented in 302 (13%) patients; 83 (4%) patients had lymph node invasion contralateral to the dominant prostatic lobe. A model including prostate-specific antigen, maximum diameter of the index lesion, seminal vesicle invasion on magnetic resonance imaging, International Society of Urological Pathology grade in the nondominant side, and percentage of positive cores in the nondominant side achieved an area under the curve of 84% after internal validation. With a cutoff of contralateral lymph node invasion of 1%, 602 (27%) contralateral pelvic lymph node dissections would be omitted with only 1 (1.2%) lymph node invasion missed. Pelvic lymph node dissection could be omitted contralateral to the prostate lobe with worse disease features in selected patients. We propose a model that can help avoid contralateral pelvic lymph node dissection in almost one-third of cases.

Performance of Node-RADS Scoring System for a Standardized Assessment of Regional Lymph Nodes in Bladder Cancer Patients.

Current cross-sectional imaging modalities exhibit heterogenous diagnostic performances for the detection of a lymph node invasion (LNI) in bladder cancer (BCa) patients. Recently, the Node-RADS score was introduced to provide a standardized comprehensive evaluation of LNI, based on a five-item Likert scale accounting for both size and configuration criteria. In the current study, we hypothesized that the Node-RADS score accurately predicts the LNI and tested its diagnostic performance. We retrospectively reviewed BCa patients treated with radical cystectomy (RC) and bilateral extended pelvic lymph node dissection, from January 2019 to June 2022. Patients receiving preoperative systemic chemotherapy were excluded. A logistic regression analysis tested the correlation between the Node-RADS score and LNI both at patient and lymph-node level. The ROC curves and the AUC depicted the overall diagnostic performance. In addition, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for different cut-off values (>1, >2, >3, >4). Overall, data from 49 patients were collected. Node-RADS assigned on CT scans images, was found to independently predict the LNI after an adjusted multivariable regression analysis, both at the patient (OR 3.36, 95%CI 1.68-9.40, p = 0.004) and lymph node (OR 5.18, 95%CI 3.39-8.64, p < 0.001) levels. Node-RADS exhibited an AUC of 0.87 and 0.91 at the patient and lymph node levels, respectively. With increasing Node-RADS cut-off values, the specificity and PPV increased from 57.1 to 97.1% and from 48.3 to 83.3%, respectively. Conversely, the sensitivity and NPV decreased from 100 to 35.7% and from 100 to 79.1%, respectively. Similar trends were recorded at the lymph node level. Potentially, Node-RADS > 2 could be considered as the best cut-off value due to balanced values at both the patient (77.1 and 78.6%, respectively) and lymph node levels (82.4 and 93.4%, respectively). The current study lays the foundation for the introduction of Node-RADS for the regional lymph-node evaluation in BCa patients. Interestingly, the Node-RADS score exhibited a moderate-to-high overall accuracy for the identification of LNI, with the possibility of setting different cut-off values according to specific clinical scenarios. However, these results need to be validated on larger cohorts before drawing definitive conclusions.

The Effect of a Peritoneal Iliac Flap on Lymphocele Formation After Robotic Radical Prostatectomy: Results From the PLUS Trial

To assess the effectiveness of a peritoneal flap on the formation of lymphoceles after robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection. We conducted a single surgeon, assessor blinded prospective randomized controlled trial (the Prospective Lymphocele Ultrasound Study) in men undergoing robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection. At the conclusion of the node dissection, patients were block randomized 1:1 to either standard of care (no bladder peritoneal flap) or to the creation of a bladder peritoneal flap. Lymphocele formation was assessed by pelvic ultrasound postoperatively. The primary outcome was lymphocele formation. Rates of lymphocele formation and complications were analyzed using chi-square. Other outcomes, including length of stay, number of lymph nodes removed, lymphocele volume, and quality of life measures, were analyzed by t-tests or Wilcoxon Ranked Sum Tests, as appropriate. An a priori power calculation was performed using O'Brien-Fleming alpha sharing for the interim analyses. Two preplanned interim analyses were performed when 45 and 90 patients per group had follow-up ultrasounds. A statistically significant difference in lymphocele formation was seen on the second interim analysis for 183 patients (4.3% vs. 15.6%, p=.011) stopping enrollment; this remained significant in the final analysis of 216 patients (3.6% vs 14.2%, p=.006). No other significant differences were observed. This prospective randomized trial supports the implementation of this simple modification for robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection.

Selecting lymph node-positive patients for adjuvant therapy after radical prostatectomy and extended pelvic lymphadenectomy: An outcome analysis of 100 node-positive patients managed without adjuvant therapy.

The aim of the study is to evaluate the effect of deferred androgen deprivation therapy on biochemical recurrence (BCR) and other survival parameters in node-positive prostate cancer patients after robot-assisted radical prostatectomy with bilateral extended pelvic lymph node dissection (RARP + EPLND). Of the 453 consecutive RARP procedures performed from 2011 to 2018, 100 patients with no prior use of androgen deprivation therapy were found to be lymph node (LN) positive and were observed, with initiation of salvage treatment at the time of BCR only. Patients were divided into 1 or 2 LNs (67)-and more than 2 LNs (33)-positive groups to assess survival outcomes. At a median follow-up of 21 months (1-70 months), the LN group (p < 0.000), preoperative prostate-specific antigen (PSA, p = 0.013), tumor volume (TV, p = 0.031), and LND (p = 0.004) were significantly associated with BCR. In multivariate analysis, only the LN group (p = 0.035) and PSA level (p = 0.026) were statistically significant. The estimated BCR-free survival rates in the 1/2 LN group were 37.6% (27%-52.2%), 26.5% (16.8%-41.7%), and 19.9% (9.6%-41.0%) at 1, 3, and 5 years, respectively, with a hazard of developing BCR of 0.462 (0.225-0.948) compared with the more than 2 LN-positive group. Estimated 5-year overall survival, cancer-specific, metastasis-free, and local recurrence-free survival rates were 88.4% (73.1%-100%), 89.5% (74%-100%), 65.1% (46.0%-92.1%), and 94.8% (87.2%-100.0%), respectively, for which none of the factors were significant. Based on cutoff values for PSA, TV, and LND of 30 ng/mL, 30%, and 10%, respectively, the 1/2 LN group was substratified, wherein the median BCR-free survival for the low- and intermediate-risk groups was 40 and 12 months, respectively. Nearly one fourth and one fifth of 1/2 node-positive patients were BCR-free at 3 and 5 years after RARP + EPLND. Further substratification using PSA, TV, and LN density may help in providing individualized care regarding the initiation of adjuvant therapy.

Cost-effectiveness of the implementation of [68Ga]Ga-PSMA-11 PET/CT at initial prostate cancer staging

BackgroundDespite its high specificity, PSMA PET/CT has a moderate to low sensitivity of 40–50% for pelvic lymph node detection, implicating that a negative PSMA PET/CT cannot rule out lymph node metastases. This study investigates a strategy of implementing PSMA PET/CT for initial prostate cancer staging and treatment planning compared to conventional diagnostics. In this PSMA PET/CT strategy, a bilateral extended pelvic lymph node dissection (ePLND) is only performed in case of a negative PSMA PET/CT; in case of a positive scan treatment planning is solely based on PSMA PET/CT results.MethodA decision table and lifetime state transition model were created. Quality-adjusted life years and health care costs were modelled over lifetime.ResultsThe PSMA PET/CT strategy of treatment planning based on initial staging with [68Ga]Ga-PSMA-11 PET/CT results in cost-savings of €674 and a small loss in quality of life (QoL), 0.011 QALY per patient. The positive effect of [68Ga]Ga-PSMA-11 PET/CT was caused by abandoning both an ePLND and unnecessary treatment in iM1 patients, saving costs and resulting in higher QoL. The negative effect was caused by lower QoL and high costs in the false palliative state, due to pN1lim patients (≤ 4 pelvic lymph node metastases) being falsely diagnosed as iN1ext (> 4 pelvic lymph node metastases). These patients received subsequently palliative treatment instead of potentially curative therapy.ConclusionInitial staging and treatment planning based on [68Ga]Ga-PSMA-11 PET/CT saves cost but results in small QALY loss due to the rate of false positive findings.

PD54-04 CHALLENGING THE DOGMA: SHOULD UNILATERAL PELVIC LYMPH NODE DISSECTION BE ENVISIONED IN THE MULTIPARAMETRIC PROSTATE MRI ERA?

PD54-04 CHALLENGING THE DOGMA: SHOULD UNILATERAL PELVIC LYMPH NODE DISSECTION BE ENVISIONED IN THE MULTIPARAMETRIC PROSTATE MRI ERA?

MP62-08 PROSTATE CANCER LYMPH NODE METASTASIS: HOW OFTEN IS CLOQUET’S NODE INVOLVED?

You have accessJournal of UrologyProstate Cancer: Staging I (MP62)1 Apr 2020MP62-08 PROSTATE CANCER LYMPH NODE METASTASIS: HOW OFTEN IS CLOQUET’S NODE INVOLVED? Sarah E Apatov, Ines Rivero Belenchon*, Clauda Mercader Barrull, Natalia Picola Brau, Nicole Benfante, Samson Fine, and Karim A Touijer Sarah E ApatovSarah E Apatov More articles by this author , Ines Rivero Belenchon*Ines Rivero Belenchon* More articles by this author , Clauda Mercader BarrullClauda Mercader Barrull More articles by this author , Natalia Picola BrauNatalia Picola Brau More articles by this author , Nicole BenfanteNicole Benfante More articles by this author , Samson FineSamson Fine More articles by this author , and Karim A TouijerKarim A Touijer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000937.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Located below the inguinal ligament and anterior to Cooper’s ligament, Cloquet’s node is easily accessible and commonly dissected during pelvic lymph node dissection for prostate cancer. We hypothesize that Cloquet’s node - the junction between the deep inguinal nodes and the external iliac chain – is not part of lymphatic metastatic spread of prostate cancer. METHODS: 100 consecutive high-risk prostate cancer patients underwent laparoscopic radical prostatectomy and bilateral extended pelvic lymph node dissection (PLND). During PLND, Cloquet’s node was dissected and submitted separately to pathology as right and left Cloquet’s node. Each lymph node retrieved was cut in 3 mm slices which were separately embedded in paraffin, stained with hematoxylin and eosin, and examined microscopically. RESULTS: The median PSA was 7.3 ng/mL (IQR: 4.8 – 12.8). 81% of the patients had biopsy grade group 4 or 5 and 10% had cT3 disease. 37% of the patients had lymph node metastasis. Cloquet’s node was involved in one patient only (1%), this patient had six other lymph nodes as well. CONCLUSIONS: Cloquet’s node is rarely involved in prostate cancer. Even in high-risk prostate cancer, Cloquet’s node removal should not be the principal focus of the lymph node dissection. Source of Funding: No funding © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e948-e948 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sarah E Apatov More articles by this author Ines Rivero Belenchon* More articles by this author Clauda Mercader Barrull More articles by this author Natalia Picola Brau More articles by this author Nicole Benfante More articles by this author Samson Fine More articles by this author Karim A Touijer More articles by this author Expand All Advertisement PDF downloadLoading ...

Robotic Radical Cystectomy with Intracorporeal Studer Pouch Formation for Bladder Cancer: Experience in Ninety-Eight Cases

Aim: To report the outcomes of robot-assisted radical cystectomy (RARC) with bilateral extended pelvic lymph node dissection (BEPLND) and intracorporeal Studer pouch formation for bladder cancer. Materials and Methods: Overall 98 patients (92 males, 6 females) were included. Patient demographics, operative and postoperative variables, pathological parameters, complications, and functional outcomes were evaluated. Results: Mean age and American Society of Anesthesiologists score and body mass index were 60.9 years, 1.7 and 26 kg/m2, respectively. Neoadjuvant chemotherapy was given to 18 patients. Mean operation time, intraoperative estimated blood loss, and mean lymph node (LN) yield were 8.22 hours, 314.6 mL, and 28.3, respectively. Mean hospitalization time was 13.6 days. There were one perioperative and one postoperative deaths, both due to cardiac arrest on postoperative 21st and 60th days. Drains were removed at a mean of 10 days. Surgical margins were positive in two patients. Postoperative pathological stages were reported as pT0 (n = 21), pTis (n = 7), pT1 (n = 7), pT2a (n = 14), pT2b (n = 14), pT3a (n = 15), pT3b (n = 11), and pT4a (n = 9). Positive LNs were found in 21 patients. Prostate cancer was incidentally detected in 23 patients. Twenty-five patients received adjuvant chemotherapy. At a mean follow-up period of 25.1 months, 13 patients died from metastatic disease and 7 from cardiac disease. According to the modified Clavien-Dindo system, 30 minor and 20 major complications were identified in the perioperative (0-30 days) period, and 6 minor and 7 major complications were detected in the postoperative (31-90 days) period. According to the available data of the 60 patients, 37 were fully continent, 14 had mild, 6 had moderate, and 4 had severe daytime incontinence. Conclusions: Due to our experience, RARC with BEPLND and intracorporeal Studer pouch reconstruction procedures are complex procedures with acceptable morbidity, excellent surgical and pathological outcomes, and satisfactory oncologic and functional results.

Four-point Peritoneal Flap Fixation in Preventing Lymphocele Formation Following Radical Prostatectomy

BackgroundSymptomatic lymphocele following radical prostatectomy (RP) and concomitant bilateral extended pelvic lymph node dissection (ePLND) has a significant impact on postoperative recovery and may sometimes require surgical intervention. ObjectiveTo report on the use of four-point peritoneal flap fixation (4PPFF) during RP to reduce lymphocele occurrence following PLND. Design, setting, and participantsBetween April 2010 and May 2017, 1358 patients underwent RP with concomitant bilateral ePLND. From this cohort, 193 patients who had undergone PNLD with 4PPFF were matched in a 1:1 ratio with respect to age, body mass index, initial PSA, and number of lymph nodes removed to patients who had undergone PLND without 4PPFF. Intervention4PPFF was performed by suturing the cut end of the ventral parietal peritoneum at four points (to the anterior and lateral pelvic side wall on both sides) following PLND so that the peritoneal surface was exposed to the iliac vessels and obturator fossa. Outcome measurements and statistical analysisAll patients underwent ultrasound on postoperative days 6, 28, and 90 to test for the presence of lymphocele. For univariate analysis, a χ2 test and analysis of variance were applied, as appropriate. Statistical significance was set at p<0.05, and all p values reported were two-sided. Results and limitationsThere were no significant differences between the two groups with respect to intraoperative blood loss, positive surgical margin rate, Gleason score, clinical stage, and number of positive cores. Asymptomatic lymphocele was observed in four patients (2.07%) in the 4PPFF group compared to 16 patients (8.3%) without 4PPFF (p=0.0058). Similarly, a significant difference in the incidence of symptomatic lymphocele was observed: two patients (1.03%) in the 4PPFF group versus nine patients (4.6%) without 4PPFF (p=0.0322). There were no differences in other complication rates between the two groups. The limitations of the study are its retrospective and nonrandomised nature, with postoperative follow-up based on ultrasound imaging rather than computed tomography because of ethical considerations, which could have caused observer bias. Conclusions4PPFF is a safe and effective procedure in preventing lymphocele occurrence in patients undergoing RP with PLND. The increase in exposure of the PLND raw area to the peritoneal surface following this procedure may aid in increased absorption of accumulating lymph fluid. Further prospective randomised multicentre studies are warranted to confirm our observations. Patient summaryWe report on the use of a surgical technique to decrease the collection of lymphatic fluid in the abdominal cavity following lymph node removal during radical removal of the prostate gland in patients with prostate cancer. Patients undergoing this procedure had significantly better outcomes when compared to patients operated on in the conventional approach.

Robotic radical perineal cystectomy and extended pelvic lymphadenectomy: initial investigation using a purpose-built single-port robotic system.

To assess the feasibility of radical perineal cystoprostatectomy using the latest generation purpose-built single-port robotic surgical system. In two male cadavers the da Vinci® SP1098 Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) was used to perform radical perineal cystoprostatectomy and bilateral extended pelvic lymph node dissection (ePLND). New features in this model include enhanced high-definition three-dimensional optics, improved instrument manoeuvrability, and a real-time instrument tracking and guidance system. The surgery was accomplished through a 3-cm perineal incision via a novel robotic single-port system, which accommodates three double-jointed articulating robotic instruments, an articulating camera, and an accessory laparoscopic instrument. The primary outcomes were technical feasibility, intraoperative complications, and total robotic operative time. The cases were completed successfully without conversion. There were no accidental punctures or lacerations. The robotic operative times were 197 and 202 min. In this preclinical model, robotic radical perineal cystoprostatectomy and ePLND was feasible using the SP1098 robotic platform. Further investigation is needed to assess the feasibility of urinary diversion using this novel approach and new technology.

Sexual Sparing Robot-Assisted Radical Cystectomy in Female: Technique Step-by-Step

Introduction and Objective: Anterior pelvic exenteration is often synonym of radical cystectomy (RC) in women, including removal of bladder, urethra, ovaries, fallopian tubes, uterus, and part of the vagina. However, preservation of the gynecologic organs is possible in selected women. After 100 minimally invasive RCs (60 laparoscopic and 40 robotic), we describe the technique of “Sexual-sparing robot-assisted radical cystectomy” (RARC) in a female. Methods: Sexual sparing RC is offered to sexually active, relatively young women affected by low stage clinical localized muscle-invasive bladder cancer (≤T2b, N0, M0), unifocal tumor away from bladder base, and with free internal genital organs. We report the technique of RARC in a female with preservation of genital organs. Results: A four robotic arm configuration is adopted. A bilateral extended pelvic lymph node dissection is performed: the proximal limit is the ureter cross over the common iliac a.; laterally the genitofemural-n. and psoas m.; caudally Cloquet's node; and medially peritoneal sheet, umbilical a. and lateral edge of the bladder. Ureters are dissected down to the ureterovesical junction at level of uterine a. crossing. Ureters are divided and distal ureteral margins are sent bilaterally for frozen section. Vascular pedicles are sealed and sectioned with articulable vessel sealing forceps (Caiman Vessels Sealers; Aesculpa BBraun) or ultrasonic forceps (SonoSurg G2; Olympus). Space between the uterus and the bladder is dissected. A vaginal spatula facilitates dissection along the vaginal wall. The anterior vagina is opened and the plane between the vagina and the bladder is developed. A limited portion of anterior vaginal wall close to the trigone is resected en bloc with the bladder 1 cm above the bladder neck. Dissection is performed along the anterolateral paravaginal plane, no further dorsal than the 2 or 10 o'clock position to preserve the paravaginal fibers and nerves. The bladder is taken down with monopolar cautery. The urethra is identified and dissected. The catheter is removed and a clip is placed to avoid tumor spillage before urethra transection. Retrieval bag is inserted through the vagina opening and bladder is removed under vision. Vagina is then closed in two continuous layers. Conclusions: Sexual sparing RARC performed when possible with orthotopic neobladder offers intact body image and lowers decrease of sexual function and normal voiding function. Those elements play an extremely important role on patient's psychology, sexuality, and potential fertility. Robotic surgery is the perfect tool to perform such a complex minimally invasive technique. No competing financial interests exist. Runtime of video: 7 mins

Laparoscopic radical cystectomy - initial experience

Introduction: Radical cystectomy with extended pelvic lymph node dissection is the standard treatment for muscle-invasive bladder cancer. The aim of this study is to report our initial experience of our series of 22 patients who underwent laparoscopic radical cystectomy with different urinary diversion. M aterials and Methods: Between March 2015 and March 2016, 22 patients underwent laparoscopic radical cystectomy with different types of extracorporeal urinary diversion. Patients were aged 54 to 85 (average age 66.3) with different clinical stages of the disease. Transperitoneal laparoscopic radical cystectomy with five ports in all cases was performed with bilateral extended pelvic lymph node dissection. Results: In 5 cases we performed radical cystectomy with subsequent ureterocutaneostomy, in 7 cases we performed ileal conduit according to the method of Bricker, and in 10 cases we formed orthotopic bladder from ileal loop by the method of Hautmann. All operations were performed with an average blood loss of 270 ml, with an average operating time of 5 hours, and an average hospital stay of 7 days. No conversion was required in any case. The patients were observed postoperatively. Early complications (within 30 days) occurred in 2 patients, and late complications occurred in 3 patients. Conclusion: Laparoscopic radical cystectomy is possible, although technically difficult, with significant reduction in patient morbidity. With more experience and an improvement of the surgical technique, laparoscopic radical cystectomy with different types of derivation becomes an alternative surgical method for treating patients with localised muscle invasive bladder carcinoma.

Combined Extraperitoneal and Transperitoneal Laparoscopic Extended Partial Cystectomy for the Treatment of Urachal Carcinoma.

To evaluate the application of laparoscopic extended partial cystectomy (PC) and bilateral extended pelvic lymph node dissection (PLND) for the treatment of urachal carcinomas (UrCs). Combined laparoscopic extended PC and bilateral extended PLND was performed in 16 cases with UrCs in our hospital between April 2009 and December 2012. The surgical procedure included the dilation of the extraperitoneal space, circumscription of the umbilicus, dissection from the umbilicus caudad to the dome of the bladder, excision of the tumor, and the suture of the bladder. The average age of the patients was 52.8 years (35-73 years). The average tumor size was 3.2 cm (1.5-5.6 cm). A median follow-up period of 36 months was obtained to evaluate patient survival and recrudescence. All 16 procedures were completed laparoscopically without open conversion. The median operation time was 85 minutes (65-125 minutes), with a median estimated blood loss of 50 mL (30-110 mL). The median hospital stay was 5 days (4-7 days). The bladder margins were negative in all cases. However, five cases were confirmed postoperatively with positive lymph nodes. No intraoperative or postoperative complications occurred. Histopathology confirmed mucous urachal adenocarcinoma in 11 cases, mixed carcinoma in 1 case, and papillary adenocarcinoma in 4 cases. After a median follow-up period of 36 months, the 2- and 3-year survival rates were 62.5% (10/16) and 50% (8/16), respectively. Combined laparoscopic extended PC and bilateral extended PLND is a safe and feasible method for treating patients with urachal malignancy.

Robotic Radical Cystectomy—Is the Diversion the Achilles' Heel?

No AccessJournal of UrologyOpposing Views1 Dec 2014Robotic Radical Cystectomy—Is the Diversion the Achilles' Heel? Richard E. Hautmann, Harry W. Herr, Raj S. Pruthi, and Monish Aron Richard E. HautmannRichard E. Hautmann More articles by this author , Harry W. HerrHarry W. Herr More articles by this author , Raj S. PruthiRaj S. Pruthi More articles by this author , and Monish AronMonish Aron More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.09.042AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail References 1 : Propensity-matched comparison of morbidity and costs of open and robot-assisted radical cystectomies: a contemporary population-based analysis in the United States. Eur Urol2014; . Epub ahead of print. Google Scholar 2 : A randomized trial of robot-assisted laparoscopic radical cystectomy. New Engl J Med2014; 371: 389. Google Scholar 3 : Selection of intestinal segments for bladder substitution: physical and physiological characteristics. J Urol1988; 139: 519. Link, Google Scholar 4 : Surgery in motion: robotic-assisted laparoscopic intracorporeal urinary diversion. Eur Urol2010; 57: 1013. Google Scholar 5 : Robot-assisted nerve-sparing radical cystectomy with bilateral extended pelvic lymph node dissection (PLND) and intracorporeal urinary diversion for bladder cancer: initial experience in 27 cases. BJU Int2011; 110: 434. Google Scholar 6 : Oncologic, functional, and complications outcomes of robotic-assisted radical cystectomy with totally intracorporeal neobladder diversion. Eur Urol2013; 64: 734. Google Scholar 7 : Laparoscopic-assisted radical cystectomy with U-shaped orthotopic ileal neobladder constructed using nonabsorbable titanium staples. Urology2006; 68: 193. Google Scholar 8 : The ileal neobladder: experience and results of more than 100 consecutive cases. J Urol1990; 143: 492. Abstract, Google Scholar 9 : Orthotopic bladder substitution in men. revisited: identification of continence predictors. J Urol2006; 176: 2081. Link, Google Scholar 10 : Robotic intracorporeal orthotopic ileal neobladder: replicating open surgical principles. Eur Urol2012; 62: 891. Google Scholar 11 : Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int2003; 92: 232. Google Scholar 12 : Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results. Eur Urol2010; 57: 196. Google Scholar 13 : Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. J Urol2013; 189: 474. Link, Google Scholar 14 : Robotic intracorporeal urinary diversion: ileal conduit. J Endourol2012; 26: 1566. Google Scholar 15 : The first 100 consecutive, robot-assisted, intracorporeal ileal conduits: evolution of technique and 90-day outcomes. Eur Urol2013; 63: 637. Google Scholar 16 : Robotic intracorporeal orthotopic neobladder during radical cystectomy in 132 patients. J Urol2014; 192: 1734. Link, Google Scholar 17 : Analysis of intracorporeal compared with extracorporeal urinary diversion after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol2014; 65: 340. Google Scholar © 2014 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byHautmann R (2017) Declining Use of Orthotopic Reconstruction Worldwide—What Went Wrong?Journal of Urology, VOL. 199, NO. 4, (900-903), Online publication date: 1-Apr-2018.Hautmann R (2016) Editorial CommentJournal of Urology, VOL. 196, NO. 5, (1556-1557), Online publication date: 1-Nov-2016. Volume 192Issue 6December 2014Page: 1601-1603 Advertisement Copyright & Permissions© 2014 by American Urological Association Education and Research, Inc.MetricsAuthor Information Richard E. Hautmann More articles by this author Harry W. Herr More articles by this author Raj S. Pruthi More articles by this author Monish Aron More articles by this author Expand All Advertisement PDF downloadLoading ...

Delayed massive hemorrhage due to external iliac artery pseudo-aneurysm and uretero-iliac artery fistula following robotic radical cystectomy and intracorporeal Studer pouch reconstruction: endovascular management of an unusual complication

We report a very unusual complication of uretero-iliac artery fistula that developed following robotic radical cystectomy (RARC), bilateral extended pelvic lymph node dissection and intracorporeal Studer pouch reconstruction. Our patient was a 54-year-old male who was admitted 1 month after undergoing robotic surgery due to intermittently occurring massive transurethral bleeding necessitating blood transfusion that stopped by itself. Angiography showed a right external iliac artery pseudo-aneurysm and a fistula tract between the pseudo-aneurysm and Wallace type ureteral anostomosis that was successfully treated by an angiographic endovascular stent insertion at this level. Uretero-iliac artery fistula might occur following RARC, bilateral extended pelvic lymph node dissection and intracorporeal Studer pouch reconstruction leading to intermittently massive transurethral bleeding. Angiography and stenting are important for diagnosis and successful treatment of this rare entity.

Commentary on “Carboplatin based induction chemotherapy for nonorgan confined bladder cancer—a reasonable alternative for cisplatin unfit patients?” Mertens LS, Meijer RP, Kerst JM, Bergman AM, van Tinteren H, van Rhijn BW, Horenblas S, Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands: J Urol 2012;188(4):1108-13 [Epub 2012 Aug 15

PurposeWe investigated induction carboplatin based chemotherapy in patients with nonorgan confined urothelial carcinoma who were considered unfit for cisplatin. A comparison was made with patients who received induction cisplatin based combination chemotherapy. Materials and methodsWe identified 167 patients with nonorgan confined urothelial carcinoma who received induction cisplatin based combination chemotherapy (126) or gemcitabine and carboplatin (41) at our hospital between 1990 and 2010. Of the patients 124 completed 4 cycles of cisplatin based combination chemotherapy or gemcitabine and carboplatin. Clinical response (ycTNM) was evaluated according to RECIST (Response Evaluation Criteria in Solid Tumors) 1.1. Radical cystectomy and bilateral extended pelvic lymph node dissection were performed in 106 patients. A pathological complete response was defined as no evidence of disease (ypT0N0). Disease specific survival was analyzed using the Kaplan-Meier method. Multivariate analysis was performed. ResultsComplete clinical response rates did not differ significantly among the treatment groups. A pathological complete response was seen in 33.7% of specimens in the cisplatin based combination chemotherapy group vs 30.3% in the gemcitabine and carboplatin group (p = 0.808). We found no significant difference in disease specific survival between patients who started cisplatin based combination chemotherapy and those who started gemcitabine and carboplatin. For patients who completed 4 cycles and underwent radical cystectomy there was also no significant difference in disease specific survival between the groups. On multivariate analysis a pathological complete response was the only variable significantly associated with disease specific survival (p<0.045). ConclusionsInduction gemcitabine and carboplatin for nonorgan confined urothelial carcinoma achieves clinical and pathological response rates, and survival outcomes comparable to those of the cisplatin based combination chemotherapy schemes. Our data suggest that a carboplatin based regimen can be considered a reasonable alternative for cisplatin unfit patients in the preoperative setting.

The Use of a Laparoscopic Bulldog Clamp to Control the Dorsal Vein Complex During Robot-Assisted Radical Prostatectomy: A Novel Technique

To describe a novel technique to control dorsal vein complex (DVC) during robot-assisted radical prostatectomy (RARP). We have been using a laparoscopic bulldog clamp to control DVC before apical dissection and urethral division. Data of 50 patients who underwent DVC control with laparoscopic bulldog clamp (group 1) were retrospectively compared with 50 consecutive patients in whom DVC was controlled with suture ligation (group 2). In the bulldog and suture groups, 30 and 31 patients underwent concomitant bilateral extended pelvic lymph node dissection (PLND), respectively. Operative and anastomosis time, estimated blood loss (EBL), apical surgical margin positivity, and early continence rates were evaluated. Patients in the bulldog group had significantly shorter operative time compared with patients in the suture group (146.8 vs 178.4 min, P=0.0005). Anastomosis time was significantly shorter in the bulldog group (12.3 vs 15.5 min, P=0.002). There was no difference in EBL between the groups (185 vs 184.2 mL). Immediate, postoperative first and third month continence rates were 62% vs 44%, 74% vs 60%, 90% vs 74% in groups 1 and 2, respectively. Although continence rates were better in favor of the bulldog group at each evaluation period, the difference did not reach statistical difference. None of the patients in both groups had apical surgical margin positivity. The use of a laparoscopic bulldog clamp to control DVC was associated with shorter operation and anastomosis time and a trend toward quicker recovery of continence. This technique provides clear vision during apical dissection and urethral division while potentially minimizing the external sphincteric trauma. Prospective randomized trials are needed for better evaluation of this technique.

Carboplatin Based Induction Chemotherapy for Nonorgan Confined Bladder Cancer—A Reasonable Alternative for Cisplatin Unfit Patients?

We investigated induction carboplatin based chemotherapy in patients with nonorgan confined urothelial carcinoma who were considered unfit for cisplatin. A comparison was made with patients who received induction cisplatin based combination chemotherapy. We identified 167 patients with nonorgan confined urothelial carcinoma who received induction cisplatin based combination chemotherapy (126) or gemcitabine and carboplatin (41) at our hospital between 1990 and 2010. Of the patients 124 completed 4 cycles of cisplatin based combination chemotherapy or gemcitabine and carboplatin. Clinical response (ycTNM) was evaluated according to RECIST (Response Evaluation Criteria in Solid Tumors) 1.1. Radical cystectomy and bilateral extended pelvic lymph node dissection were performed in 106 patients. A pathological complete response was defined as no evidence of disease (ypT0N0). Disease specific survival was analyzed using the Kaplan-Meier method. Multivariate analysis was performed. Complete clinical response rates did not differ significantly among the treatment groups. A pathological complete response was seen in 33.7% of specimens in the cisplatin based combination chemotherapy group vs 30.3% in the gemcitabine and carboplatin group (p = 0.808). We found no significant difference in disease specific survival between patients who started cisplatin based combination chemotherapy and those who started gemcitabine and carboplatin. For patients who completed 4 cycles and underwent radical cystectomy there was also no significant difference in disease specific survival between the groups. On multivariate analysis a pathological complete response was the only variable significantly associated with disease specific survival (p <0.045). Induction gemcitabine and carboplatin for nonorgan confined urothelial carcinoma achieves clinical and pathological response rates, and survival outcomes comparable to those of the cisplatin based combination chemotherapy schemes. Our data suggest that a carboplatin based regimen can be considered a reasonable alternative for cisplatin unfit patients in the preoperative setting.

528 CARBOPLATIN-BASED NEOADJUVANT CHEMOTHERAPY: A REASONABLE ALTERNATIVE FOR CISPLATIN UNFIT PATIENTS?

You have accessJournal of UrologyUrothelial Cancer: Medical & Surgical Therapy1 Apr 2012528 CARBOPLATIN-BASED NEOADJUVANT CHEMOTHERAPY: A REASONABLE ALTERNATIVE FOR CISPLATIN UNFIT PATIENTS? Laura Mertens, Richard Meijer, Bas van Rhijn, Andries Bergman, Martijn Kerst, and Simon Horenblas Laura MertensLaura Mertens Amsterdam, Netherlands More articles by this author , Richard MeijerRichard Meijer Amsterdam, Netherlands More articles by this author , Bas van RhijnBas van Rhijn Amsterdam, Netherlands More articles by this author , Andries BergmanAndries Bergman Amsterdam, Netherlands More articles by this author , Martijn KerstMartijn Kerst Amsterdam, Netherlands More articles by this author , and Simon HorenblasSimon Horenblas Amsterdam, Netherlands More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.601AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Carboplatin has not been investigated as alternative to cisplatin-based regimens in the neoadjuvant setting. We investigated the feasibility of neoadjuvant carboplatin-based chemotherapy in patients with non-organ confined urothelial carcinoma (UC) who are considered unfit for cisplatin. We analyzed the clinical and pathological response and survival of patients who were treated with a neoadjuvant combination of gemcitabine and carboplatin (Gem/Carbo). A comparison was made to patients who received neoadjuvant MVAC. METHODS We identified 152 patients (mean age: 59.9±9.4 years) with non-organ confined UC (T3-T4a and/or N+), who received neoadjuvant MVAC (n=111) or Gem/Carbo (n=41) at our hospital, between 2001-2011. One hundred and fourteen patients completed four cycles of MVAC or Gem/Carbo. Clinical post-chemotherapy status (ycTNM) was evaluated according to RECIST 1.1. A radical cystectomy (RC) and bilateral extended pelvic lymph node dissection (ePLND) was performed in 98 patients (MVAC: 75, Gem/Carbo: 23). Pathological complete response (pCR) was defined as no evidence of disease (ypT0N0); partial response as any downstaging from the baseline. Recurrence free survival (RFS) and overall survival (OS) were analysed using the Kaplan-Meier method. A multivariable analysis was performed. RESULTS Both groups had comparable baseline tumour characteristics. Complete clinical response rates did not differ significantly among the treatment groups. Moreover, pCR was found in the specimens of 25 patients (33.3%) in the MVAC group versus 7 (30,4%) in the Gem/Carbo group (P=0.795). Any downstaging from the baseline was seen in 70.7% (MVAC) versus 60.9% (GemCarbo) (P=0.444). RFS did not significantly differ between both treatment groups (log-rank, P = 0.715). Median OS was 22.0±8.4 months among patients in the MVAC group and 22.0±4.5 months among patients in the Gem/Carbo group. (log-rank, P = 0.328). In the multivariate analysis, pCR was the only variable with a significant influence on clinical outcome (P<0.05). CONCLUSIONS Neoadjuvant Gem/Carbo for non-organ confined UC achieves comparable clinical and pathological response rates as well as overall survival to the MVAC schemes. Our data suggest that a carboplatin-based regimen can be considered a reasonable alternative for cisplatin unfit patients in the neoadjuvant setting. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e217 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Laura Mertens Amsterdam, Netherlands More articles by this author Richard Meijer Amsterdam, Netherlands More articles by this author Bas van Rhijn Amsterdam, Netherlands More articles by this author Andries Bergman Amsterdam, Netherlands More articles by this author Martijn Kerst Amsterdam, Netherlands More articles by this author Simon Horenblas Amsterdam, Netherlands More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robot‐assisted nerve‐sparing radical cystectomy with bilateral extended pelvic lymph node dissection (PLND) and intracorporeal urinary diversion for bladder cancer: initial experience in 27 cases

• To report the outcomes of 27 patients whom we performed robot-assisted radical cystoprostatectomy and cystectomy (RARC) with intracorporeal urinary diversion (Studer pouch and ileal conduit) for bladder cancer. • Between December 2009 and December 2010, we performed RARC in 25 men (intrafascial bilateral [22], unilateral [one], non-neurovascular bundle [NVB] sparing [two]), NVB-sparing RARC with anterior pelvic exenteration in two women, bilateral extended robot-assisted pelvic lymph node dissection (RAPLND) (25), intracorporeal Studer pouch (23), ileal conduit (two), and extracorporeal Studer pouch (two) construction. • Patient demographics, operative and postoperative variables, pathological variables, complications (according to modified Clavien system) and functional outcomes were evaluated. • The mean (sd, range) operative duration, intraoperative estimated blood loss and mean lymph node (LN) yield were 9.9 (1.4, 7.1-12.4) h, 429 (257, 100-1200) mL and 24.8 (9.2, 8-46), respectively. • The mean (sd, range) hospital stay was 10.5 (6.8, 7-36) days, there was one perioperative death (3.7%), lodge drains were removed at a mean of 11.3 (5.6, 9-35) days and surgical margins were negative in all but one patient who had pT4b disease. • The postoperative pathological stages were: pT0 (five), pTis (one), pT1 (one), pT2a (five), pT2b (three), pT3a (six), pT3b (two), pT4a (three) and pT4b (one). • Positive LNs and incidental prostate cancer were detected in six and nine patients, respectively and at a mean follow-up of 6.3 (2.9, 1.8-11.3) months, three patients died from metastatic disease and one from cardiac disease. • According to the modified Clavien system, there were nine minor (Grade 1 and 2) and four major (Grade 3-5) complications in the perioperative (0-30 days) period; four minor and three major complications in the postoperative (31-90 days) period. Of the available 18 patients, 11 were fully continent, four had mild and two had severe day-time incontinence. • Bilateral NVB-sparing RARC with RAPLND and intracorporeal Studer pouch or ileal conduit reconstruction are complex procedures with acceptable morbidity, excellent short-term surgical and pathological outcomes and satisfactory functional results. • Studies with more patients and longer follow-ups are required to evaluate the feasibility of these RA totally intracorporeal complex procedures.