Extended Pelvic Lymphadenectomy Research Articles

Preperitoneal vas deferens infiltration in high-risk prostate cancer.

The objective of this study is to evaluate the prevalence and the importance of preperitoneal vas deferens (VD) infiltration in high-risk prostate cancer (PCa). In this prospectively designed study, we included 332 high-risk PCa patients with a Briganti score >5%, who were treated by robot-assisted radical prostatectomy between July 2017 and February 2022 at the Urology Department, SLK Kliniken Heilbronn. In addition to the standard histological analysis of the distal VD, which was attached to the prostate specimen, we analysed the infiltration status of preperitoneal VD in this cohort. The preperitoneal VD, which represents the middle part of ductus deferens and extends between the internal inguinal ring and obturator fossa, was resected during extended pelvic lymphadenectomy. Distal and preperitoneal VD status was registered together with preoperative and postoperative disease characteristics. Descriptive analysis methods and logistic regression analysis were used. Briganti score of the target cohort had a median value of 19%, while 235 patients (70.8%) of the group demonstrated a locally advanced disease. The Grade Group at prostatectomy specimen was at least 3 for 286 patients (86.1%). Distal VD infiltration was found in 20 patients (6%) and preperitoneal VD infiltration in two patients (0.6%). Distal VD infiltration was not associated with an increased possibility for positive surgical margins or nodal status among pT3b patients, while both patients with preperitoneal VD infiltration were characterized by highly aggressive disease in locally advanced stage and bilateral distal VD infiltration. PCa extension along VD may reach a more proximal point of VD than the reported from the existing data infiltration of VD adjacent to seminal vesicles. This rare manifestation of PCa local extension may be the intermediate step to the rare cases of recurrence in the testicles. However, more robust data are needed to confirm the aforementioned hypothesis. Distal VD infiltration seems to have no additional prognostic value among patients with infiltrated seminal vesicles.

Can contralateral lymph-node metastases be ruled out in prostate cancer patients with only unilaterally positive prostate biopsy?

PurposeOur study evaluated the diagnostic benefits of bilateral pelvic lymphadenectomy in prostate cancer patients with unilaterally positive prostate biopsy.MethodsOur retrospective analysis included clinical, surgical, and histopathological data of 440 prostate cancer patients treated with radical prostatectomy and bilateral sentinel-guided and risk-adapted complementary extended pelvic lymphadenectomy at our hospital between 2015 and 2022. We performed multiparametric logistic regression analysis to identify the most relevant predictive factors for detecting lymph-node metastasis in this group of patients.ResultsOverall, 373 patients (85%) had histopathologically bilateral tumours and 45 (10%) pN1 status, of which 22 (49%) also had lymph-node metastasis contralateral to the side of the positive prostate biopsy. In two patients with confirmed unilateral disease in prostatectomy specimens, bilateral lymph-node metastases were observed. Eight pN1 patients would have been missed by unilateral pelvic lymphadenectomy, resulting in a false-negative rate of 18%, 82% sensitivity, and 98% accuracy. Clinical tumour category, International Society of Urological Pathology grade, and percentage of prostate biopsy cores that are positive, as well as number of dissected lymph nodes contralateral to positive prostate biopsy, were determined as the most relevant predictive factors for detecting lymph-node metastasis. Our analysis was limited by its retrospective nature as well as by the fact that 80% of the patients did not receive MRI-targeted biopsy.ConclusionOur study highlights the diagnostic value of bilateral pelvic lymphadenectomy and the need for careful planning in surgery for prostate cancer patients with unilaterally positive prostate biopsy.

Standard versus extended pelvic lymphadenectomy in the patients with clinically localized prostate cancer

Background/Aim. Pelvic lymph node dissection (PLND) is the most accurate staging procedure in the diagnosis of lymph node involvement by prostate cancer. However, the therapeutic value of this procedure is still unclear. The objective of the study was to compare diagnostic and therapeutic values of extended and standard PLND as an adjunct of radical prostatectomy. Methods. The patients who underwent surgical treatment for clinically localized prostate cancer (n = 157) were enrolled in this open nonrandomized prospective study. In the standard PLND (sPLND) group 109 patients were enrolled while the extended PLND (ePLND) group involved 48 patients. Both groups were compared regarding age, prostate-specific antigen (PSA) level, a percentage of positive biopsies, preoperative and postoperative Gleason score, number of retrieved and positive lymph nodes, duration of surgery, blood loss, amount of lymphorrhea and biochemical recurrence-free survival. Results. The average number of retrieved lymph nodes was 17.27 and 24.46 in the sPLND and ePLND group, respectively (p = 0.001). The rate of positive lymph nodes was 9/109 (8.3%) and 8/48 (16.7%) in the sPLND and ePLND groups, respectively. Biochemical recurrence was noted in 38/109 (31.2%) and 7/48 (14.6%) patients in the sPLND and ePLND group, respectively (p = 0.003). Conclusion. Comparison of sPLND to ePLND led to the following conclusions: nodal yield was significantly higher in the ePLND group; the ePLND template was associated with a much higher rate of lymph node metastases; the biochemical recurrence-free survival rate was significantly more favorable in the ePLND group comparing to the sPLND group.

Effectiveness of extended pelvic lymphadenectomy in the survival of prostate cancer: a systematic review and meta-analysis.

IntroductionTo determine the effectiveness and safety of extended pelvic lymphadenectomy compared with standard lymphadenectomy in the overall, cancer-specific survival and biochemical recurrence-free survival of patients with localized prostate cancer who underwent radical prostatectomy.Material and methodsClinical trials and cohort studies were included without language restrictions with the following participants: men older than 40 years of age diagnosed with localized prostate cancer who received radical prostatectomy plus pelvic lymphadenectomy. Standard vs. extended pelvic lymphadenectomy were compared. The primary outcomes were overall and cancer-specific survival. A search strategy in MEDLINE, EMBASE, CENTRAL, LILACS, and other databases was conducted to obtain published and unpublished literature. The risk of bias was evaluated with the Cochrane Collaboration tool. The statistical analysis was performed in STATA 14.ResultsSix studies were included, of which only one was experimental; the other studies were cohort studies. The surgical technique was robot-assisted in three studies. Two studies only had information concerning the adverse effects. It was not possible to include one clinical trial that met the criteria because an erratum was published in which falsification of the experimental data was proven. There was a biochemical recurrence-free survival hazard ratio (HR) = 0.62 and a 95% confidence interval (CI) (0.36 to 0.87).ConclusionsAccording to current literature, a mild difference was evident favoring the extended lymphadenectomy in biochemical recurrence-free survival. Additionally, there was no evidence to draw a conclusion regarding the overall survival since we did not find any studies concerning this outcome.

Robot assisted retroperitoneal lymph-node dissection after adjuvant therapy: different indications.

Today, access to technology through robotic surgery has allowed urologists to have a valuable tool in order to perform various robot -assisted laparoscopic procedures. Robotic surgery allows reproducing complex techniques such as retroperitoneal or extended pelvic lymphadenectomy. The aim of the study was to report our series of robot assisted retroperitoneal lymphadenectomy and to demonstrate its technical and oncological feasibility. A retrospective analysis on 7 patients (four cases of testicular tumors, one prostate adenocarcinoma, and two bladder urothelial carcinomas), who underwent retroperitoneal para-aortic, interaorto-cava and extended pelvic lymphadenectomy by robot assisted laparoscopic surgery, was conducted. We analyzed demographic, oncologic and operative data (surgical time, blood loss, and hospital stay). Demographic and operative data showed a mean age of 49 years (18-65), mean BMI of 26.1 kg/m2(23.7-29.1), mean operative time of198 minutes (180-220), mean estimated blood loss of 88 mL, and mean hospital stay of 3.6 days (3-5). No intraoperative complications occurred. Themean number of dissected nodes was 12 (3-20). Histopathology findings showed one case of postchemotherapy recurrenceof seminoma and six cases of fibrosis. At a mean postoperative follow-up of 39 months (7-75) no patients showed disease recurrence. Our case series demonstrated that the robot assisted approach isa feasible and reproducible option in skilled robotic surgical referral centers. The surgeons' experience and the optical magnification, associated to the degree of freedom offered by robotic assisted laparoscopy allow achievinga precise lymph node dissection, also in advanced oncologic patients.

MP69-08 AN ANALYSIS OF THE MORBIDITY OF LIMITED, EXTENDED, AND SUPER-EXTENDED PELVIC LYMPHADENECTOMY TEMPLATES DURING RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy V1 Apr 2016MP69-08 AN ANALYSIS OF THE MORBIDITY OF LIMITED, EXTENDED, AND SUPER-EXTENDED PELVIC LYMPHADENECTOMY TEMPLATES DURING RADICAL PROSTATECTOMY Vidit Sharma, Alessandro Morlacco, Jason E Joseph, Avinash K Nehra, Matthew K Tollefson, R. Houston Thompson, Stephen A Boorjian, Igor Frank, Matthew T Gettman, and R. Jeffrey Karnes Vidit SharmaVidit Sharma More articles by this author , Alessandro MorlaccoAlessandro Morlacco More articles by this author , Jason E JosephJason E Joseph More articles by this author , Avinash K NehraAvinash K Nehra More articles by this author , Matthew K TollefsonMatthew K Tollefson More articles by this author , R. Houston ThompsonR. Houston Thompson More articles by this author , Stephen A BoorjianStephen A Boorjian More articles by this author , Igor FrankIgor Frank More articles by this author , Matthew T GettmanMatthew T Gettman More articles by this author , and R. Jeffrey KarnesR. Jeffrey Karnes More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1386AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The impact of pelvic lymphadenectomy (PLND) templates on operative complications and functional outcomes during radical prostatectomy (RP) remains understudied. Here we analyze a large single institution series to determine the relationship between PLND templates, complications and functional outcomes after RP. METHODS Years 2001 to 2013 of a prospectively maintained single institution RP registry were queried for NCCN intermediate and high risk PCa patients undergoing PLND. Patients received 1 of 4 possible PLND templates: 1) obturator alone; 2) obturator + external iliac; 3) obturator + external iliac + hypogastric (ePLND); and 4) common iliac + ePLND (super-ePLND). Descriptive statistics and multivariate logistic regression models were used to compare rates of complications, 1-yr potency (erections with our without medications) and 1-yr incontinence (1 or more pads per day) across PLND templates. RESULTS Out of 2,962 RPs, there were 735 (24.8%) obturator PLNDs, 574 (19.4%) obturator + external PLNDs, 1501 (50.7%) ePLNDs, and 152 (5.1%) super-ePLNDs. The overall complication rates were 20.6%, 26.5%, 24.5%, and 38.3%, respectively (p<0.001). The incidences of lymphedema (0.3%, 0.2%, 0.5%, 2.7% p=0.001) and lymphocele (1.6%, 1.7%, 2.7%, 6.3%, p=0.005) were significantly higher in the super-ePLND cohort. The groups did not differ significantly in terms of intra-operative complications (1.0%, 2.1%, 0.9%, 2.0%, p=0.089). Rates of venous thromboembolism also did not vary significantly (2.5%, 2.4%, 2.2%, 3.5% p=0.796). On multivariate logistic regression analysis (after adjusting for Age, BMI, pT stage, open vs robotic), only super-ePLND (OR 2.120, p<0.001) remained significantly associated with increased overall complications. At 1 year, potency (61.5%, 48.5%, 45.4%, and 44.8%, p<0.001) was lower and incontinence higher (5.6%, 11.6%, 10.5%, 12.3%, p<0.001) with wider PLND templates. After adjusting for nerve sparing status, age, BMI, open vs robotic, pT stage, adjuvant hormonal therapy, and adjuvant radiation: potency was no longer associated with PLND template (all p>0.05), however incontinence continued to be associated with wider PLND template (Odds ratio range 1.896-2.103, p<0.053). CONCLUSIONS A super-extended PLND was associated with increased overall complications, lymphedema and lymphoceles. An ePLND alone was not independently associated with these complications. Further investigation into the relationship between PLND template and incontinence is warranted. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e900 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Vidit Sharma More articles by this author Alessandro Morlacco More articles by this author Jason E Joseph More articles by this author Avinash K Nehra More articles by this author Matthew K Tollefson More articles by this author R. Houston Thompson More articles by this author Stephen A Boorjian More articles by this author Igor Frank More articles by this author Matthew T Gettman More articles by this author R. Jeffrey Karnes More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP40-02 SHORT-TERM RESULTS OF EXTENDED PELVIC LYMPHADENECTOMY DURING LAPAROSCOPIC RADICAL PROSTATECTOMY IN 1,000 CONSECUTIVE PATIENTS.

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I1 Apr 2016MP40-02 SHORT-TERM RESULTS OF EXTENDED PELVIC LYMPHADENECTOMY DURING LAPAROSCOPIC RADICAL PROSTATECTOMY IN 1,000 CONSECUTIVE PATIENTS. Ricardo Soares, Simon Bott, Richard Hindley, Roy McGregor, and Christopher Eden Ricardo SoaresRicardo Soares More articles by this author , Simon BottSimon Bott More articles by this author , Richard HindleyRichard Hindley More articles by this author , Roy McGregorRoy McGregor More articles by this author , and Christopher EdenChristopher Eden More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.148AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Pelvic lymphadenectomy (PLND) is the most reliable method of detecting lymph node (LN) involvement (LNI) by prostate cancer. Extended PLND (ePLND) is recommended for patients with a probability of LNI of 5% or above as evidence shows that removal of a greater number of pelvic LNs improves detection of LNI, allows stratification of affected patients to receive adjuvant therapy and may improve oncological outcomes. However, there is some suggestion that it is also associated with a greater operating time and a higher complication rate. The aim of this study was to determine whether the potential advantages of ePLND outweighed its disadvantages in the short-term. METHODS Of a total of 1,330 consecutive patients undergoing LRP, performed or supervised by a single surgeon during a 90 month period from 2008-2015, 1,000 (75%) had an ePLND for d'Amico intermediate- or high-risk prostate cancer. The results of this group were compared with an historical cohort of 311 men who had a standard PLND (sPLND) done during LRP between 2000-2008. RESULTS Patient age, BMI, PSA and gland weight were similar in the two groups but biopsy Gleason grade (p = <0.0001) and clinical stage (p = 0.001 and <0.0001 for cT2 and cT3) were higher in ePLND patients. Operating time, blood loss, conversion and transfusion rates and hospital stay were similar in both groups. Median LN count was significantly greater following ePLND versus sPLND (17 vs 6; p = <0.0001). Complication rates were also similar but trended (p = 0.06) towards a greater rate after ePLND versus sPLND: 8.3% and 4.8%. LNI was detected more frequently following ePLND in patients with: PSA = 0-9.9 (p = 0.01) and PSA = 10-19.9 (p=<0.0001); biopsy Gleason sum <=8 (p = <0.0001 to 0.03); intermediate- (p = <0.0001) and high-risk (p = <0.0001) cancer; pathological Gleason grade 7 (p = <0.0001) and pathological stage T3 (p = 0.0009 for pT3a and p = <0.0001 for pT3b). CONCLUSIONS This series supports the recommendations of the 2015 EAU guidelines on prostate cancer that PLND can be safely omitted in patients with low-risk prostate cancer, that patients with intermediate- and high-risk prostate cancer require a PLND and that ePLND is a more effective tool than sPLND in detecting LNI for patients in all prognostic clinical groups (PSA, biopsy Gleason grade, clinical stage and d'Amico risk category). This series also demonstrates that in a high-volume setting this can be achieved without significant penalty with respect to operating time or complication rates. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e550 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Ricardo Soares More articles by this author Simon Bott More articles by this author Richard Hindley More articles by this author Roy McGregor More articles by this author Christopher Eden More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

904 Extended vs limited pelvic lymphadenectomy during radical prostatectomy for intermediate- and high-risk prostate cancer: A prospective randomized trial

904 Extended vs limited pelvic lymphadenectomy during radical prostatectomy for intermediate- and high-risk prostate cancer: A prospective randomized trial

747 Prospective randomized multicenter study comparing limited vs extended pelvic lymphadenectomy in intermediate and high risk prostate cancer – first descriptive results (SEAL, AUO AP 55/09)

747 Prospective randomized multicenter study comparing limited vs extended pelvic lymphadenectomy in intermediate and high risk prostate cancer – first descriptive results (SEAL, AUO AP 55/09)

270 Prospective randomized multicenter study comparing limited vs extended pelvic lymphadenectomy in intermediate and high risk prostate cancer – comparison of complications (SEAL, AUO AP 55/09)

270 Prospective randomized multicenter study comparing limited vs extended pelvic lymphadenectomy in intermediate and high risk prostate cancer – comparison of complications (SEAL, AUO AP 55/09)

The learning curve for laparoscopic extended pelvic lymphadenectomy for intermediate‐ and high‐risk prostate cancer: implications for compliance with existing guidelines

To investigate the learning curve for performing extended pelvic lymphadenectomy (ePLND) during laparoscopic radical prostatectomy (LRP) in patients with intermediate- and high-risk prostate cancer. In all, 500 patients underwent ePLND for intermediate- or high-risk prostate cancer by one surgeon during a 48-month period. A transperitoneal laparoscopic approach was used in all patients to allow adequate access to the internal iliac vessels. The variables chosen as being the most important discriminators of the quality of ePLND were operating time, complication rate and lymph node (LN) yield. The learning curves for ePLND were calculated using the cumulative sum and cumulative average methods and the number of procedures performed until attainment of acceptable failure rates (competence levels) was calculated. LN parameters were compared with the results from the preceding 311 cases where limited PLND was undertaken. The median (range) preoperative PSA level was 8.0(1-62.5) ng/mL and biopsy Gleason score was 7(6-10). In all, 64% of patients had intermediate-risk and 36% had high-risk prostate cancer. There were no intraoperative blood transfusions and no conversions to open surgery. The median (range) blood loss was 200(10-1400) mL and the postoperative transfusion rate was 1.6%. The operating time fell at a steady rate of 2.7% after the 15th case and plateaued after 130 patients. At competence levels of 5% and 10%, the learning curve for all complications ended after 346 and 136 patients, respectively. At a 5% competence level the learning curve for PLND-specific complications was 40 cases and there was no learning curve at a 10% competence level. The overall complication rate was 7.2% of which almost half (47%) were deemed to be PLND-specific. The cumulative average of the LN counts plateaued after 150 procedures. Furthermore, the median LN count after ePLND was more than double that of the authors' historical standard PLND controls (14 vs 6, P < 0.001) and increased with experience up to the end of the series (9 to 20). The likelihood of LN involvement (LNI) correlated with biopsy and pathological Gleason grade, clinical and pathological stage and d'Amico risk group. This study suggests a learning curve of ≈130 cases for operating time, 136 cases for all complications, 40 cases for PLND-specific complications and 150 cases for LN yield. The risk of LNI for patients with intermediate- and high-risk prostate cancer was 8.4% and 19.4%, respectively, which suggests that a significant proportion would benefit from ePLND. It also shows that ePLND can be safely incorporated into LRP, and therefore also into robot-assisted RP, in a high-volume setting.

Standardized comparison of robot‐assisted limited and extended pelvic lymphadenectomy for prostate cancer

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Extended pelvic lymphadenectomy is the present standard of care according to European Association of Urology guidelines. Extended dissection improves staging, removes more metastatic lymph nodes, and potentially has therapeutic benefits. Previous reports have examined the morbidity of extended dissection compared with a more limited dissection in the open and laparoscopic setting. While some have suggested an increased complication rate with extended node dissection, others have not. This represents the first study focused on comparing the complications associated with the extent of node dissection using the modified Clavien system and Martin criteria in the literature on robot-assisted surgery. In a single surgeon series, we found no statistically significant differences in complications. With careful anatomic dissection, robot-assisted extended lymph node dissection can be performed safely and effectively, although operating time and length of hospital of stay are slightly increased. To compare the perioperative course of patients undergoing robot-assisted limited lymph node dissection (LLND) or extended lymph node dissection (ELND) for prostate cancer. To examine the differential lymph node counts and rates of detection of lymph node metastases. Between 2008 and 2012, 406 consecutive patients with D'Amico intermediate- or high-risk prostate cancer underwent either bilateral LLND (n = 204) or ELND (n = 202) and robot-assisted laparoscopic radical prostatectomy by a single surgeon. The region of dissection was the obturator fossa for LLND, while ELND included, in addition, the common iliac, external iliac and internal iliac lymph nodes. All complications within 90 days of surgery were recorded according to a modified Clavien system. Clinical variables were summarized and compared. Logistic regression was used to identify predictors of complications. There were no differences in demographics when comparing patients who underwent ELND with those who underwent LLND. The median operating time was 3.0 h for the ELND cohort and 2.8 h in the LLND cohort (P < 0.001). Intraoperative blood loss was 200 mL in both cohorts. Hospital stay was longer for a small percentage of patients in the ELND cohort, with 75% of ELND patients and 85% of LLND patients staying 1 day (P = 0.004). No significant difference was found in the overall or major complication rates between LLND (21.6% overall; 6.9% major) and ELND (22.8% overall; 4.5% major). No difference was seen in the symptomatic lymphocele rate between LLND and ELND, 2.9 vs 2.5%, respectively. Overall, the lymph-node-positive rate was 12% compared with 4% for the ELND and LLND groups, respectively (P = 0.002). A higher Charlson comorbidity index score was associated with the development of major complications. ELND at the time of robot-assisted radical prostatectomy can be performed safely with minimal additional morbidity. Long-term oncological and functional outcomes require further study.

Laparoscopic radical prostatectomy for high risk localized and locally advanced disease

The indication for surgery in locally advanced prostate cancer is growing considering and long-term follow-up shows that 60-80% of patients can be free of clinical recurrence. The aim of this video is demonstrate the modifications in traditional laparoscopic surgery that permit to observe the oncological principles reproducing open surgery. A 55 years-old male presented with an initial PSA = 25ng/dL, the digital rectal examination found a prostate with hardened nodules bilaterally (clinical stage T2c). Prostate biopsy showed an adenocarcinoma Gleason 7, the patient's disease was classified as a localized high-risk prostate cancer. Surgery was offered as initial therapeutic option and the critical technical points were: transperitoneal approach to evaluate if separation of rectum from prostate and seminal vesicles was possible, extended pelvic lymphadenectomy, opening of endopelvic fascia lateral to the prostate, bladder neck section without preservation, pedicle control without neurovascular bundle preservation, meticulous dissection of apical region, reconstruction of posterior bladder neck before the anastomosis. The operative time was 240 minutes without conversion to open surgery and an estimated blood loss around 520 mL. Neither intraoperative nor postoperative complications occurred and the hospital stay was about 36 hours. Pathological report confirmed a prostate adenocarcinoma Gleason 4+4, negative margins and stage pT3a pN0 pMx. Laparoscopic surgery adopting oncological principles can be utilized with efficacy to selected patients with high risk localized and locally advanced prostate cancer maintaining the advantages of minimally invasive surgical approach.

Laparoscopic extended pelvic lymphadenectomy for staging can be performed with limited morbidity and short hospital stay in patients with prostate cancer

Assessing lymph-node status in prostate cancer patients with high accuracy is only possible with surgical staging, despite the evolution of modern imaging techniques. The use of surgical staging has to be balanced against the complications of the procedure, the individual patient's risk for harbouring metastases and the consequences for the treatment of the patient if such metastases are present. The aim of this study was to investigate complications at 90 days using a standardized method (Clavien) in a consecutive series of patients submitted to laparoscopic extended pelvic lymphadenectomy. This population-based study included 133 high-risk prostate cancer patients scheduled for external beam radiation. Laparoscopic extended pelvic lymphadenectomy and registration of complications were performed in a standardized fashion. Complications were registered on a five-grade scale, and differences between groups were compared with the chi-squared test. The mean hospital stay was 1.3 days. Only three patients (2%) suffered from grade 3 complications after surgery, whereas 35 patients (26%) had grade 1 complications and another 11 patients (8%) were treated for grade 2 complications. Of all patients, 35% had lymph-node metastasis, of whom 50% received intensified oncological treatment including adjuvant androgen deprivation and regional lymph-node radiation. Thus, 65% of the patients could be spared regional lymph-node radiation and its associated long-term toxicity. Laparoscopic extended pelvic lymphadenectomy can be performed with minimal significant complications and short hospital stay in patients with high-risk prostate cancer.

Evaluation of (18F) FDG-PET-CT for preoperative lymph-node staging of bladder cancer.

275 Background: Radical cystectomy with extended pelvic lymphadenectomy (EPLA) is the treatment of choice for muscle-invasive bladder cancer. For preoperative staging computed tomography and magnetic resonance imaging of the abdomen and the small pelvis are most commonly used in daily routine.Since the aforementioned methods, have a low sensitivity to detect local lymph node metastasis (LNM) we have prospectively evaluated the role of FDG – PET/CT for locoregional staging. Methods: In 27 patients (n = 27) with known invasive urothelial carcinoma or squamous cell carcinoma of the bladder a staging FDG – PET - CT was performed 1-2 days prior to radical cystectomy with EPLA. Subsequently, the results of the histopathological work-up of lymph node specimens and their anatomical localisations were correlated to the FDG-PET/CT findings. Total of 452 lymph nodes were removed, on average ≈ 16.7 per patient. Results: In 3/27 (11.1%) patients LNM were detected in histopathology. 2 patients showed one positive lymph node, 1 patient had two LNM. In two of these patients, the FDG-PET/CT showed an increased enrichment of FDG in projection to the corresponding histologically positive LN. One false negative and one false positive result of FDG-PET/CT were found. Calculated based on the patient population, the following statistics were calculated: Sensitivity (SENS) 66%, specificity (SPEC) 95.8%, positive predictive value (PPV) 66%, negative predictive value (NPV) 95.8%. Related to the absolute number of LN (n = 452), the following numbers were calculated: SENS 75% SPEC 98.7, PPV 37.5%, NPV 99.7%. Conclusions: To date, few studies have been conducted with regard to FDG-PET/CT and its role in locoregional staging. The reported specificity and NPV was between 86% and 100%, sensitivity and PPV were between 50% and 100%. Our results demonstrate specificity and NPV values of larger than 90% and make FDG-PET/CT a valuable staging tool to potentially identify patients with negative nodes in whom EPLA could be safely ommitted. Curently, routine use of PET CT scans can not be recommended and it is currently tested in a prospective multicenter study including a larger patient cohort.

Laparoscopic partial cystectomy with bilateral pelvic lymphadenectomy for urachal adenocarcinoma

Objective To discuss the techniques and clinical efficacy of laparoscopic partial cystectomy with bilateral pelvic lymphadenectomy for urachal adenocarcinoma. Methods From July 2006 to April 2008, 4 patients with urachal adenocarcinoma were managed by the laparoscopic procedure. Three patients were male, the other one was female, with a median age of 51 (range 42 to 66)years. The mean size of tumors was 3.4(rang 1.9 to 5.4)cm in diameter. Three of them were diagnosed as mucinous adenocarcinoma, the other one was adenocarcinoma. There was 1 patient at stage Ⅱ , and the other three as stage Ⅲ according to Sheldon Stage. Four patients were performed by transperitoneal approach. The boundaries of resection were similar to the open surgery, including resection of the tumor with normal margins, the peritoneum lateral to the two medial unbilical ligaments,the posterior sheath of the rectus muscle and the muscle fibers of the rectus muscle below it, and bilateral pelvic lymphanodes. Results The procedure was successfully in all 4 patients, with a mean operative time of 220(range 150 to 350)min, a mean estimated blood loss of 180 (range 120 to 290)ml.No significant intraoperative or postoperative complications occurred, except for an inferior epigastric artery injury in 1 case. The mean postoperative in-dwelling urinary catheter time was 6 (range 5 to 7)d, and the mean postoperative hospital stay was 6 (range 5 to 8)d. All 36 resected lymph nodes (range 8 to 11) were negative. At a median follow-up of 25(range 15 to 36) months, there was no evidence of recurrent disease by radiologic or cystoscopic evaluation. Conclusion Laparoscopic partial cystectomy and bilateral extended pelvic lymphadenectomy in selected patients with urachal tumors could be a safe, feasible, minimally invasive procedure. Key words: Laparoscopes; Urachal carcinoma

Comparison of HER2 amplification in primary tumors and lymph node metastases of urinary bladder cancer.

4577 Background: HER2 is a growth factor receptor that serves for targeted therapies when overexpressed in breast cancer. Overexpression of HER2 is primarily related to gene amplification. Aim of this study was to evaluate the HER2 status by fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC) in primary bladder cancer and matched lymph node metastases. Methods: A tissue microarray was constructed from 150 lymph node positive urothelial bladder cancers treated by cystectomy and standardized extended pelvic lymphadenectomy. Four tissue cores were taken per patient, two from the primary tumor (center and invasion front) and two from the nodal metastases. HER2 gene/Centromer 17 FISH (PathVysion; Vysis-Abbott) ratios > 2.2, 1.8-2.2 and <1.8 were considered positive, borderline and negative for amplification, respectively. HER2 expression (Herceptest, DAKO) was classified according to the Herceptest criteria (score 0-3). Results: HER2 FISH status was significantly different between the primary tumors and the lymph node metastases (p=0.003) with amplification in 8.8 % of the primary tumors and 15.3% of the lymph node metastases. Of the primary tumors with HER2 amplification/borderline-amplification 94.7% had the same findings in the metastases. There was a high degree of concordance in FISH results between the two cancer spots from the primary tumors (Cohen's Kappa: 0.8530) and the nodal metastases (Cohen's Kappa: 0.9300). Conversely, the concordance between IHC results and FISH data was lower in the primary tumor (Cohen's Kappa: 0.5661) and the nodal metastases (Cohen's Kappa: 0.6734). Her2 data (IHC, FISH) were not significantly related to pT stage or nodal tumor burden (pN, diameter of largest metastasis, total diameter of all metastases). The trend for poorer survival in HER2 positive cancers (amplified OR IHC 3+) was not significant. Conclusions: HER2 amplification is highly homogeneous in each tumor component and significantly more frequent in lymph node metastases than in primary bladder cancer. This suggests determining the HER2 status in the metastasizing tumor component and argues for a possible response of HER2 amplified cases to anti-HER2 therapies. No significant financial relationships to disclose.

Robot-assisted Intracorporeal Ileal Conduit: Marionette Technique and Initial Experience at Roswell Park Cancer Institute

To present our technique and initial experience with patients who underwent robot-assisted intracorporeal creation of ileal conduit and to compare them with patients who underwent extracorporeal ileal diversion after robot-assisted radical cystectomy. Twenty-six patients diagnosed with invasive transitional cell carcinoma of the bladder underwent a robot-assisted radical cystectomy with bilateral extended pelvic lymphadenectomy with ileal conduit diversion. Total intracorporeal ileal conduit creation was performed in the last 13 patients. Operative data and short-term outcomes between the 2 groups were assessed. The novel surgical technique for intracorporeal ileal conduit will be presented. The intracorporeal group (IC) included 2 female and 11 male patients (mean age 71 years). The extracorporeal group (EC) included 4 female and 9 male patients (mean age 66 years). No significant differences were noted between the groups in terms of patient age, BMI, sex, prior surgery, or pathologic stage. Overall operative time and intraoperative complications were similar. No significant differences were noted between the 2 groups in terms of diversion time or estimated blood loss. There were 4 complications recorded in IC patients, including nonspecific colitis, small bowel obstruction requiring exploratory laparotomy with lysis of adhesions, a urine leak that eventually resolved but required a temporary nephrostomy tube, and a fever of unknown origin that resolved without intervention. Robot-assisted intracorporeal ileal conduit can be accomplished safely with acceptable operative times even during early experience. Larger series with favorable results will be required to add this new paradigm to minimally invasive surgery for bladder cancer.

1718 HIGH CD10 EXPRESSION IN THE PRIMARY TUMOR INDEPENDENTLY PREDICTS FAVORABLE SURVIVAL IN SURGICALLY TREATED PATIENTS WITH LYMPH NODE POSITIVE UROTHELIAL CANCER OF THE BLADDER

You have accessJournal of UrologyBladder Cancer: Invasive/Metastatic Disease II1 Apr 20101718 HIGH CD10 EXPRESSION IN THE PRIMARY TUMOR INDEPENDENTLY PREDICTS FAVORABLE SURVIVAL IN SURGICALLY TREATED PATIENTS WITH LYMPH NODE POSITIVE UROTHELIAL CANCER OF THE BLADDER Roland Seiler, Michael von Gunten, Achim Fleischmann, and George N. Thalmann Roland SeilerRoland Seiler More articles by this author , Michael von GuntenMichael von Gunten More articles by this author , Achim FleischmannAchim Fleischmann More articles by this author , and George N. ThalmannGeorge N. Thalmann More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1565AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES CD10 is an ectopeptidase bound to the cell surface and predicts survival in different cancers. We determined the prognostic relevance of CD10 expression in lymph node positive urothelial cancer of the bladder. METHODS Hundred and fifty consecutive patients with urothelial bladder cancer who underwent cystectomy and standardized extended pelvic lymphadenectomy in curative intent and had positive lymph nodes upon histological examination were included in this study. CD10 expression was evaluated by immunohistochemistry in tissue microarrays (TMA) constructed from normal urothelium (NU), primary tumor (PT) and matched lymph node metastases (MET) of each patient. CD10 expression was assessed using the monoclonal antibody CD10 clone 56C6 (Novocastra, UK) at 1:50 antibody dilution with positive and negative controls. CD10 expression score, defined as the product of percentage of positive cells and intensity of staining (1-3), was correlated with different tumor features (primary tumor stage and extracapsular extension of lymph node metastases) and outcome (disease-specific (DSS), overall (OS) and recurrence-free (RFS) survival). RESULTS Median CD10 expression was successively lost from NU to PT to MET (scores: 27.5, 15, 7.5; p<0.05). CD10 expression neither in PT nor in MET was correlated with any histopathologic tumor features. In multivariate analysis, all tested parameters (primary tumor stage, extracapsular extension, CD10 expression in PT and MET) were independent risk factors for at least one endpoint. High CD10 expression was a favorable risk factor (DSS: p<0.02; hazard ratio: 0.2; RFS: p<0.03, hazard ratio: 0.6), whereas high CD10 expression in MET predicted early tumor associated death (DSS: p<0.05, hazard ratio: 1.9). CONCLUSIONS CD10 expression is successively lost from NU over PT to MET suggesting a role in tumor progression. The independent prognostic information of CD10 in nodal positive urothelial bladder cancer might help to guide therapeutic decisions and schedule adjuvant therapy. Bern, Switzerland© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e663 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Roland Seiler More articles by this author Michael von Gunten More articles by this author Achim Fleischmann More articles by this author George N. Thalmann More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

912 ROBOTIC LIMITED AND EXTENDED PELVIC LYMPHADENECTOMY FOR PROSTATE CANCER

You have accessJournal of UrologyTechnology & Instruments: Robotics/Laparoscopy/Ureteroscopy II1 Apr 2010912 ROBOTIC LIMITED AND EXTENDED PELVIC LYMPHADENECTOMY FOR PROSTATE CANCER Hugh Lavery and Ronney Abaza Hugh LaveryHugh Lavery More articles by this author and Ronney AbazaRonney Abaza More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1668AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The optimal extent of lymphadenectomy for prostate cancer is unknown. More extensive dissections have shown increased overall nodal yields as well as more frequent identification of positive nodes. With the advent of robot-assisted laparoscopic prostatectomy (RALP), the ability to achieve adequate lymph node dissections with this approach has been questioned with many series reporting lower nodal yields than historical series or lower nodal positivity than expected based upon the biology of the disease. We reviewed our experience with both extended (ePLND) and limited pelvic lymphadenectomy (PLND) to determine nodal yield, complications, and rate of node positivity. METHODS We reviewed 250 consecutive RALP procedures with PLND from Feb 2008 to Jan 2009 by a single surgeon (RA). Nodal packets were dissected en bloc and nodes counted before paraffin-embedding to prevent double counting from cutting of nodes. Pathology processing was without knowledge of the study. ¡°Low-risk¡± patients underwent a limited PLND including the external iliac and obturator lymph nodes. An extended dissection was performed in ¡°high-risk¡± patients with preoperative PSA >10ng/dl, cT3 disease, Gleason ¡Ý8, or cancer in ¡Ý50% of biopsy tissue extending the template to all nodes medial to the genitofemoral nerve including the hypogastric nodes and common iliac nodes up to the crossing of the ureter. Patient and pathologic outcomes were evaluated. RESULTS Of 250 patients, 173 underwent limited PLND while 77 underwent ePLND. Mean nodal yield for all patients was 11 nodes, with 8.6 and 16.4 nodes for limited and extended PLND, respectively. A total of 17 (7%) node-positive (N+) patients were identified overall, with 2 (1.1%) in the limited group and 15 (19.5%) in the ePLND group. Of the 183 organ-confined (OC) tumors, only 1 was N+ (0.5%), compared to 16 of 67 (24%) non-OC tumors. Complications of the lymphadenectomy included four symptomatic lymphoceles requiring percutaneous drainage, one ureteral injury requiring a temporary stent, and one transient obturator nerve palsy for an overall complication rate of 2.4% (0.5% of limited and 8% of ePLND). CONCLUSIONS Pelvic lymphadenectomy for prostate cancer can be adequately performed in robot-assisted laparoscopic fashion with nodal yields and rate of positivity comparable to published open surgical series. The role of limited PLND remains unclear, but ePLND appears warranted for high risk cancers. Columbus, OH© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byAbaza R, Dangle P, Gong M, Bahnson R and Pohar K (2018) Quality of Lymphadenectomy is Equivalent With Robotic and Open Cystectomy Using an Extended TemplateJournal of Urology, VOL. 187, NO. 4, (1200-1205), Online publication date: 1-Apr-2012. Volume 183Issue 4SApril 2010Page: e356 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hugh Lavery More articles by this author Ronney Abaza More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...