Extent Of Pelvic Lymphadenectomy Research Articles

Near-infrared fluorescence lymph node template region dissection plus backup lymphadenectomy in open radical cystectomy for bladder cancer using an innovative handheld device: A single center experience.

The extent of pelvic lymphadenectomy (PLND) as part of radical cystectomy (RC) for bladder cancer (BC) remains unclear. Sentinel-based and lymphangiographic approaches could lead to reduced morbidity without sacrificing oncologic safety. To evaluate the feasibility and diagnostic value of fluorescence-guided template sentinel region dissection (FTD) using a handheld near-infrared fluorescence (NIRF) camera in open radical cystectomy. After peritumoral cystoscopic injection of indocyanine green (ICG) 21 patients underwent open RC with FTD due to BC between June 2019 and June 2021. Intraoperatively, the FIS-00 Hamamatsu Photonics® NIRF camera was used to identify and resect fluorescent template sentinel regions (FTRs) followed by extended pelvic lymphadenectomy (ePLND) as oncological back-up. Descriptive analysis of positive and negative results per template region. FTRs were identified in all 21 cases. Median time (range) from ICG injection to fluorescence detection was 75 (55-125) minutes. On average (SD), 33.4 (9.6) lymph nodes were dissected per patient. Considering template regions as the basis of analysis, 67 (38.3%) of 175 resected regions were NIRF-positive, with 13 (7.4%) regions harboring lymph node metastases. We found no metastatic lymph nodes in NIRF-negative template regions. Outside the standard template, two NIRF-positive benign nodes were identified. The concept of NIRF-guided FTD proved for this group all lymph node metastases to be found in NIRF-positive template regions. Pending validation in a larger collective, resection of approximately 40% of standard regions may be sufficient and may result in less morbidity.

Region-specific Risk Factors for Pelvic Lymph Node Metastasis in Patients with Stage IB1 Cervical Cancer.

Objectives: We aimed to identify the risk factors associated with pelvic lymph node metastasis (LNM) at each anatomic location in patients with stage IB1 cervical cancer.Methods: A primary cohort of 728 patients with stage IB1 cervical cancer who underwent radical hysterectomy and systematic pelvic lymphadenectomy were retrospectively studied. All removed pelvic nodes (N=20,134) were pathologically examined. The risk factors for LNM in different anatomic regions (obturator, internal iliac, external iliac, and common iliac) were evaluated by multivariate logistic regression analyses. Nomograms were generated from the primary cohort and validated in another external cohort (N=242). The performance of the nomogram was assessed by its calibration and discrimination. Overall survival and progression-free survival in patients with different LNM patterns were compared.Results: LNM was found in 266 (1.3%) removed nodes and 106 (14.6%) patients. The incidences of LNM at the obturator, internal iliac, external iliac, common iliac, and parametrial regions were 8.5%, 5.4%, 4.7%, 1.9% and 1.8%, respectively. Among others, tumour size and lymph-vascular space invasion (LVSI), which are preoperatively assessable, were identified as independent risk factors of LNM in the common iliac region and the lower pelvis, respectively, and age was an additional independent risk factor of obturator LNM. The negative predictive values of tumour size <2 cm for common iliac LNM and negative LVSI combined with older age (> 50 years) for obturator LNM were 100% and 98.7%, respectively. A nomogram of these two factors showed good calibration and discrimination (concordance index, 0.761 in the primary cohort and 0.830 in validation cohort). The patients with common iliac LNM had poorer survival than those with LNM confined to the lower pelvis, while the differences in survival between patients with LNM confined to one node, one region or single side and those with more widely spreading LNM were not statistically significant.Conclusions: Tumour size, LVSI and age are region-specific risk factors for pelvic LNM in IB1 cervical cancer, which could be used to allocate the appropriate extent of pelvic lymphadenectomy.

Is the extent of pelvic lymphadenectomy in the staging of endometrial cancer associated with the yield of metastatic nodes? An Israeli Gynecologic Oncology Group study

ObjectivesPrimary, to explore correlation between the extent of pelvic lymphadenectomy in the surgical staging of endometrial cancer and the number of nodes with metastasis. Secondary, evaluate survival measures in relation to the number of excised nodes. MethodsA retrospective multi-center study of prospectively collected information of 2014 women with endometrial cancer, 1032 of whom underwent lymph node staging. Spearman's rank correlation was used to assess the correlation between the number of pelvic nodes excised and the number of metastatic nodes. Women's data were dichotomized by the median number of excised pelvic nodes. Kaplan-Meier and log rank tests were used to examine the effect of the number of pelvic nodes excised on survival. ResultsThere was no significant correlation between the number of pelvic nodes harvested and the number of metastatic lymph nodes (r = 0.301; p = 0.28). The median number of excised pelvic nodes was 9 (range 1–77). There was no difference between women with up to 9 and women with more than 9 lymph nodes excised in the 5-year recurrence-free survival (82.4% vs. 83.9%; p = 0.90), disease-specific survival (83.6% vs. 86.7%; p = 0.37), or overall survival (75.8% vs. 82.8%; p = 0.11). ConclusionsThe extent of pelvic lymphadenectomy in the surgical staging of endometrial cancer is not associated with a higher yield of metastatic nodes or with longer survival. Current focus should be on sentinel node procedures that offer women the benefit of accurate staging without the complications associated with extensive lymphadenectomy.

Facility-Level Variation in Pelvic Lymphadenectomy During Radical Prostatectomy and Effect on Overall Survival in Men with High-Risk Prostate Cancer.

This study was designed to examine facility-level variation in the extent of pelvic lymphadenectomy and to determine whether more extensive lymphadenectomy is associated with a survival benefit among men with localized high-risk prostate cancer. Using data from the National Cancer Data Base, we identified 13,652 men with a high predicted probability of 10-year survival (≤ 65years of age and Charlson Comorbidity Index score of 0) who underwent radical prostatectomy at 1023 facilities for biopsy-confirmed localized high-risk prostate cancer diagnosed between January 2004 and December 2011. Multilevel, multinomial logistic regression was fitted to predict facility-level probability of receiving different extents of lymphadenectomy. Inverse probability of treatment weighting-adjusted Cox regression model with Bonferroni correction was fitted to compare risk of overall mortality. Overall, 11,284 (82.7%), 1601 (11.7%), and 767 (5.6%) men who underwent radical prostatectomy underwent concomitant none/limited lymphadenectomy (0-9 lymph nodes), standard lymphadenectomy (10-16 lymph nodes), and extended lymphadenectomy (≥ 17 lymph nodes), respectively. Extended lymphadenectomy was not associated with a survival benefit relative to standard lymphadenectomy (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.48-1.23; p = 0.4) nor no/limited lymphadenectomy (HR 0.77, 95% CI 0.87-2.20; p = 0.29) at a median follow-up of 83.3months. Risk-adjusted facility-level predicted probabilities of extended, standard, or no/limited lymphadenectomy ranged from 0.01 to 52.6%, 3.3-53.3%, and 17.8-96.3%, respectively. We found significant facility-level variation in the extent of pelvic lymphadenectomy during radical prostatectomy despite no apparent survival benefit associated with more extensive lymphadenectomy. Further prospective data are needed to reevaluate the role of lymphadenectomy in the management of clinically localized prostate cancer.

Perioperative venous thromboembolism prophylaxis in prostate cancer surgery.

To describe a patient and procedure specific approach to selecting Venous thromboembolism (VTE) prophylaxis for men who undergo radical prostatectomy. We performed a literature search and narrative review of VTE after radical prostatectomy. We describe the current paradigm of perioperative thromboprophylaxis and underlying rationale. Relevant findings from the European Association of Urology thromboprophylaxis guidelines are interpreted and summarized. The use of extended post-operative thromboprophylaxis for patients who undergo radical prostatectomy is appropriate when the risk of symptomatic VTE outweighs the risk of major bleeding. Patient and procedure factors impact VTE risk. Patient risk can be stratified as low, moderate or high based on 4 factors; age > 75, BMI > 35, VTE in a first degree relative, and personal history of VTE. Procedure risk of VTE and bleeding can be stratified by modality of surgery (open, laparoscopic, robotic) and extent of pelvic lymphadenectomy. Using these factors, patients at the lowest risk for VTE will have an expected incidence of VTE of 0.4-0.8% and those at highest risk from 1.5 to 15.7%. Incidence of major bleeding ranges from 0.4 to 1.4%. These ranges emphasize the need to consider the net benefit for each specific patient. Use of mechanical prophylaxis is supported by weaker evidence but has fewer harms and is likely reasonable for most patients. Many patients who undergo radical prostatectomy will benefit from extended post-operative thromboprophylaxis. Risk of thrombosis is likely higher with open approach and extended lymph node dissection. The net benefit of treatment should be considered using patient- and procedure-specific criteria. When the net benefit is negligible or possibly harmful no pharmacological thromboprophylaxis should be used.

Rise in Node-Positive Prostate Cancer Incidence in Context of Evolving Use and Extent of Pelvic Lymphadenectomy.

The incidence of node-positive prostate cancer has risen and might be partially explained by evolving use of lymphadenectomy at a population level. We assessed trends of node-positive prostate cancer in context of extent of lymphadenectomy among men treated surgically for prostate cancer. This was a retrospective study using data from a population-based cancer registry to identify men older than 50 years of age diagnosed with prostate cancer from 2010 to 2015 without distant metastases. We considered extent of node dissection as ordinal (1-4, 5-9, 10-14, 15-19,≥20) and dichotomous (1-14,≥15) variables. We fit multivariable models to assess trends in receipt of extended lymphadenectomy and then estimated odds of node-positive cancer on the basis of extent of lymphadenectomy. We identified 280,156 men diagnosed from 2010 to 2015; 5355 men (1.9%) had positive lymph nodes. Incidence of positive nodes increased from 6.4 to 8.4 cases per 100,000 men from 2010 to 2015 (standardized rate ratio, 1.31; 95% confidence interval [CI], 1.20-1.44). Compared with 2010, prostatectomy patients with high-risk (odds ratio [OR], 1.66; 95% CI, 1.42-1.95) and intermediate-risk tumors (OR, 1.66; 95% CI, 1.47-1.88) were more likely to undergo extended lymphadenectomy in 2015. Among high-risk patients, men with≥20 nodes removed were 7 times more likely to have positive nodes, versus<5 removed (6.1% for 1-4 vs. 32.4% for≥20; OR, 7.32; 95% CI, 6.16-8.71). After adjusting for extent of dissection, odds of node-positive disease did not increase between 2010 and 2015 (OR, 1.17; 95% CI, 0.98-1.39) among high-risk patients. Increased incidence of node-positive prostate cancer in the United States is partially explained by more frequent use of extended lymphadenectomy.

PD10-01 OUTCOMES OF FLUORESCENCE SUPPORTED LYMPH NODE DISSECTION IN ROBOT-ASSISTED RADICAL PROSTATECTOMY – A PROSPECTIVE RANDOMIZED CLINICAL TRIAL

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I1 Apr 2017PD10-01 OUTCOMES OF FLUORESCENCE SUPPORTED LYMPH NODE DISSECTION IN ROBOT-ASSISTED RADICAL PROSTATECTOMY – A PROSPECTIVE RANDOMIZED CLINICAL TRIAL Nina Harke, Christian Wagner, Katarina Urbanova, Michael Godes, Mustapha Addali, Bernhard Fangmeyer, Andreas Schuette, and Jorn H. Witt Nina HarkeNina Harke More articles by this author , Christian WagnerChristian Wagner More articles by this author , Katarina UrbanovaKatarina Urbanova More articles by this author , Michael GodesMichael Godes More articles by this author , Mustapha AddaliMustapha Addali More articles by this author , Bernhard FangmeyerBernhard Fangmeyer More articles by this author , Andreas SchuetteAndreas Schuette More articles by this author , and Jorn H. WittJorn H. Witt More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.564AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The detection of lymph node metastases has a major impact on patients with prostate cancer. However, there is still a debate on the extent of pelvic lymphadenectomy, the usage of near-infrared fluorescence (NIRF) and sentinel node dissection in radical prostatectomy. This study aims to demonstrate the outcomes of NIRF lymph node dissection in robot-assisted radical prostatectomy. METHODS 120 patients with intermediate (72%) or high risk (28%) prostate cancer were prospectively randomized (1:1): in the intervention group indocyanine green (ICG) was injected transrectally into the prostate before docking of the robot. In both groups an extended pelvic lymph node dissection (ePLND) was performed including eventual dissection of fluorescent lymph nodes (LN) in the ICG group. RESULTS After exclusion of two drop-outs, 59 patients were allocated in the control (A) and intervention group (B) with a median PSA of 8,6 ng/ml. Median console time was 159 (A) vs. 168 (B) minutes (p=0,20) with a longer time for NIRF ePLND: 43 (A) vs. 55 minutes (B) (p=0,001). Overall, 2609 LN (median 22 LN) were found. In the ICG group 582 fluorescent LN were identified, while 899 were non-fluorescent. Significantly more LN could be harvested in B with median 25 LN vs. 17 in A (p<0,001). In 6 of the 59 patients in the intervention group, 19 additional fluorescent LN were found outside of the routine ePLND field. 15 out of 118 patients presented 87 nodal metastases. These metastases were detected in 6 patients in A (25 cancerous LN) vs. 9 patients in B (62 positive LN) (p=0,40). In 7 of 9 patients, NIRF ePLND identified at least one cancer-positive LN (sensitivity 78%), although 35 of 62 cancerous LN were non-fluorescent. No adverse reactions to ICG, no significant differences in complication rates (p=0,15); lymphocele occurred in one patient in A and in three patients in B (p=0,62). After six months, 5,8% vs. 3,7% showed a PSA>0,2 ng/ml (p=0,37) with a median PSA of 0,01 ng/ml in both groups (p=0,96). There was no difference in adjuvant therapy with 10 patients undergoing radiation therapy, 7 patients with androgen deprivation therapy (ADT) and 3 patients with combined radiation and ADT (p=0,78). CONCLUSIONS Without increased risk for the patient, NIRF ePLND leads to a significantly higher yield of lymph nodes. While it therefore seems to be beneficial with regard to a better understanding of the lymphatic drainage and a more meticulous diagnostic approach, the sensitivity seems not to be sufficient to recommend stand-alone NIRF sentinel lymph node dissection. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e199 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Nina Harke More articles by this author Christian Wagner More articles by this author Katarina Urbanova More articles by this author Michael Godes More articles by this author Mustapha Addali More articles by this author Bernhard Fangmeyer More articles by this author Andreas Schuette More articles by this author Jorn H. Witt More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

National Comprehensive Cancer Network Practice Guidelines 2011: Need for More Accurate Recommendations for Pelvic Lymph Node Dissection in Prostate Cancer

The 2011 NCCN (National Comprehensive Cancer Network) guidelines for prostate cancer recommend pelvic lymph node dissection at radical prostatectomy in all individuals with a nomogram predicted lymph node invasion probability of 2% or greater. We examined the ability of these guidelines to correctly predict lymph node invasion in patients treated with extended pelvic lymph node dissection. We examined 3,064 consecutive patients treated with radical prostatectomy and extended pelvic lymph node dissection between 2000 and 2010. We formally validated the NCCN guideline nomogram using discrimination, calibration and decision curve analysis as benchmarks. Moreover the performance characteristics of the 2% nomogram cutoff as well as other cutoff values (range 1% to 10%) were tested. Overall 10.0% of patients had lymph node invasion. The discrimination accuracy of the NCCN guideline nomogram was 79.8%, with a maximum underestimation of the lymph node invasion risk of 41.2%. On decision curve analysis the NCCN nomogram fared better than not performing pelvic lymph node dissection in all patients. However, in the prediction range between 0% and 9% the nomogram did not fare better than performing pelvic lymph node dissection in all patients. The use of the 2% cutoff would allow the avoidance of 49.3% of pelvic lymph node dissections, at the cost of missing 20.3% of patients with lymph node invasion. The NCCN nomogram tends to significantly underestimate the real lymph node invasion rate. Moreover the use of the currently recommended cutoff of 2% to trigger pelvic lymph node dissection might not be appropriate.

Standard Lymph Node Dissection for Bladder Cancer: Significant Variability in the Number of Reported Lymph Nodes

We compared the nodal yield after histopathological examination of extended bilateral pelvic lymph node dissection specimens for bladder cancer at 2 hospitals. Surgery at each hospital was done by the same 4 staff urologists using a standardized extended bilateral pelvic lymph node dissection template. All consecutive patients with bladder cancer who underwent extended bilateral pelvic lymph node dissection from January 1, 2007 to December 31, 2009 were included in this study. Specimens were sent for pathological evaluation in a minimum of 2 packages per side. At the 2 pathology departments specimens were processed according to institutional protocols. A total of 174 patients with a mean age of 62.7 years were included in analysis. At hospital 1 a mean of 16 lymph nodes were found after dissection vs a mean of 28 reported at hospital 2 (p <0.001). No significant differences were found in the number of tumor positive lymph nodes (p = 0.65). Mean lymph node density at hospitals 1 and 2 was 9.3% and 3.9%, respectively (p = 0.056). Despite equal anatomical clearance by the same experienced surgeons we report a statistically significant difference between 2 pathology departments where the number of lymph nodes was evaluated after extended bilateral pelvic lymph node dissection for bladder cancer. Unless standardized methods are agreed on by pathologists, the number of reported lymph nodes as an indicator of surgical quality and lymph node density as a prognostic factor should be used cautiously.

Neoadjuvant or adjuvant chemotherapy: what is the best treatment of muscle invasive bladder cancer?

Bladder cancer is the fourth most common cancer for men and the eighth most common cancer for women. Transitional cell carcinoma is the most predominant histological type. Bladder cancer is highly chemosensitive. In metastatic setting the treatment is based on cisplatin chemotherapy regimens type MVAC, MVAC-HD or gemcitabine plus cisplatin. The standard treatment of muscle invasive operable bladder cancer (T2–T4) used widely was radical cystectomy with pelvic lymph nodes dissection; the anatomical extent of pelvic lymphadenectomy has not accurately been defined so far. However, in the last decade, the treatment of tumors was improved by the introduction of chemotherapy as part of the management of the disease. Neoadjuvant chemotherapy should be considered at first, as standard treatment of choice, before local treatment for patients with good performance status (0–1) and good renal function–glomerular filtration rate (GFR) >60 mL/min. For patients treated with primary surgery, adjuvant chemotherapy is a valuable option in the case of lymph nodes involvement. This brief review would provide the evidence of the role of neoadjuvant chemotherapy in the management of operable muscle invasive (T2–T4) bladder cancer.

Prognostic Risk Stratification of Pathological Stage T3N0 Bladder Cancer After Radical Cystectomy

Patients with pathological T3N0 stage urothelial carcinoma of the bladder show a range of outcomes after radical cystectomy. Given that nomograms have included heterogeneous groups of patients, we focused on and stratified patients with pT3N0 urothelial carcinoma of the bladder after radical cystectomy into prognostically different risk groups to facilitate the development of adjuvant therapy trials for those at high risk. The study comprised a total of 578 patients from 9 centers worldwide with pT3N0 urothelial carcinoma of the bladder who underwent radical cystectomy without perioperative chemotherapy. We evaluated the effect of pT3 substage at radical cystectomy, age, grade, lymphovascular invasion, margin status and number of lymph nodes removed on recurrence-free survival using Cox regression analysis. A weighted prognostic model was devised. Median followup was 39.4 months (IQR 64). On multivariate analysis pT3 substage at radical cystectomy (pT3b vs pT3a HR 2.056, p <0.0001), lymphovascular invasion (positive vs negative HR 2.004, p <0.0001) and margin status (positive vs negative HR 2.503, p = 0.002) were associated with recurrence-free survival (concordance index 0.66) in the context of generally adequate lymph node dissection, that is with a median of 17 removed. Three risk groups were devised based on weighted variables with a 5-year recurrence-free survival rate of 79% (95% CI 70-84), 57% (95% CI 50-64) and 37% (95% CI 26-48) in the low, intermediate and high risk groups, respectively. We constructed a user friendly prognostic risk model for patients with pT3N0 urothelial carcinoma of the bladder treated with radical cystectomy based on pT3 substage at radical cystectomy, lymphovascular invasion and margin status. These data warrant validation and may enable tailored monitoring and selection of appropriate patients for adjuvant therapy trials.

Biochemical Recurrence After Radical Prostatectomy: Multiplicative Interaction Between Surgical Margin Status and Pathological Stage

A positive surgical margin after radical prostatectomy is considered an adverse prognostic feature. However, few groups have explored the potential interaction between surgical margin status and other cancer characteristics, specifically pathological stage. We addressed the first degree of interaction between positive surgical margins and other established adverse predictors of biochemical recurrence after radical prostatectomy. We used univariate and multivariate analysis to test the effect of surgical margin status on biochemical recurrence in 4,490 patients treated at a single institution between 1992 and 2008. We systematically tested all first-degree interactions between surgical margin status, and pretreatment prostate specific antigen, pT and pN stage, and radical prostatectomy Gleason sum. If interactions were significant, we quantified the effect on the biochemical recurrence rate. Overall 850 patients (18.9%) had positive surgical margins. In those with negative vs positive surgical margins the 5-year biochemical recurrence-free survival rate was 95% vs 83%, 74% vs 62% and 47% vs 29% for pT2, pT3a and pT3b disease, respectively. In multivariate models only the pT stage-surgical margin status interaction achieved independent predictor status (p = 0.003). Negative vs positive surgical margin multivariate HRs were 1 vs 2.9, 2.3 vs 4.3 and 4.1 vs 5.6 in pT2, pT3a and pT3b cases, respectively. Compared to negative surgical margins, positive surgical margins increase the absolute biochemical recurrence 5-year rate by 12% to 18%. More importantly, positive surgical margins may substantially worsen the prognosis beyond that of the original pathological disease stage.

Pelvic lymph nodes: distribution and nodal tumour burden of urothelial bladder cancer

AimsTo evaluate the number of lymph nodes and the lymph node tumour burden in different anatomical pelvic regions to better asses the impact of variations in the extent of lymphadenectomy...

Extended Pelvic Lymph Node Dissection in Robotic-assisted Radical Prostatectomy: Surgical Technique and Initial Experience

To describe, and show in the accompanying video segments, a technique for extended pelvic lymph node dissection (ePLND) in robotic-assisted radical prostatectomy (RARP) and report our clinicopathologic and perioperative outcomes. The extent of pelvic lymphadenectomy during radical prostatectomy has not been standardized. However, evidence demonstrates that an ePLND yields a greater number of positive nodes. A total of 32 patients with clinically localized prostate cancer underwent RARP with ePLND by a single surgeon (J.C.) between January and August 2008. The template for the ePLND included the obturator, hypogastric, external iliac, and common iliac lymph nodes up to the bifurcation of the aorta. Systematic review and grading of adverse events were performed. The median number of lymph nodes retrieved was 18 (interquartile range [IQR] 12-28). Four patients (12.5%) had lymph node metastases. Of the 4 patients with lymph node metastases, 1 patient (25%) had the involved lymph node exclusively in the common iliac region. Median operative time for the ePLND was 72 minutes (IQR 66-86). Median hospital length of stay was 2.0 days (IQR 2.0-2.8). Graded complications included 13 grade 1 events and 1 grade 2 event, with 1 grade 1 event being considered related to ePLND. No clinically presenting lymphoceles or thrombotic events were encountered. An ePLND during RARP is technically feasible and appears to have minimal morbidity. It produces a high lymph node yield and may result in improved pathologic staging.

Oncological Outcomes After Radical Cystectomy for Bladder Cancer: Open Versus Minimally Invasive Approaches

The number of centers performing robotic assisted radical cystectomy has recently increased, spurring greater concerns about oncological outcomes. In this review we summarize the most comprehensive articles published on the oncological outcomes of laparoscopic assisted, robotic assisted and open radical cystectomy. A MEDLINE/PubMed literature search was conducted in March 2009 to review English language articles published from 1998 onward. Of 217 selected articles on the 3 techniques 19 studies were selected for this review. The laparoscopic series reported recurrence-free survival rates in the range of 83% to 85% at 1 to 2 years and 60% to 77% at 2 to 3 years, while the robotic assisted studies reported recurrence-free survival rates of 86% to 91% at 1 to 2 years. Large open surgery studies showed 62% to 68% recurrence-free survival at 5 years and 50% to 60% at 10 years, with overall survival of 59% to 66% at 5 years and 37% to 43% at 10 years. Overall survival in the laparoscopic cohorts was 90% to 100% at 1 to 2 years and 50% to 87% at 2 to 3 years. Publications reporting robotic cases demonstrated a 90% to 96% overall survival in 1 to 2 years of followup. Despite the surge of centers adopting minimally invasive approaches for radical cystectomy, the long-term effectiveness of these techniques has not yet been proven. This review of recent and landmark articles on open and minimally invasive procedures emphasizes the need for prospective controlled studies and long-term followup data to determine the proper use of laparoscopic and robotic assisted techniques in bladder cancer surgery.

How Do Commonly Performed Lymphadenectomy Templates Influence Bladder Cancer Nodal Stage?

Determining pathological nodal stage in patients with bladder cancer is important for prognosis. We determined how the extent of lymphadenectomy and the lymph node count influence accurate nodal staging. The study included 120 patients who underwent at least extended lymphadenectomy at radical cystectomy. Different anatomical templates for lymphadenectomy were evaluated for nodal staging accuracy. The cumulative percent was plotted to determine a lymph node count that confidently identified node positive cases. The mean +/- SD total lymph node count in the study population was 36.9 +/- 14.8 at extended lymphadenectomy. Of the patients 36 (30%) had lymph node metastasis, including 14 (39%) with metastasis involving the common iliac and/or presacral lymph nodes. Limited, standard and extended lymphadenectomy accurately identified 75%, 88.9% and 100% of node positive cases, respectively. Removing 23 and 27 lymph nodes provided 80% and 90% confidence, respectively, that a case was accurately staged as pN0. No patient had lymph node metastasis above the aortic bifurcation without nodal metastasis below the aortic bifurcation and none had a change in pN stage by extending lymphadenectomy above the aortic bifurcation. To accurately identify node positive and negative cases, and correctly assign pN stage in node positive cases it is necessary to perform extended lymphadenectomy. Identifying at least 23 to 27 lymph nodes on final pathological evaluation provides a high level of confidence that a case is correctly staged as node positive or negative.

O321 Extent of pelvic lymphadenectomy in women with squamous cell carcinoma of the uterine cervix: is there any prognostic value?

O321 Extent of pelvic lymphadenectomy in women with squamous cell carcinoma of the uterine cervix: is there any prognostic value?

The Role and Extent of Pelvic Lymphadenectomy in the Management of Patients with Invasive Urothelial Carcinoma

Lymph node metastases are the most important prognostic variable in determining outcome following radical cystectomy. An anatomic bilateral node dissection includes at a minimum the external and internal iliac and obturator lymph nodes. An extended node dissection may include the distal aortic and vena caval nodes, bilateral common iliac, and pre-sacral nodes, which receive direct lymphatic drainage from the posterior bladder and trigone. This approach sets up the cystectomy, maximizes sensitivity for detection of nodal metastasis, assures optimum local pelvic cancer control, and accurately identifies those high-risk patients with node metastases who may benefit from adjuvant chemotherapy. Lymph node retrieval is affected by several variables of node specimens addition to the anatomic extent of the node dissection. These include presentation to the pathologist in packets, specimen processing and what the pathologist calls a lymph node, and patient age. The current TNM staging system accounts for the number and size of node metastases and may be improved by incorporating lymph node density, which is a composite variable incorporating the number of positive nodes and number of nodes retrieved--a possible surrogate for the extent of the node dissection. Innovations in imaging including novel MRI contrast agents and lymphoscintigraphy may improve the pre-treatment and intra-operative identification of node metastases and lymphatic anatomy. Minimally invasive surgical techniques including robotic-assisted laparoscopic cystectomy may improve peri-operative outcomes but must meet the standard of anatomic node dissection and long-term cancer control afforded by the gold standard of anatomic radical cystectomy and bilateral pelvic and iliac node dissection.

Extent of pelvic lymphadenectomy in women with squamous cell carcinoma of the uterine cervix: Is there any prognostic value?

Some authors states that the removal of lymph node would only contribute towards assessing the lymph node status and regional disease control, without any benefit for the patients' survival. The aim of this paper was to assess the influence of the number of surgically dissected pelvic lymph nodes (PLN) on disease-free survival. Retrospective cohort study on 42 women presenting squamous cell carcinoma (SCC) of the uterine cervix, with metastases in PLN treated by radical surgery. The Cox model was used to identify risk factors for recurrence. The model variables were adjusted for treatment-related factors (year of treatment, surgical margins and postoperative radiotherapy). The cutoff value for classifying the lymphadenectomy as comprehensive (15 PLN or more) or non-comprehensive (<15 PLN) was determined from analysis of the ROC curve. Fourteen recurrences (32.6%) were recorded: three pelvic, eight distant, two both pelvic and distant, and one at an unknown location. The following risk factors for recurrence were identified: invasion of the deep third of the cervix and number of dissected lymph nodes <15. Deep invasion and non-comprehensive pelvic lymphadenectomy are possible risk factors for recurrence of SCC of the uterine cervix with metastases in PLN.

The incidence of lymph node metastases in prostate carcinoma depends not only on tumor characteristics but also on surgical performance and extent of pelvic lymphadenectomy

The purpose of the present study was to determine whether predictions of the incidence of pelvic lymph node metastases in patients with similar prostate cancer characteristics are influenced by the extent of pelvic lymphadenectomy or surgical performance. Data from a prostate cancer database were analyzed to investigate associations between incidence of lymph node metastasis and preoperative prostate-specific antigen level, clinical stage, biopsy Gleason score, extent of pelvic lymphadenectomy, and surgical performance. Subgroups of patients with the same characteristics were formed, and a multivariate analysis was performed. Data of 668 patients with cT1-T2c prostate cancer who underwent radical retropubic prostatectomy with pelvic lymphadenectomy were analyzed. Lymph node metastases were found in 8.7% of these patients. In the subgroup of patients undergoing limited pelvic lymphadenectomy, 6.3% were affected compared with 14.7% of patients undergoing extended pelvic lymphadenectomy (P<0.0005). In the subgroups of patients with the same tumor characteristics (with only two exceptions), the impact of the extent of lymphadenectomy on the incidence of lymph node metastases was evident. The results of the multivariate analysis corroborated the influence of the extent of pelvic lymphadenectomy (P<0.03) and surgical performance (P<0.04) on the incidence of lymph node metastases. The incidence of lymph node metastases was dependent not only on preoperative prostate-specific antigen level, clinical stage, and biopsy Gleason score but also to a large degree on surgical performance and the extent of pelvic lymphadenectomy. Our data suggest that a limited and/or not thoroughly performed pelvic lymphadenectomy results in failure to detect a relevant proportion of lymph node metastases.