External Obturator Research Articles

Detection of lymph nodes in pelvic malignancies with computed tomography and magnetic resonance imaging

Thirty patients with prostate or bladder cancer underwent CT and MRI for nodal staging. CT detected 189 nodes, and MRI detected 271 nodes. This difference was statistically significant in the external iliac (CT/MRI=73/87 nodes), obturator (CT/MRI=48/75 nodes), and internal iliac (CT/MRI=24/46 nodes) nodal chains. Based on size, the number of nodes detected by CT and MRI were as follows: 1–5 mm, CT/MRI=91/166; 6–10 mm, CT/MRI=91/98; >10 mm, CT/MRI=7/7 nodes. MRI detected significantly more lymph nodes in the size range of 1–5 mm.

Anatomy of piriformis, obturator internus and obturator externus

We dissected 20 cadaver hips in order to investigate the anatomy and excursion of the trochanteric muscles in relation to the posterior approach for total hip replacement. String models of each muscle were created and their excursion measured while the femur was moved between its anatomical position and the dislocated position. The position of the hip was determined by computer navigation. In contrast to previous studies which showed a separate insertion of piriformis and obturator internus, our findings indicated that piriformis inserted onto the superior and anterior margins of the greater trochanter through a conjoint tendon with obturator internus, and had connections to gluteus medius posteriorly. Division of these connections allowed lateral mobilisation of gluteus medius with minimal retraction. Analysis of the excursion of these muscles revealed that positioning the thigh for preparation of the femur through this approach elongated piriformis to a maximum of 182%, obturator internus to 185% and obturator externus to 220% of their resting lengths, which are above the thresholds for rupture of these muscles. Our findings suggested that gluteus medius may be protected from overstretching by release of its connection with the conjoint tendon. In addition, failure to detach piriformis or the obturators during a posterior approach for total hip replacement could potentially produce damage to these muscles because of over-stretching, obturator externus being the most vulnerable.

Unusual Presentation of Urothelial Carcinoma of the Bladder With Noncontiguous Rectal and Diffuse Muscular Skeletal Metastases

AN 83-year-old man presented with frequent bowel movements and weight loss in the last 6 months. History was remarkable for hypertension and diabetes mellitus. Digital rectal examination revealed a tumor 3 cm from the anal verge, which was subsequently confirmed by rectoscopy. Biopsy revealed poorly differentiated carcinoma. The tumor cells stained strongly positive for CK7, weakly positive for CK20, and negative for CDX-2 and S-100. Therefore, primary adenocarcinoma of the colon was less likely and tumor growth of urothelial origin was suspected. Subsequent computerized tomography (CT) of the abdomen showed thickening of the right posterior wall of the bladder and noncontiguous circumferential thickening of the rectal wall (figs. 1 and 2). CT also revealed extensively infiltrative, strong enhancing lesions in multiple skeletal muscles, including bilateral psoas major, quadratus lumborum, iliacus, gluteus medius/minimus, obturator externus, quadratus femoris and adductor brevis/magnus. Cystoscopic biopsy of the bladder tumor confirmed high grade urothelial carcinoma. Ultrasound biopsy was performed for the skeletal muscle lesion and the result was consistent with metastatic urothelial carcinoma. The patient was treated with chemotherapy. Bladder urothelial carcinoma often metastasizes to regional lymph nodes, liver, lung and bone. The lower gastrointestinal tract is usually involved by direct tumor invasion. Noncontiguous rectal metastasis from urothelial carcinoma presenting as an annular rectal tumor is rare. 1 This case had concomitant diffuse skeletal muscle metastasis, which is an even rarer presentation of urothelial carcinoma. 2 Metastatic muscular lesions of urothelial carcinoma origin usually show low density and ring enhancement on CT. 3 However, in

Pelvic node dissection in prostate cancer: extended, limited, or not at all?

Pelvic lymph node dissection in patients with clinically localized prostate cancer has long been an established part of radical prostatectomy that provides prognostic information in men with locally metastatic disease. However, given downward stage migration over the last 25 years, it is no longer clear that pelvic lymphadenectomy is pertinent for most men diagnosed today. In men in whom it is pertinent, it is unclear how extensive a lymphadenectomy should be performed. Computed tomography and magnetic resonance imaging alone are not accurate for detecting nodal metastases, but new modalities such as magnetic resonance lymphography have great apparent potential. Until these become widely available, pelvic lymph node dissection remains the modality of choice for detecting lymph node metastasis. A variety of predictive nomograms exists to predict lymph node involvement. As a pelvic lymphadenectomy has complications that generally increase with extent of dissection, lymphadenectomy should be limited to patients at an increased risk of nodal metastasis. There is good evidence that a pelvic lymph node dissection limited to the external iliac vein nodes is unnecessary in men with low-risk prostate cancer. A standard external iliac and obturator lymph node dissection, with or without extension to hypogastric nodes, makes sense in cases of intermediate and high risk. Harvesting a greater number of lymph nodes adds prognostic and even therapeutic benefit in many cases, including in some men with no obvious nodal metastases.

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...

396 IS MORE NECESSARILY BETTER?: STANDARD VERSUS EXTENDED PELVIC LYMPH NODE DISSECTION DURING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Staging III1 Apr 2010396 IS MORE NECESSARILY BETTER?: STANDARD VERSUS EXTENDED PELVIC LYMPH NODE DISSECTION DURING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY Jay Shah, Huong Truong, Mary Achim, and John Davis Jay ShahJay Shah More articles by this author , Huong TruongHuong Truong More articles by this author , Mary AchimMary Achim More articles by this author , and John DavisJohn Davis More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.465AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES For men undergoing open radical prostatectomy, recent literature suggests that extended PLND is better than standard PLND for detecting lymph node-positive prostate cancer. In keeping with this, the most recent NCCN guidelines recommend that an extended template be used in those cases where PLND is performed. In contrast to this trend, PLND is often omitted during robotic-assisted laparoscopic prostatectomy (RALP) due to the technical difficulty of reaching the lymph node fields and to the low-risk nature of the disease in most men undergoing RALP. We sought to evaluate the utility of extended PLND in men undergoing RALP. METHODS We retrospectively reviewed the experience of a single surgeon (JWD) performing RALP over three years. From May 2006 to October 2007, all robotic PLND were performed using a standard template (obturator nodes only). From November 2007 to May 2009, the technique was modified and all robotic PLND were performed using an extended template (external iliac, internal iliac, obturator, and hypogastric nodes). These two cohorts of men were well-matched with regards to pre-operative PSA, Gleason sum, and clinical stage. We compared lymph node yields in men undergoing standard versus extended PLND during RALP and we used the Fisher's exact test to determine differences in rates of LN positivity. RESULTS Of 612 patients that underwent RALP between May 2006 and May 2009, 118 had standard PLND and 150 had extended PLND. The average number of LNs removed was 8.0 for standard PLND and 17.4 for extended PLND. The rate of LN positive disease was 6.8% for standard PLND versus 20% for extended PLND (p = 0.0024). CONCLUSIONS Routine use of extended PLND as part of RALP provides higher LN yield and greater detection of LN positive disease. In keeping with current NCCN guidelines and similar to the trend for open radical prostatectomy, an extended template should be considered for all men undergoing RALP in whom a PLND is to be performed. Houston, TX© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e157 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jay Shah More articles by this author Huong Truong More articles by this author Mary Achim More articles by this author John Davis 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 ...

399 PELVIC LYMPH NODE COUNT AND DISTRIBUTION IN 500 ROBOT ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY: ANALYSIS OF 6723 NODES

You have accessJournal of UrologyProstate Cancer: Staging III1 Apr 2010399 PELVIC LYMPH NODE COUNT AND DISTRIBUTION IN 500 ROBOT ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY: ANALYSIS OF 6723 NODES Enrique Ian Lorenzo, Wooju Jeong, Cheol Kyu Oh, Young Hoon Lee, Won Tae Kim, Yong Seung Lee, Kyung Hyun Min, and Koon Ho Rha Enrique Ian LorenzoEnrique Ian Lorenzo More articles by this author , Wooju JeongWooju Jeong More articles by this author , Cheol Kyu OhCheol Kyu Oh More articles by this author , Young Hoon LeeYoung Hoon Lee More articles by this author , Won Tae KimWon Tae Kim More articles by this author , Yong Seung LeeYong Seung Lee More articles by this author , Kyung Hyun MinKyung Hyun Min More articles by this author , and Koon Ho RhaKoon Ho Rha More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.468AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To compare lymph node yield and distribution in pathologic T2 and T3-4 prostate cancer METHODS From July 2005 to June 2009, more than 600 RALP were conducted by a single surgeon. 500 underwent pelvic lymph node dissection in either standard or extended template depending on patient and disease characteristics. Data were gathered retrospectively. Standard template includes external iliac, inguinal, and obturator chains of nodes. Extended template includes the same as the standard plus nodes over the internal and common iliac vessels. Data was summarized according to distribution and grouped according to pathologic T stage. Results were compared via T-test for independent variables. RESULTS Standard dissection was done in 467 cases, extended in 33. A total of 6723 nodes were extracted. More nodes were extracted in the left compared to the right (p=.004). Comparing nodal yield in the standard template between pT2 and pT3-4 disease revealed more nodes extracted on the second group (12.43 vs 14.35) p=.002. A similar pattern was observed in the extended template, 17.36 vs 21.36 (p=.041). Table 1 shows the mean lymph node harvest per area. Noted is the higher nodal yield in all areas in T3-4 disease. Positive nodes were detected in the obturator chain in 43.14%, external iliac chain in 37.25%, inguinal nodes in 3.92%, internal and common iliac chain 7.84% and 7.84% in perivesical fat area. CONCLUSIONS More nodes are harvested on the left compared to the right. Interestingly more nodes were dissected in pT3-4 disease than in pT2 disease in all lymph node chains. Most common sites of nodal metastasis are the obturator and external iliac chains. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e158 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Enrique Ian Lorenzo More articles by this author Wooju Jeong More articles by this author Cheol Kyu Oh More articles by this author Young Hoon Lee More articles by this author Won Tae Kim More articles by this author Yong Seung Lee More articles by this author Kyung Hyun Min More articles by this author Koon Ho Rha More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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

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

398 SUBJECTIVITY IN MEASURING THE QUALITY OF PELVIC LYMPH NODE DISSECTION BY THE NUMBER OF LYMPH NODES REMOVED

You have accessJournal of UrologyProstate Cancer: Staging III1 Apr 2010398 SUBJECTIVITY IN MEASURING THE QUALITY OF PELVIC LYMPH NODE DISSECTION BY THE NUMBER OF LYMPH NODES REMOVED Karim Touijer, Caroline Savage, James Eastham, Peter Scardino, and Bertrand Guillonneau Karim TouijerKarim Touijer More articles by this author , Caroline SavageCaroline Savage More articles by this author , James EasthamJames Eastham More articles by this author , Peter ScardinoPeter Scardino More articles by this author , and Bertrand GuillonneauBertrand Guillonneau More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.467AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The correlation between the anatomical extent and number of lymph node (LN) retrieval during radical prostatectomy has led some investigators to propose a required minimal number of LN to determine the quality of a lymph node dissection (LND). Our aim was to examine the number of LN removed over time for men undergoing a standard pelvic LND during radical prostatectomy METHODS Between February 2005 and September 2009, 2119 patients with clinically localized prostate cancer underwent a standard pelvic LND including the external iliac, hypogastric and obturator fossa nodal groups, during radical prostatectomy. Surgery was performed via an open or laparoscopic approach. Those who were missing data on the number of LN removed (n=17) were excluded, leaving 2102 patients available for analysis. To test whether the number of LN increased over time, we entered the date of each patient's surgery into a linear regression model. To allow for a potential non-linear relationship between the date of surgery and number of LN removed, date of surgery was entered into the model with non-linear terms (restricted cubic splines). To account for potential differences in the patient population over time, we also adjusted for the probability of having a positive LN using the nomogram. RESULTS Overall we did not observe large differences in the number of LN removed between 2005 and 2008 (median 13; IQR 9, 19). From 2008 onward, there appears to be a large increase in the number of LN removed (median 18; IQR 12, 26). When the date of surgery was included as a predictor of the number of LN, it was highly significant (p<0.001; Figure). Adjustment for the probability of having a positive LN did not importantly change the results. The anatomical template of the LND, the specimen submission and pathological assessment were unchanged during the study period. However, the nodal yield increase in the later part of the study coincides with an increase in the academic interest in LND and metastasis in prostate cancer department wide. CONCLUSIONS Although a good surrogate of the quality of lymph node dissection, the number of lymph node retrieved in our databases in general is influenced by a number of subjective factors often unaccounted for in the scientific analyses conducted. New York, NY© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e157-e158 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Karim Touijer More articles by this author Caroline Savage More articles by this author James Eastham More articles by this author Peter Scardino More articles by this author Bertrand Guillonneau More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robot‐assisted laparoscopic radical prostatectomy in the Asian population: Modified port configuration and ultradissection

We have carried out over 360 cases of robot-assisted laparoscopic radical prostatectomy (RARP) to date. In the present study, we detail our current technique at Yonsei University College of Medicine. The six-port transperitoneal approach is utilized. The most lateral two ports were placed medially and caudally in patients with a small pelvis to avoid interference between the ports and the pelvis (modified port configuration). Lymph node dissection is carried out in the external iliac, obturator and infraobturator area. The dissection on the lateral border of the bladder neck is carried out until it reaches the seminal vesicle (ultradissection). After transection of the bladder neck, vasa seminal vesicles are dissected further. Neurovascular bundles are preserved in selected patients. The dorsal venous complex (DVC) and the urethra are transected without suturing. Urethrovesical anastomosis is carried out with 3-0 monocryl running suture, incorporating with the edge of DVC. The puboprostatic collar and bladder are incorporated by 3-0 monocryl running suture (puboperineoplasty). Between November 2007 and September 2008, RARP was carried out using this technique in 182 patients. Median height, weight, body mass index and prostate-specific antigen (PSA) were 168 cm, 68 kg, 24 kg/M(2) and 7.1 ng/mL, respectively. Mean operative time was 192 min and average blood loss was 250 mL. Median catheterization time was 8 days. Positive surgical margin rates for pT2, pT3 and pT4 disease was 12.7, 48 and 100%, respectively. Intraoperative complication rate was 2.7%. Fifty-five patients completed a minimum of 10 months follow up. Their continence rate was 91%. RARP is a safe and feasible surgical modality for prostate cancer among Asian patients with a small pelvis. Our technique achieves a precise bladder neck dissection.

The Role of Lymphadenectomy in Radical Cystectomy

Abstract Detection of lymph node metastases in patients undergoing radical cystectomy and pelvic lymph node dissection (PLND) for bladder cancer indicates poor prognosis. For pretreatment assessment of lymph node status, computed tomography and magnetic resonance imaging are generally performed, both of which show a low sensitivity of approximately 30%. Newer imaging techniques are being developed; however, it will take time until they can be used in everyday clinical practice. Therefore, PLND remains the only reliable method for lymph node staging in the pelvis. The extent of PLND remains a matter of discussion, but a recent study mapping the lymphatic drainage from the bladder suggests that the template for an appropriate PLND at cystectomy should include the external iliac, obturator, and internal iliac region (lateral and medial to the internal iliac vessels) as well as the common iliac vessels up to the uretero-iliac junctions bilaterally. Additionally, the lymph nodes of the fossa of Marcille should be removed. Questions remain about whether it is worthwhile to resect the few draining lymph nodes between the uretero-iliac junctions and the inferior mesenteric artery with regard to both the increased risk of complications and the injury to the autonomic sympathetic nerves. In addition, PLND at the time of radical cystectomy not only is associated with more accurate staging but also allows removal of undetected micrometastases in patients with bladder cancer. Evidence is growing that extended PLND in patients with bladder cancer may confer a survival benefit for node-positive and node-negative patients without increasing morbidity.

Single photon emission computed tomography SPECT-CT improves sentinel node detection and localization in cervical and uterine malignancy

Objectives. Planar lymphoscintigraphy (LSG) is frequently performed for the assessment of the sentinel lymph nodes (SLN) in gynecologic malignancies. Planar imaging helps to localize hot nodes but lacks accuracy of the anatomic location of those nodes. In this study, we compared SPECT-CT to planar LSG in endometrial and cervical cancer to assess its ability to localize SLN. Methods. We conducted a prospective nonrandomized study of SLN mapping in women with endometrial and cervical cancer. Forty patients with endometrial cancer and 10 with cervical cancer underwent pre-operative LSG with 1 or 4 mCi of 99mTc sulfur colloid administered as injections into the cervix. All patients were scanned immediately with planar LSG obtained in the anterior and lateral views. SPECT-CT imaging was obtained following the planar imaging. Results. Planar LSG alone localized SLN in 30/40 (75%) endometrial cancer patients while SPECT-CT localized SLN in all 40 patients (100%). In the 10 cases where SLN was not identified with planar imaging, SPECT-CT localized nodes in the external iliac, internal iliac, common iliac and obturator groups. In cervical cancer, planar LSG alone localized sentinel lymph nodes in 8/10 patients (80%) as compared to SPECT-CT, which localized nodes in all 10 patients (100%). SPECT-CT imaging was especially useful in delineating external iliac versus internal iliac or obturator nodes, and the parametrial nodal uptake. Conclusions. SPECT-CT appears to improve sentinel lymph node detection and anatomic localization as compared to planar imaging in cervical and uterine cancer.

Advanced carcinoma of the prostatic urethra in a patient with marked response to chemotherapy, leading to preservation of the bladder

We performed transurethral resection of the prostate (TUR-P) for a 66-year-old man with benign prostatic hyperplasia. Pathological examination diagnosed poorly differentiated urothelial carcinoma of the urethra with broad prostatic permeation. Random bladder biopsies showed no malignancy, but a second TUR-P revealed urothelial carcinoma in the prostate and bladder neck. Computed tomography (CT) showed lymph node metastases from para-aortic to right/left external iliac and left obturator nodes, so clinical stage T3N2M0 carcinoma of the prostatic urethra was diagnosed. Given the presence of lymph node metastases, neoadjuvant chemotherapy using cisplatin 70 mg/m(2), ifosfamide 1.2 g/m(2) and docetaxel 70 mg/m(2) (PIT) was considered. After chemotherapy, CT showed complete response (CR) of all lymph nodes. Local control in the bladder was considered to be good, so total prostatectomy and retroperitoneal lymph node dissection was selected instead of total cystoprostatectomy. Pathological findings of surgical specimens showed no residual carcinoma in the prostatic urethra or lymph nodes, although prostatic adenocarcinoma was recognized. No recurrences or metastases have been encountered as of 3 years and 5 months since surgery.

Relationship between cup position and obturator externus muscle in total hip arthroplasty

BackgroundIt is often challenging to find the causes for postoperative pain syndromes after total hip replacement, since they can be very allotropic. One possible cause is the muscular impingement syndrome. The most commonly known impingement syndrome is the psoas impingement. Another recently described impingement syndrome is the obturator externus muscle impingement. The aim of this study is to analyze pathological conditions of the Obturator externus and to show possible causes.Methods40 patients who had undergone a total hip replacement were subjected to clinical and MRI examinations 12 months after the surgery. The Harris Hip Score (HHS) was used to analyze pain and function. Additionally, a satisfaction score and a pain score (VAS) were determined. The MRI allowed for the assessment of the spatial relation between the obturator externus muscle and the acetabulum. Also measured were the acetabular inclination angle as well as the volume and cross-sectional area of the obturator externus muscle.ResultsThe patients were assigned to 3 groups in accordance with their MRI results. Group 1 patients (n = 18) showed no contact between the obturator externus and the acetabulum. Group 2 (n = 13) showed contact, and group 3 (n = 9) an additional clear displacement of the muscle in its course. It was not possible to establish a connection between the imaging findings, the HHS, the VAS, and patient satisfaction. What was striking, however, was a significant difference between the median inclination angle in group 1 (40° ± 5.4°) and group 3 (49° ± 4.7°) (p < 0.05), and the corresponding image-morphological pathology. The average inclination angle in group 2 was 43.3° ± 3.8°ConclusionContact between the obturator externus muscle and the caudal acetabula border occurs frequently, but is only rarely accompanied by a painful muscular impingement. The position of the acetabula must be seen as one of the main risk factors for contact between the acetabula border and the obturator. The hip replacement process must provide for sufficient osseous coverage of the caudal acetabula border. Furthermore, the retention of the transverse ligament may serve as protective cover for the incisura acetabuli.

Detecting Lymph Nodes Metastasis in Prostate Cancer through Extended vs. Standard Laparoscopic Pelvic Lymphadenectomy

Pelvic lymphadenectomy is the best method for staging localized prostate cancer. There is no consensus about how the pelvic lymphadenectomy should be performed for patients with cT2, Gleason score 7 or higher, PSA higher than 10 ng/mL. Scintigraphic studies of prostate lymph drainage show that many lymph nodes are not dissected according to the current recommendation of lymphadenectomy which could explain the high rate of cancer recurrence. The objectives of this work are an analysis of the local lymph node metastasis according to the preoperative data (digital examination, PSA and Gleason score) and a comparison between laparoscopic extended and limited pelvic lymphadenectomy, for staging, their technique and complications. Two groups were created for analysis. The indications for laparoscopic pelvic lymph-adenectomy are the following: preoperative PSA 10 ng/mL or higher, Gleason score 7 or higher and/or digital examination cT2. Patients with suspected distant metastasis were excluded. The first group is composed of the patients who under-went a limited laparoscopic pelvic lymphadenectomy (LLPL) between January 1995 and December 2002. The medical data were analyzed retrospectively. The second group was created with patients who received extended laparoscopic pelvic lymphadenectomy (ELPL). These data were consecutively collected between November 2006 and October 2007. LLPL was the extraction of the external iliac and obturator lymph nodes. ELPL included, additionally, dissection of the internal iliac lymph nodes as well as tissue medial to the genitofemoral nerve. Histopathological findings were compared with serum PSA, histopathological stage and preoperative biopsy. Complications, operating time, and number of extracted lymph nodes were also compared. There were no significant differences in age, serum PSA or mean biopsy Gleason between two groups. The first group (LPLL) is composed of 381 patients and the second (ELPL), 163. The mean operating time was 72.5 minutes for LLPL and 84.3 for ELPL. The mean number of lymph nodes extracted was 13.8 (LLPL) and 31.1 (ELPL). Metastases were detected in 18.8% (LLPL) and 24.7% (ELPL). In 37.5% of cases, the metastasis occurred in lymph nodes outside from those dissected by LPLL. The rates of complications and conversion rate were not significantly different for the two groups. For patients with clinically localized prostate cancer, ELPL is associated with a higher rate of detection of lymph node metastasis outside of the field dissected in the LPLL. Pelvic lymphadenectomy, especially extraction of the lymph nodes of the internal iliac is important in patients with preoperative Gleason score 7 or greater and/or serum PSA greater than 10 ng/mL. Laparoscopic lymphadenectomy does not augment the rate of complications and is an excellent technique in prostate cancer staging.

Letter to the Editor: Use of a Trochanteric Flip Osteotomy Improves Outcomes in Pipkin IV Fractures

To the Editor: We were interested to read the article by Solberg et al. [3] entitled “Use of a trochanteric flip osteotomy improves outcomes in Pipkin IV fractures.” The authors reported that combined fractures of the femoral head and acetabulum are relatively rare injuries and the debate continues regarding optimal surgical management of these injuries. We commend the authors on their excellent results and would like to add our support to their selection of this surgical approach. St George’s Healthcare NHS Trust provides a supraregional service for pelvic and actetabular trauma referrals. We corroborate the authors’ observation that a trochanteric flip osteotomy during the course of a posterior approach allows excellent access to the femoral head and acetabular fragments through one incision. However, we note some differences in our practice and wish to bring these to the authors’ attention. While describing the surgical approach, Solberg et al. explained that they tag and release the piriformis tendon but preserve the short external rotators. This contrasts with the approach originally described by Siebenrock et al. [2], which is the technique we tend to follow. Releasing the gemelli and obturator internus close to their insertion at the posterior trochanteric crest improves exposure of the posterior wall and facilitates application of a buttress plate for osteosynthesis. We do not believe this approach jeopardizes the vascularity of the femoral head. The retinacular vessels are identified and protected during surgery. The obturator externus and quadratus femoris, however, are not released, thus preserving the deep branch of the medial circumflex artery. Solberg et al. identified coexisting labral tears in all their patients and repaired seven of 12 tears by direct osteosynthesis. The technique of osteosynthesis is not described and a brief description would be appreciated. We also have found coexistent labral tears that we have repaired using Mitek suture anchors to exposed cancellous bone at the acetabular rim. We also administer low molecular weight heparin (eg, Fragmin) 6 hours postoperatively. Subsequently, warfarin is commenced with a loading regimen and is continued for 3 months. We do not routinely perform duplex ultrasound screening, although high-risk patients would be considered for a vena cava filter. Solberg et al. reported one case of wound dehiscence in their series and we would be interested to know if a cause was identified. Prophylaxis for heterotopic ossification remains controversial with a recent review [1] stating the benefit of prophylactic radiotherapy when compared with nonsteroidal antiinflammatory drugs. Another systematic review [4] however, concluded the opposite. In our practice, we reserve prophylactic radiation for high-risk patients, for example, those who have a coexisting head injury or a history of heterotopic ossification. We once again commend the authors on their contribution and look forward to their clarification of these issues.

Safe Zone for Transacetabular Screw Fixation in Prosthetic Acetabular Reconstruction of High Developmental Dysplasia of the Hip

Prosthetic reconstruction of hips with Crowe type-IV developmental dysplasia (a high complete dislocation) is technically demanding. Insufficient osseous coverage and osteopenic bone stock frequently necessitate transacetabular screw fixation to augment primary stability of the metal acetabular shell. We sought to determine whether a previously reported quadrant system for screw fixation of the acetabular cup can be applied in patients with high dislocation of the hip and to define a specialized safe zone for screw fixation in these hips, if needed. Using volumetric computed tomographic data and image-processing software, we made three-dimensional reconstructions of the osseous and vascular structures in eighteen hips in twelve patients. We virtually reconstructed a cup in the true acetabulum and dynamically simulated transacetabular screw fixation. We mapped the hemispheric cup into several areas and, for each, measured the distance between the virtual screw and the external iliac (femoral) and obturator blood vessels. In the six patients with unilateral high dislocation of the hip and a relatively normal, contralateral hip, the six relatively normal hips served as controls. Reconstruction of the cup at the level of the true acetabulum shifted the center of rotation anteroinferiorly in the hips with a high, complete dislocation. Screws guided by the quadrant system frequently injured the obturator blood vessels in the hips with a high dislocation. In these patients, the safe zone shifted as a result of moving the prosthetic cup. The quadrant system, although helpful in determining screw placement in hips with a normal center of rotation, can be misleading and of less value in guiding screw insertion to augment acetabular shells for hips with a high dislocation. We believe that a safe zone specific to hips with a high dislocation should be used to guide transacetabular screw fixation.

A New Multimodality Technique Accurately Maps the Primary Lymphatic Landing Sites of the Bladder

BackgroundPathoanatomic studies have failed to map accurately the primary lymphatic landing sites of the urinary bladder. ObjectiveTo use single-photon emission computed tomography (SPECT) combined with computed tomography (CT) plus intraoperative gamma probe verification to map the primary lymphatic landing sites of the bladder. Design, setting, and participantsClinical trial of 60 consecutive cystectomy patients at a single centre. InterventionFlexible cystoscopy-guided injection of technetium nanocolloid into one of six non-tumour-bearing sites of the bladder for preoperative detection of radioactive lymph nodes (LNs) with SPECT/CT followed by intraoperative verification with a gamma probe. Backup extended pelvic LN dissection (PLND) for ex vivo detection of missed LNs. MeasurementsThree-dimensional projection of each LN site. Results and limitationsA median of 4 (range: 1–14) radioactive LNs were detected per site and patient. Ninety-two percent of all LNs were found distal and caudal to where the ureter crosses the common iliac arteries. Eight percent were found proximal to the uretero-iliac crossing, none without simultaneous detection of additional radioactive LNs within the endopelvic region. Extended PLND resected 92% of all primary lymphatic landing sites; limited PLND resected only 52%. A few LNs may have been missed despite preoperative SPECT/CT, intraoperative gamma probe verification, and extended backup PLND. ConclusionsMultimodality SPECT/CT plus intraoperative gamma probe show the template of the bladder’s primary lymphatic landing sites to be larger than is often thought. PLND limited to the ventral portion of the external iliac vessels and obturator fossa removes only about 50% of all primary lymphatic landing sites, whereas extended PLND along the major pelvic vessels, including the internal iliac, external iliac, obturator, and common iliac region up to the uretero-iliac crossing, removes about 90%. Trial registrationClinicalTrials.gov, ISRCTN39379749.

Pelvic lymphadenectomy in cervical cancer—surgical anatomy and proposal for a new classification system

Background Pelvic lymphadenectomy is an integral component of gynecologic cancer surgery, yet there is a lack of standardization in the terminology used, the extent of the procedure, and the definition of anatomic landmarks. This lack of standardization if corrected will likely facilitate a more clear communication and analysis of outcomes from various institutions, and reduce confusion to trainees about the procedure being performed. Methods We summarize the anatomic data concerning pelvic lymphatic drainage; describe the procedure based on clearly defined anatomic landmarks; and finally propose a new classification system to facilitate standardization, communication, and comparison of results. The accompanying video demonstrates the anatomic landmarks. Results We list and define four commonly used terms related to pelvic lymph node harvesting: sentinel node mapping, excision of bulky nodes, pelvic lymph node sampling, and systematic pelvic lymphadenectomy. We list the five specific anatomic regions of the pelvic lymphatic basin: external iliac, obturator, internal iliac, common iliac, and presacral. We highlight the important neural structures located in regions of the pelvic lymphadenectomy: genitofemoral nerve, obturator nerve, cranial part of the lumbosacral plexus, hypogastric plexus, and splanchnic nerves. Finally, we propose a new, four-part classification system of types of pelvic lymph node dissection. Conclusion In this report and video, we demonstrate anatomy and offer a new classification system for pelvic lymphadenectomy.