Open Pelvic Lymph Node Dissection Research Articles

Robot-assisted pelvic node dissection has similar operative and melanoma outcomes to open pelvic node dissection with shorter hospital stays

Background: Robot-assisted pelvic lymph node dissection (rPLND) has been employed for the surgical management of enlarged lymph nodes to reduce treatment related morbidity. With the adoption of adjuvant systemic therapy in melanoma reducing surgical indications, we set out to investigate its benefits and long-term outcomes compared to open pelvic lymph node dissection (oPLND).

Laparoscopic versus open lateral pelvic lymph node dissection in locally advanced rectal cancer: multicentre retrospective cohort study.

BackgroundLateral pelvic lymph node dissection (LPLND) is an option in the treatment of rectal cancer and may reduce local recurrence/improve disease-free survival. Advancements in minimally invasive technology have improved the ability to identify anatomy and neurovascular structures that may help in LPLND. The aim of this retrospective study was to evaluate the technical feasibility and oncological safety of laparoscopic LPLND compared with the open LPLND.MethodBetween July 2010 and July 2019, patients from three tertiary referral hospitals who underwent LPLND with total mesorectal excision for primary rectal cancer were included. Baseline patient characteristics, perioperative outcomes, pathologic results, recurrence, and survival were compared between the laparoscopic and open groups.ResultsThere were 126 and 70 patients in the laparoscopic and open groups respectively. The laparoscopic group had less estimated blood loss (100 ml versus 300 ml, P < 0.001) and lower transfusion rate (0.8 per cent versus 10.0 per cent; P = 0.003) but longer operating times (318 min versus 270 min, P = 0.004). The laparoscopic group had fewer wound infections (1.6 per cent versus 10.0 per cent, P = 0.011) and neuropathy (0 per cent versus 4.3 per cent, P = 0.044). Lateral pelvic recurrence rate was 7.6 per cent in the laparoscopic group and 19.6 per cent in the open group (P = 0.053). Recurrence-free survival (72.2 per cent versus 63.5 per cent; P = 0.190) and overall survival (93.3 per cent versus 85.0 per cent; P = 0.118) were not significantly different.ConclusionLaparoscopic LPLND was associated with improved perioperative outcomes and non-inferior oncological outcomes.

How reliable are imaging techniques in aging males with bladder cancer?

Introduction The aim of this study was to evaluate consistency between clinical lymph node positivity and pathological lymph node positivity in patients undergoing open radical cystectomy and pelvic lymph node dissection due to bladder cancer. Material and method A total of 135 patients who had open radical cystectomy, extended lymph node dissection, and clear preoperative contrast-enhanced abdominopelvic computed tomography (CT) or magnetic resonance imaging (MRI) images were included in the study. Positive clinical lymph nodes and positive pathological lymph nodeswere recorded. The largest positive clinical and pathological lymph nodeswere recorded. In terms of clinical lymph node involvement, compatibility between radiological findings and pathological results was evaluated. Results In the CT group, the sensitivity was 25.81%, specificity was 95.45%, positive predictive value (PPV) was 66.67%, negative predictive value (NPV) was 78.50%, and accuracy was 77.31%. In the MRI group, the sensitivity was 50.00%, specificity was 100%, PPV was 100%, NPV was 76.92%, and accuracy was 81.25%. For consistency between pathological lymph nodes and clinical lymph nodes according to the imaging type, there was no statistically significant difference in the sensitivity, specificity, NPV, and accuracy rates between the imaging techniques (p > 0.05). However, the PPV was significantly higher in the MRI group than the CT group (100% vs.66.67%, respectively; p = 0.014). Conclusion Positive lymph nodes play a critical role in the prognosis of patients with bladder cancer and the sensitivity of contrast-enhanced abdominopelvic CT and MRI used routinely in clinical practice is low in lymph node detection. MRI seems more reliable than CT in lymph node detection.

Laparoscopic versus open selective lateral pelvic lymph node dissection following total mesorectal excision for locally advanced low rectal cancer.

Lateral pelvic lymph node (LPLN) dissection represents a technically challenging procedure with a high potential risk of surgical morbidity. The purpose of this study was to compare the technical feasibility, safety, and oncological efficacy of laparoscopic LPLN dissection (LPLD) following total mesorectal excision (TME) with open LPLD for locally advanced low rectal cancer (LALRC). Between January 2010 and December 2016, consecutive patients with LALRC and swollen LPLNs who underwent laparoscopic or open TME with LPLD at our institution were enrolled in this retrospective observational study. Data regarding patient demographics, perioperative characteristics, and oncological outcomes were analyzed and compared. A total of 64 patients met the inclusion criteria. Thirty-four patients underwent open procedure, and 30 underwent laparoscopic procedure. The mean blood loss volume was significantly less in the laparoscopic group than in the open group (165 vs. 422mL; P = 0.012). The mean operative time was not significantly different between the laparoscopic and the open groups (354 ± 91 vs. 315 ± 78min; P = 0.522). The overall postoperative complication rates were 30.0% and 35.3% for the laparoscopic and open groups (P = 0.428), respectively. Postoperative urinary retention was significantly less in the laparoscopic group than in the open group (14.7 vs. 0%; P = 0.036).The duration of postoperative hospital stay was significantly shorter in the laparoscopic group (8.5 ± 3.8 vs. 13.6 ± 6.5days; P = 0.025). The numbers of harvested lymph nodes and positive resection margin rates showed no significant differences. Pathological LPLN metastases were confirmed in 10 patients (29.4%) in the open group and 11 (36.7%) in the laparoscopic group (P = 0.537). The median follow-up duration was 41.5months (range 3-98). The laparoscopic and open groups also showed a similar 3-year overall survival rate (88.2% vs. 85.3%; P = 0.577), relapse-free survival rate (73.3% vs. 67.6%; P = 0.889), and local recurrence rate (3.3 vs. 5.9%; P = 0.653). Laparoscopic TME with LPLD is technically feasible and safe in selected patients with LALRC and is associated with similar oncological outcomes as open approach.

Complication reporting with the Bern Comprehensive Complication Index CCI after open radical prostatectomy: A longitudinal long-term single-center study

ObjectiveTo impartially optimize complication reporting in patients after open radical prostatectomy (ORP) and pelvic lymph node dissection (PLND) by adopting the modified Bern Comprehensive Complication Index (CCI). ORP and PLND are associated with relevant postoperative morbidity. The CCI—ranging from 0 (no complications) to 100 (death)—is a tool that aims to integrate all complications occuring within 90 days postoperatively weighted by severity in a single formula. MethodsIn an observational single-center cohort, 90-day postoperative complications of 1,123 consecutive patients undergoing standardized ORP and PLND between 1996 and 2017 were evaluated. Prospectively collected complications were graded according to the Clavien-Dindo Classification. Grade I to II complications were defined as minor and grade IIIa to V as major. Finally, the recently developed modified Bern CCI using an exponential function, which transforms the sum of the weights into a value between 0 and 100 and the original CCI for each patient were extracted and compared. The correlation between the modified Bern and original CCI values was depicted graphically. ResultsThe complication rate was 42%, with 18% minor and 24% major complications. With the original CCI, the threshold of 100 was exceeded in 1 patient who had a maximal index value of 101 within 90d postoperatively. The maximal value of the Bern CCI was 97.5. Mean Bern and original CCI scores and standard deviations were 6.2 (11.3) and 7.6 (12.2) at 30 days, and 9.3 (13.9) and 10.7 (14.2) at 90 days. ConclusionsThe Bern CCI provides a more precise depiction of postoperative morbidity and represents the burden in patients with >1 complication after ORP and PLND more accurately than the original CCI allowing for a more reliable evaluation of quality of care and recovery. It therefore warrants consideration for standardized reporting of complications after ORP and PLND.

Prostatic ductal adenocarcinoma: an unusual case of a rare prostate cancer

A 65 year old gentleman was referred with symptoms of haematuria and haematospermia in association with an elevated prostate specific antigen (PSA). He was investigated with a flexible cystoscopy, Ultrasound scan and a computed tomography (CT) of his abdomen and pelvis. These failed to reveal any abnormality. Magnetic resonance imaging (MRI) revealed a Prostate Imaging Reporting and Data System PIRADS 2 lesion in the left peripheral gland and PIRADS 3 lesion on the right side posterolaterally at the level of mid gland of the prostate. He went on to have Transrectal ultrasound biopsies of his prostate (TRUS Bx) that excluded any pathology. On follow up visits his PSA continued to rise and he underwent Template biopsies of the prostate. The histological features had no evidence of any Prostatic intraepithelial carcinoma (PIN) or other malignancies. Flexible cystoscopy was repeated due to his persistent haematospermia. This showed prominent papillary lesions over his verumontanum and prostatic urethra. Biopsies from these areas revealed Ductal Adenocarcinoma of the Prostate (DACP). A subsequent staging MRI revealed unchanged appearance of the PIRADS2 nodule. There was however some low signal extending into the right seminal vesicle which is more pronounced than on the previous scan reported as PIRADS3. Subsequent mapping Template biopsies and Transurethral biopsies revealed a Gleason 4+4 DCAP. A staging CT and bone scan excluded any metastasis. He went on to receive an open radical prostatectomy and pelvic lymph node dissection as a curative treatment for his locally advanced disease.

Comparison of efficacy between extended pelvic lymph node dissection and standard pelvic lymph node dissection in open radical cystectomy

Objective To compare the efficacy of extended pelvic lymph node dissection (ePLND) and standard pelvic lymph node dissection (sPLND) in open radical cystectomy. Methods We retrospectively analyzed the clinical data of 139 patients with bladder cancer cases in our hospital from January 2007 to January 2017, who underwent open radical cystectomy and pelvic lymph node dissection performed by the same group of surgeons. There were 117 males and 22 females, aged from 20 to 84 years old, with an average of (64.6±11.7) years, 91 patients were underwent ePLND group and 48 patients were underwent sPLND group. The preoperative anemia-free patients was compared between the ePLND group and the sPLND group [24 (50.0%)] vs. 58 (54.9%), respectively], the patients with anemia were [24 (50.0%) vs. 41 (45.1%)]. The range of ePLND is: sway to the common iliac artery and the lower aortic (unreaching the inferior mesenteric artery); the lateral boundary to the reproductive femoral nerve; the distal end of the iliac artery at the groin level, the posterior border to the iliac vessels and closure, which contains the anterior tibial lymph nodes between the two sides. The range of sPLND is below the level of the common iliac artery bifurcation, and the rest of the range is the same as ePLND. The average operative time, average intraoperative blood loss, intraoperative blood transfusion, intraoperative and postoperative complications, postoperative eating time, postoperative activity time, postoperative exhaust time, postoperative hospital stay, mean gastric tube indwelling time, average pelvic drainage tube indwelling time, lymph nodes positive rate, lymph node density, and cancer-free survival were evaluated. Results All 139 patients underwent surgery successfully. The average operative time in the ePLND group and the sPLND group were [(351.2±79.5) min vs.(342.5±69.3) min], average intraoperative blood loss [(314.6±120.6) ml vs.(298.3±126.3) ml], intraoperative blood transfusion [(702.9±645.7) ml vs.(936.9±818.1) ml], no intraoperative complications, postoperative complications [29 cases (31.9%)vs.18 cases (37.5%)], postoperative eating time [(5.4±1.9)d vs.(4.8±2.1)d], postoperative activity time[(2.1±0.9)d vs.(1.9±0.8)d], postoperative exhaust time [(3.8±0.9)d vs.(3.6±1.0)d], postoperative hospital stay [(14.9±7.8) d vs.(15.5 ± 6.9) d], average gastric tube indwelling time [(4.8 ± 2.6) d vs.(4.53± 1.9) d], average pelvic drainage tube indwelling time [( 11.1±4.9)d vs.(10.9±4.9)d], the difference was not statistically significant (P>0.05). A total of 2 359 lymph nodes were dissected from the two groups. The number of lymph nodes dissected in each of the ePLND group and the sPLND group was [(20.3±3.8) vs. (10.6±3.1), P<0.01], and the average number of positive lymph nodes was [(0.6±1.3) vs.(0.3±1.0), P=0.034], the ratio of lymph node positive patients was [33 (36.3%) vs. 9 (18.8%), P=0.026], and the lymph node density was [7.9% (146/1848) vs. 4.1% (21/511)], the difference was statistically significant (P<0.05). In regard to prognosis, the disease-free survival rate (DFS) of ePLND group was 94.5%, 91.0%, 84.4%, 81.1%, 75.3% at 1, 2, 3, 4 and 5 years follow-up respectively. The other group was 70.5%, 63.5%, 57.8%, 51.4%, 41.1% respectively. DFS of ePLND group tended to be higher than that of sPLND group in lymph node positive subgroups. The difference between the two groups was statistically significant (P<0.001). Conclusions In open radical cystectomy, ePLND and sPLND have similar surgical safety, but expanded lymph node dissection can improve disease-free survival in patients and improve the prognosis by increasing the detection range of positive lymph nodes. Key words: Bladder cancer; Radical cystectomy; Lymph node dissection; Cancer-free survival; Prognosis

Comparison of efficacy between extended pelvic lymph node dissection and standard pelvic lymph node dissection in laparoscopic radical cystectomy

Objective To investigate the difference of surgical efficacy between extended lymph node dissection and standard lymph node dissection in laparoscopic radical cystectomy. Methods We retrospectively analyzed 62 bladder cancer cases, icluding 52 males and 10 females patients in our hospital from January 2011 to October 2016, who underwent laparoscopic radical cystectomy and pelvic lymph node dissection. Their mean age was (62.5±9.6)years, ranged from 42 to 83 years.27 cases were underwent extended lymph node dissection and 35 cases were underwent standard lymph node dissection respectively. The basic characters, operative time, intraoperative blood loss, intraoperative and postoperative complications, postoperative eating time, postoperative activity time, postoperative hospital stay, lymph nodes positive rate, lymph node density, and cancer-free survival were evaluated. Results All patients were underwent successful operation. There was no significant difference in operation time[(326.2±77.5)min vs. (345.5±66.8)min, P=0.297], blood loss[ (198.2±77.5)ml vs. (213.7±160.0)ml, P= 0.590], intraoperative complications(0/27 vs. 5/35, F=0.063), postoperative complications(8/27 and 9/35, P=0.732), postoperative eating time[ (4.8±2.2)d vs.(4.6±1.9)d, P=0.817], postoperative activity time[ (1.9±0.8)d vs. (1.9±0.9)d, P=0.838]and postoperative hospital stay[ (15.6±7.5)d vs. (16.0±5.9)d, P=0.483]. In this study, 994 lymph nodes and 100 positive lymph nodes were dissected. There were significant differences in the number of lymph nodes dissected in the two groups (23.2±6.6 vs. 10.5±3.6, P 0.05), DFS of ePLND group tended to be higher than that of sPLND group in lymph node positive subgroups. Conclusions Extended lymph node dissection and standard lymph node dissection have similar surgical safety and prognosis, and appropriate surgical procedures should be selected according to the patient′s condition. Key words: Laparoscopic radical cystectomy; Lymph node dissection; Safety; Prognosis

MP64-16 ADVERSE FEATURES AND COMPETING RISK MORTALITY IN PATIENTS WITH HIGH-RISK PROSTATE CANCER

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy V1 Apr 2017MP64-16 ADVERSE FEATURES AND COMPETING RISK MORTALITY IN PATIENTS WITH HIGH-RISK PROSTATE CANCER Valerio Vagnoni, Lorenzo Bianchi, Marco Borghesi, Cristian Vincenzo Pultrone, Hussam Dababneh, Marco Giampaoli, Martina Sofia Rossi, Francesco Chessa, Daniele Romagnoli, Andrea Angiolini, Giuseppe Martorana, Riccardo Schiavina, and Eugenio Brunocilla Valerio VagnoniValerio Vagnoni More articles by this author , Lorenzo BianchiLorenzo Bianchi More articles by this author , Marco BorghesiMarco Borghesi More articles by this author , Cristian Vincenzo PultroneCristian Vincenzo Pultrone More articles by this author , Hussam DababnehHussam Dababneh More articles by this author , Marco GiampaoliMarco Giampaoli More articles by this author , Martina Sofia RossiMartina Sofia Rossi More articles by this author , Francesco ChessaFrancesco Chessa More articles by this author , Daniele RomagnoliDaniele Romagnoli More articles by this author , Andrea AngioliniAndrea Angiolini More articles by this author , Giuseppe MartoranaGiuseppe Martorana More articles by this author , Riccardo SchiavinaRiccardo Schiavina More articles by this author , and Eugenio BrunocillaEugenio Brunocilla More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1989AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To assess survival and competing causes of mortality in prostate cancer (PCa) patients referred to radical prostatectomy (RP) through a combination of pathologic adverse features (AFs). METHODS A single Tertiary Referral academic institution cohort of 2886 consecutive patients who underwent open or laparoscopic RP and pelvic lymph node dissection (PLND) for PCa between November 1995 and April 2015 was evaluated. Patients referred to neoadjuvant therapy and those lacking clinical, pathologic, and follow-up data were excluded. The final population consisted of 615 patients with at least one AF: preoperative PSA =20 ng/mL, pathologic Gleason score =8 and no organ-confined disease at final pathology (seminal vesicle involvement, and/or positive surgical margins, and/or lymph node invasion). Kaplan-Meier analyses were used to assess cancer-specific mortality (CSM)-free survival rates by stratifying patients into 3 risk categories according to the number of AFs (namely, 1, 2, and 3 AFs). Multivariable competing risk Cox regression analyses were used to assess CSM. The study was performed in line with the Helsinki Declaration. RESULTS Overall, 420 (68.2%) men had 1 AF, 156 (25.3%) had 2 AFs and 39 had 3 AFs (6.3%): among these different risk categories, significant differences in terms of preoperative and pathologic tumor characteristics, adjuvant therapies and biochemical recurrence were found (all p=0.01); overall, 44 (7.1%) of 615 patients died of PCa. Men with 1 AF had higher CSM-free survival estimates compared to those with 2 and 3 AFs (92.8% vs. 84.2% vs. 27.7% at 10 years' follow-up, p<0.001 - Figure). At multivariate competing risk Cox regression analyses, the presence of 3 AFs (hazard ratio [HR]: 2.59), postoperative treatment status, namely adjuvant androgen deprivation therapy (aADT) alone/aADT plus adjuvant radiotherapy (aRT; HR: 2.44) and time to BCR (HR: 0.96), were all independent predictors of CSM (all p<0.04). In the subgroup of individuals referred to aADT alone, men with 2 AFs (HR: 3.11) and 3 AFs (HR: 5.14) had a higher risk of cancer-related death compared to those with 1 AF (all P=0.04). CONCLUSIONS The risk group stratification according to the number of AFs could help physicians to accurately predict oncologic outcomes selecting PCa patients for the most appropriate postoperative strategies. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e850-e851 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Valerio Vagnoni More articles by this author Lorenzo Bianchi More articles by this author Marco Borghesi More articles by this author Cristian Vincenzo Pultrone More articles by this author Hussam Dababneh More articles by this author Marco Giampaoli More articles by this author Martina Sofia Rossi More articles by this author Francesco Chessa More articles by this author Daniele Romagnoli More articles by this author Andrea Angiolini More articles by this author Giuseppe Martorana More articles by this author Riccardo Schiavina More articles by this author Eugenio Brunocilla More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Contemporary minimally-invasive extended pelvic lymph node dissection for prostate cancer before curative radiotherapy: prospective standardized analysis of complications.

To prospectively assess contemporary complication rates of minimally-invasive staging pelvic lymph node dissection before curative radiotherapy for prostate cancer using a standardized classification. A total of 100 prostate cancer patients underwent laparoscopic or robot-assisted pelvic lymph node dissection (95% extended). Surgical outcomes were compared with those of 43 patients undergoing open pelvic lymph node dissection (33% extended). Complications were recorded prospectively during hospitalization and follow-up visits, and graded using Clavien-Dindo classification. Lymphocele size was measured on postoperative magnetic resonance imaging or computed tomography. Of the complications recorded, 10% were grade 1, 3% were grade 2 and 6% were grade 3. No grade 4-5 complications occurred. Compared with open pelvic lymph node dissection, minimally-invasive pelvic lymph node dissection was associated with less blood loss (P = 0.001) and shorter hospital stay (median 3 vs 6 days; P < 0.001), but longer operation time (130 vs 98 min; P < 0.001). The complication rate was similar in both groups. For the entire cohort, overall and symptomatic lymphoceles were seen in 91 (64%) and 18 patients (13%), respectively. On multivariate logistic regression, minimally-invasive surgery was the only independent predictor for lymphocele development (odds ratio 3.99; P = 0.015). Minimally-invasive extended pelvic lymph node dissection before curative radiotherapy is associated with low morbidity. Asymptomatic lymphocele development rate is higher compared with open pelvic lymph node dissection.

Fast recovery after radical cystectomy. A multidisciplinary challenge.

Radical cystectomy nowadays is the treatment of choice for muscle-invasive bladder cancer. Despite many efforts, the overall, cancer-specific survival and complication rate of patients after this procedure has not changed in the last few decades. In the recent years many fast recovery protocols or “fast track” programs have been designed to become the basis of perioperative management after colorectal surgery, vascular, thoracic, and even more recently radical cystectomy [1, 2]. These programs attempt to modify the physiological and psychological responses to major surgery, contributing to the reduction of post- surgical complications and hospital stay, and to the improvement of the cardiopulmonary and bowel function after surgery; this is translated into a faster recovery for patients [3, 4]. Nowadays, there are only a few studies based on the use of fast recovery protocols in urological surgery, this is why the authors of the paper “Alvimopan: A cost-effective tool to decrease cystectomy length of stay” [5] should be congratulated on presenting their experience concerning this topic. Arumainayagam et al. in 2007 implemented a fast recovery protocol which led to a significant reduction in hospital stay and an equivalent reduction in morbidity for patients undergoing radical cystectomy compared with traditional clinical guidelines [1]. The usage of a minimally invasive approach is included in the 22 items of the ERAS society recommendations [4]. Minimally invasive pelvic surgery has been shown to decrease the inflammatory response when compared to the open approach. Recently, laparoscopic and robotic radical cystectomy has been increasingly performed in the treatment of bladder cancer and merits special consideration. While open radical cystectomy and pelvic lymph node dissection remain the gold standard in treating non-metastatic muscle invasive bladder cancer, this major surgery is still associated with high morbidity close to 70% in some cases. Numerous centers have reported in the last years their experience with laparoscopic or robotic approach [6]. Unfortunately, most of these studies reported retrospective data or prospective comparative data. Despite these limitations, laparoscopic and robot-assisted radical cystectomy seem to be associated with overall lower perioperative complications, and shorter hospital stay with equivalent short term oncological safety. Future high quality, high volume controlled studies should help in reaching definitive conclusions. Intestinal complications are one of the most common problems after radical cystectomy. The etiology of ileus is multifactorial with a combination of central and peripheral nervous system, hormonal influences, neurotransmitter and local inflammatory pathways. Surgical stress, bowel manipulation, opioids and intraoperative fluids can break the standard homeostasis in the gastrointestinal tract and produce postoperative ileus and impaired function of gastrointestinal absorption; so the prevention and management of this complication should be with a multidisciplinary team (Nutrition, Anesthesiology and Urologist). Factors that help to reduce this are epidural anesthesia, minimally invasive surgery, fine tissue manipulation, avoidance of fluid overload, and early oral feeding. In addition, the routine use of nasogastric tube decompression should be avoided after surgery because of the higher incidence of fever, atelectasis and pneumonia in patients who carry it, and if any nasogastric tube is used during surgery it should be removed before extubation. Since 2012 our department has been exercising the application of an “early recovery protocol after surgery” program for patients undergoing laparoscopic radical cystectomy and urinary diversion with the collaboration of the Anesthesiology and Reanimation Department, and the Nutrition Unit of our hospital. We hope to have positive results in the years to come. The usage of fast recovery programs as the presented in this article using the Alvimopan shows that this is a feasible multidisciplinary challenge and is useful in the recovery of patients undergoing radical cystectomy, demonstrated by a shorter hospital stay without the increasing risk of postoperative complications. Future multicenter collaborations evaluating prospective cohorts of urological patients following identical standardized care pathways should be performed.

前立腺全摘除術における閉鎖リンパ節転移陽性部位の検討

In this study, we assessed the significance of complete dissection of the dorsal lymph node of the obturator nerve during radical prostatectomy. Fifty-six patients undergoing open radical prostatectomy and pelvic lymph node dissection for treatment of prostate cancer were included in this study. Neoadjuvant hormonal therapy and radiation therapy were not performed in any of the patients. First, pelvic lymph node dissection was performed between the external iliac vein and obturator nerve and classified as "ventral lymph node of the obturator nerve". Then, the tissue located in the area between the obturator nerve and the surface of the obturator internus muscle was removed and classified as "dorsal lymph node of the obturator nerve". Both lymph nodes were meticulously examined by identical pathologist. Lymph node yields, lymph node positive rate, and the factors associated with lymph node metastasis were studied. Eight of the 56 patients had pelvic lymph node metastases (6 were high risk and 2 were intermediate risk according to the D'Amico's criteria). In the 8 node-positive patients, only 1 patient had positive lymph node in "ventral lymph node of the obturator nerve" exclusively. Four patients had positive lymph node exclusively in "dorsal lymph node of the obturator nerve" and 3 patients had in both "ventral and dorsal lymph nodes of the obturator nerve". The total lymph node yields from "ventral lymph node of the obturator nerve" and "dorsal lymph node of the obturator nerve" were 459 (8.2 per patient) and 117 (2.1 per patient), respectively. The total numbers of positive lymph nodes from "ventral lymph node of the obturator nerve" and "dorsal lymph node of the obturator nerve" were 6 and 12, respectively. Lymph node positive rate was significantly higher in "dorsal lymph node of the obturator nerve" (10%) than "ventral lymph node of the obturator nerve" (1.3%) (P < 0.0001). The level of prostate-specific antigen (> or = 20 ng ml), Gleason score sum at prostate biopsy (> or = 9), and lymph node yield (> or = 16) were associated with lymph node status on univariate analysis. In multivariate analysis, only lymph node yield was associated with lymph node status. Dorsal lymph nodes of the obturator nerve should be dissected completely during radical prostatectomy.

Implications of laparoscopic inguinal hernia repair on open, laparoscopic, and robotic radical prostatectomy

Purpose:There have been anecdotal reports of surgeons having to abandon radical prostatectomy (RP) after laparoscopic inguinal hernia repair (LIHR) due to obliteration of tissue planes by mesh. Nodal dissection may also be compromised. We prospectively collected data from four experienced prostate surgeons from separate institutions. Our objective was to evaluate the success rate of performing open RP (ORP), laparoscopic RP (LRP) and robotic assisted RP (RALRP) and pelvic lymph node dissection (PLND) after LIHR, and the frequency of complications.Methods:A retrospective analysis of prospectively maintained databases of men who underwent RP after LIHR between 2004 and 2010 at four institutions was undertaken. The data recorded included age, preoperative prostate-specific antigen, preoperative Gleason score, and clinical stage. The operative approach, success or failure to perform RP, success or failure to perform PLND, pathological stage, and complications were also recorded.Results:A total of 1,181 men underwent RP between 2004 and 2010. Fifty-seven patients (4.8%) underwent RP after LIHR. An ORP was attempted in 19 patients, LRP in 33, and RALRP in 5. All 57 cases were able to be successfully completed. Ten of the 18 open PLND were able to be completed (55.6%). Four of the 22 laparoscopic LND were able to be completed (18.2%). Robotic LND was possible in 5 of 5 cases (100%). Therefore, it was not possible to complete a LND 56.8% of patients. Complications were limited to ten patients. These complications included one LRP converted to ORP due to failure to progress, and one rectourethral fistula in a salvage procedure post failed high intensity focused ultrasound.Conclusions:LIHR is an increasingly common method of treating inguinal hernias. LIHR is not a contra-indication to RP. However PLND may not be possible in over 50% of patients who have had LIHR. Therefore, these patients may be under-staged and under treated.

Does minimally invasive surgery for radical cystectomy provide similar long-term cancer control as open radical surgery?

Open radical cystectomy (ORC) and pelvic lymph node dissection (PLND) is the standard treatment for muscle-invasive and high-risk nonmuscle-invasive bladder cancer (BCa), but is associated with significant morbidity. In the hope of decreasing the complications and improving the surgical tolerance, minimally invasive techniques to perform radical cystectomy and PLND have been adopted. This review focuses on the present state of the literature regarding the oncological efficacy of minimally invasive radical cystectomy (MIRC) and PLND. Most studies are retrospective, single surgeon or institution, and are subjected to significant selection bias. There is scarce data regarding intermediate and long term oncological outcomes following MIRC, and most reported series contain a lower proportion of patients with locally advanced disease compared with ORC series. Positive surgical margin rates are similar between the approaches in localized disease, but may be significantly higher in MIRC in patients with more advanced tumors. The current review of the literature demonstrates insufficient evidence regarding the long-term oncological outcomes of MIRC. There is a need for well controlled, prospective, randomized trials with sufficient follow-up to compare MIRC to ORC for the treatment of invasive BCa before the oncologic efficacy of these techniques can be adequately compared to the standards established by ORC.

Outcomes after radical prostatectomy for patients with clinical stages T1-T2 prostate cancer with pathologically positive lymph nodes in the prostate-specific antigen era

ObjectivesTo evaluate the outcomes of radical prostatectomy (RP) and pelvic lymph node dissection (PLND) for clinically organ confined prostate cancer (CaP) with regional lymph node metastases (pN1) treated in the era of prostate-specific antigen (PSA) screening. Materials and methodsA single institution cohort of 2,487 men with cT1-T2 CaP treated with open radical prostatectomy and pelvic lymph node dissection between 1988 and 2008 were analyzed. Kaplan-Meier and Cox proportional regression models were used to analyze overall survival (OS), clinical recurrence-free survival (cRFS), and biochemical recurrence-free survival (bRFS). ResultsOverall, 150 out of 2,487 patients (6%) had pN1 disease, with a median follow-up of 10.4 years. The predicted 10-year OS, cRFS, and bRFS rates for patients with pN0 and pN1 were 86% and 74% (Log rank P < 0.001), 97% and 84% (Log rank P < 0.001), and 88% and 57% (Log rank P < 0.001), respectively. In the subset of pN1 patients treated with surgery only (n = 49), the predicted 10-year OS, cRFS, and bRFS rates were 81%, 80%, and 59%, respectively. Exploratory univariate regression analysis showed that age (P = 0.003), total number of lymph nodes identified (P = 0.040), and total number of positive lymph nodes identified (P = 0.004) were associated with OS. Total number of positive lymph nodes (LNs) identified was also significantly associated with cRFS (P = 0.05). ConclusionsThe incidence of pN1 in patients with cT1-T2 CaP treated with surgery in the era of PSA screening was low. RP and PLND demonstrated therapeutic efficacy in a subset of pN1 patients treated with surgery alone.

Editorial Comment

This series from the University of Southern California (USC) Department of Urology emphasizes the reproducible effectiveness of open radical prostatectomy (ORP) in the management of prostate cancer. As the reference standard treatment for localized prostate cancer, it is curious that ORP with pelvic lymph node dissection has largely been abandoned for robotic-assisted laparoscopic radical prostatectomy (RARP). It would appear that those extrapolating the results of open surgery to support a robotic approach are justified: removing the entire prostate gland by any technique should produce the same results. However, reasons exist—supported by this series from USC—to question such an extrapolation. Long-term Outcomes of Open Radical Retropubic Prostatectomy for Clinically Localized Prostate Cancer in the Prostate-specific Antigen EraUrologyVol. 79Issue 3PreviewTo determine long-term oncological outcomes and complication rates for patients with clinically organ confined prostate adenocarcinoma (PCa) treated with open radical retropubic prostatectomy and pelvic lymph node dissection (RRP/PLND) in the prostate-specific antigen (PSA) era. Full-Text PDF

Long-term Outcomes of Open Radical Retropubic Prostatectomy for Clinically Localized Prostate Cancer in the Prostate-specific Antigen Era

To determine long-term oncological outcomes and complication rates for patients with clinically organ confined prostate adenocarcinoma (PCa) treated with open radical retropubic prostatectomy and pelvic lymph node dissection (RRP/PLND) in the prostate-specific antigen (PSA) era. Outcomes data were obtained from a prospectively maintained prostate cancer database. Patients with cT1/cT2 PCa undergoing RRP/PLND without neoadjuvant therapy between July 1988 and June 2008 were included. Kaplan-Meier and Cox proportional regression models were used to evaluate factors influencing biochemical recurrence, clinical recurrence, and overall survival (OS). A total of 2487 patients met inclusion criteria, and median follow-up was 7.2 years (range 1-21 years). Of the patients, 49.7% were low risk, 33.2% intermediate risk, and 16.1% high risk by D'Amico criteria, and 6% were LN+. The 10-year biochemical recurrence-free survival (BCRFS) for low-, intermediate-, and high-risk patients was 92%, 83%, and 76%, respectively (P < .001), and 10 year OS was 91%, 83%, and 74%, respectively (P < .001). BCRFS at 10 years was 76% and 88% for patients with positive and negative margins, respectively (P < .001). Of the 2487 patients, 11% developed BCR, and 3.7% experienced CR, with 9 local recurrences. The overall complication rate was 2.3%, and the cancer specific mortality rate was 2%. D'Amico risk group, margin status, and LN status are significantly correlated with outcomes in patients undergoing RRP/PLND for clinically localized PCa. Local recurrence and death from prostate cancer are rare in patients undergoing open RRP/PLND for clinically organ confined disease in the PSA era.

Robot Assisted Extended Pelvic Lymphadenectomy at Radical Cystectomy: Lymph Node Yield Compared With Second Look Open Dissection

Robot assisted radical cystectomy outcomes show feasibility and potential benefits for patient recovery. However, it is difficult to judge the completeness of extended robot assisted vs open pelvic lymph node dissection using only the lymph node count and template description. We performed a prospective protocol in which radical cystectomy and pelvic lymph node dissection done in robot assisted fashion were followed by second look open pelvic lymph node dissection. Our primary objective was to determine the fraction of lymph nodes yielded by robot assisted pelvic lymph node dissection. Patients with pure transitional cell carcinoma and no locally advanced features were selected for robot assisted radical cystectomy. A team of 2 urological oncologists performed radical cystectomy and pelvic lymph node dissection in robot assisted fashion, followed by second look open pelvic lymph node dissection. Lymph nodes from robot assisted dissection were submitted in up to 8 separate specimens by anatomical location. Any additional specimens retrieved at open dissection were submitted separately. The protocol was completed in 11 patients from October 2007 to June 2009. The median yield of robot assisted and second look open pelvic lymph node dissection was 43 (range 19 to 63) and 4 (range 0 to 8), respectively, for an overall robot assisted yield of 93%. Of second look open pelvic lymph node dissections 67% were clear of residual tissue, 13% had tissue without lymph nodes and 20% had 1 or more lymph nodes. Median operative time for robot assisted pelvic lymph node dissection was 117 minutes. Concurrently open radical cystectomy without required multiple lymph node specimen submission yielded a median 24 nodes. Our data showing a robot assisted pelvic lymph node dissection yield of 93% of that of open surgery should allay concern that the robot assisted technique limits the completeness of pelvic lymph node dissection.

Microscopic Evaluation of Lymph-Node-Bearing Tissue in Early-Stage Cervical Cancer: A Dual-Institution Review

We compared two different methods of microscopic lymph node examination of cervical cancer radical hysterectomy specimens to ascertain which method translates into higher nodal counts and improved detection of nodal metastasis, at M. D. Anderson Cancer Center (MDACC) and the University of North Carolina (UNC). We retrospectively reviewed the records of 155 patients with early-stage cervical cancer who underwent open radical hysterectomy and pelvic lymph node dissection from 2000 to 2006. At MDACC lymph nodes were grossly dissected from submitted adipose tissue surgical specimens and then microscopically examined. At UNC, grossly detected lymph nodes and the remaining adipose tissue were microscopically examined. Data regarding clinicopathologic features and lymph node dissection were available for all patients. No differences in stage, grade or histology were noted between the two centers. The median age and body mass index were both higher at MDACC (40 versus 36 years of age; 28 versus 26 mg/m(2); P < 0.05) The median lymph node count was lower at MDACC (16 versus 23; P = 0.001). By multivariate analysis, UNC evaluation was associated with higher total lymph node count (P = 0.001). However, no significant difference was noted between institutions in proportion of patients with nodal metastases (MDACC 20.3%; UNC 13.5%; P = 0.47). The UNC method of microscopically examining the entire adipose tissue sample may be associated with higher nodal count at open radical hysterectomy. Higher nodal count, however, may not translate into increased identification of nodal metastases.

The Use of a Surgical Patch in the Prevention of Lymphoceles After Extraperitoneal Pelvic Lymphadenectomy for Prostate Cancer: A Randomized Prospective Pilot Study

Pelvic lymphadenectomy is frequently performed simultaneously with radical prostatectomy to determine lymph node status and the most frequently recorded postoperative complication is the development of a symptomatic lymphocele. This study evaluated TachoSil as an adjunct treatment in preventing lymphoceles after extraperitoneal pelvic lymphadenectomy for prostate cancer. A total of 60 consecutive patients who had undergone radical prostatectomy and pelvic lymphadenectomy were prospectively enrolled in this study. The patients were randomly assigned to a standard technique with the use of clips and electrocoagulation plus TachoSil, or to standard technique only. All patients underwent ultrasound examination on postoperative days 7, 14 and 28 to test for the development of symptomatic or asymptomatic lymphoceles. Drainage volume and duration were also recorded. The baseline characteristics of the 2 randomized groups were well matched. Those patients in whom we used TachoSil showed a lower drainage volume with a mean total volume of 64 +/- 45 ml (range 0 to 110) vs 190 +/- 62.72 ml (range 70 to 270, p = 0.009), and had significantly fewer symptomatic and asymptomatic lymphoceles (5 vs 19, p = 0.001). Only 5 percutaneous surgical procedures to drain the lymphoceles proved necessary, 1 of which occurred in the group with TachoSil. TachoSil seems to provide a useful additional treatment option for reducing drainage volume and preventing lymphocele development after extraperitoneal radical retropubic prostatectomy with pelvic lymphadenectomy.