Pelvic Dissection Research Articles

Identifying the optimal candidates for a super-extended staging pelvic lymph-node dissection in prostate cancer patients treated in the PET-PSMA era. Results from a multi-institutional series

Identifying the optimal candidates for a super-extended staging pelvic lymph-node dissection in prostate cancer patients treated in the PET-PSMA era. Results from a multi-institutional series

Diagnostic performance of Node-RADS by preoperative CT or MRI scans for prediction of pathological Nodal (pN) status from Muscle-Invasive Bladder Cancers (MIBCs) undergoing Radical Cystectomy (RC) with extended Pelvic Lymph-node Dissection (ePLND)

Diagnostic performance of Node-RADS by preoperative CT or MRI scans for prediction of pathological Nodal (pN) status from Muscle-Invasive Bladder Cancers (MIBCs) undergoing Radical Cystectomy (RC) with extended Pelvic Lymph-node Dissection (ePLND)

Outcomes of Robot-assisted Radical Prostatectomy with the Hugo RAS Surgical System: Initial Experience at a High-volume Robotic Center

Clinical data on robot-assisted radical prostatectomy (RARP) performed with the new Hugo robot-assisted surgery (RAS) system are scarce. We described surgical outcomes of 112 consecutive patients who underwent RARP ± extended pelvic lymph-node dissection (ePLND) at OLV Hospital (Aalst, Belgium) between February and November 2022. The median age was 65 yr (interquartile range [IQR] 60–70) and median preoperative prostate-specific antigen (PSA) was 7.9 ng/ml (5.8–10.7). Thirty-eight patients (34%) had International Society of Urological Pathology grade group ≥3 tumor on prostate biopsy. On preoperative magnetic resonance imaging, 26 (23%) patients had a suspicion of extraprostatic disease. The median operative time was 180 min (IQR 145–200) and 27 men (24%) underwent ePLND. On final pathology, 34 patients (31%) had extraprostatic disease and ten (9%) had positive surgical margins. The median number of nodes removed was 15 (IQR 9–19). Among men with data available on the first PSA after surgery, 88% (60/68) had undetectable PSA (<0.1 ng/ml). The probability of urinary continence (UC) recovery was 36% (95% confidence interval [CI] 28–47%) at 1 mo and 81% (95% CI 72–89%) at 3 mo. The median time to UC recovery was 36 d (95% CI 34–44). This is the first report of data on UC recovery and surgical pathology for patients undergoing RARP for prostate cancer performed with the Hugo RAS robotic system. Future investigations with longer follow-up are awaited. Patient summaryWe describe surgical outcomes of patients undergoing robot-assisted surgical removal of the prostate for cancer performed with the Hugo RAS robotic system at our institution. In our experience this platform provided adequate results in terms of surgical results and early recovery of urinary continence. Studies with longer follow-up are awaited.

Optimal anastomotic technique in rectal surgery to prevent anastomotic leakage.

Complications after colorectal surgery remain inevitable, and anastomotic leakage is one of the most severe and potentially fatal complications. Generally, anastomotic leakage is associated with severe peritonitis, the need for emergency reoperation, and an increased mortality rate. Additionally, particularly after rectal cancer surgery, it has a negative impact on long-term outcomes, including postoperative anorectal function, local recurrence, and survival. To prevent anastomotic leakage, understanding the characteristics of each anastomotic technique and establishing a stable anastomotic procedure are important. Transanal total mesorectal excision (TaTME) is a relatively new advanced surgical access technique for pelvic dissection and facilitates different anastomotic techniques without the need for transabdominal rectal transection. Especially, stapled anastomosis in TaTME, also known as double purse-string circular stapled anastomosis or the single stapling technique (SST), has gained much attention as an alternative to the conventional double stapling technique (DST). In this article, we describe the DST, SST, and hand-sewn anastomosis as anastomotic techniques after rectal surgery, focusing mainly on the differences between conventional anastomotic techniques and SST in TaTME. Furthermore, the blood flow evaluation method for the reconstructive colon before anastomosis, which is extremely important in anastomotic leakage prevention regardless of the anastomotic type, is also described.

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).

Robot-Assisted Treatment of Symptomatic Lymphocele Postradical Prostatectomy and Lymphadenectomy in the Era or Robotic Surgery: Narrative Review.

Background: Pelvic lymphnode dissection (PLND) is an integral part of surgical treatment for localized intermediate and high-risk prostate cancer. The most common complication of PLND is lymphocele formation. In the majority of cases the development of lymphoceles is clinically asymptomatic but in case of symptomatic/infected lymphocele an active treatment is required. The aim of this article is to analyse the current evidence on the treatment of symptomatic/infected lymphocele trough robotic approach. Materials and Methods: The search was applied to PubMed, EMBASE, and Cochrane databases with following terms: "lymphocele", "symptomatic", "infected", "robot-assisted AND radical prostatectomy", "robot-assisted", "treatment". Results: The search identified three series focusing on the treatment by robot-assisted approach of symptomatic and/or infected lymphocele. The main and most frequent reason for performing the robotic treatment was an infected lymphocele, the median time from robot-assisted radical prostatectomy and PLND to robotic treatment of lymphocele was 118 days (range 30-240). Robot-assisted treatment was successful in all reports. Conclusions: The drainage of lymphocele with the robot-assisted approach appeared safe, feasible, and with satisfactory outcomes for the definitive treatment of symptomatic/infected lymphocele.

Current role of PSMA-PET imaging in the clinical management of prostate cancer.

Despite the developments of the last few years, metastatic castration-resistant prostate cancer (PC) remains a deadly disease. Until recently, almost all guidelines recommended magnetic resonance imaging (MRI) or computed tomography (CT) for the initial staging and local/systematic recurrence. Positron emission tomography/computed tomography (PET/CT) with prostate-specific membrane antigen (PSMA) at the present stage, emerged as a promising diagnostic imaging tool for PC. PSMA PET/CT alone or in combination with multiparametric magnetic resonance imaging (mpMRI) can improve the detection of clinically significant PC, especially for Prostate Imaging Reporting & Data System (PI-RADS) = 3 lesions. In addition, PSMA PET/CT is more accurate than CT and bone scan for intermediate to high-risk disease at the initial staging. Contrariwise, a negative PET is not useful for surgeons to avoid a pelvic nodal dissection. PET-PSMA imaging is appropriate for prostate-specific antigen (PSA) persistence or PSA rise from undetectable level after radical prostatectomy or for PSA rise above nadir after definitive radiotherapy. Also, it is recommended for patients fit for curative salvage treatment. It should be noted that in patients, candidates for radionuclide therapy with Lutetium-177 (117Lu), a PSMA strong expression from PET/CT at baseline is considered necessary. This review summarizes the evolution of PSMA PET/CT and its current role in the management of PC.

The infrequent large pelvi-perineal tumors as a surgical dilemma: en bloc resection and long-term results

To assess long-term results of surgical resections of the sporadic extra-large pelvi-perineal soft tissue tumors, a retrospective series of patients referred to the National Cancer Institute 2001–2022 (tertiary care cancer university hospital in Egypt) was designed. Thirteen patients (3 males) averaged age 57 years had large 29 cm (18–38) pelvi-perineal tumors (10 to the paraanal ischiorectal spaces and 3 to the vulva) plus upper intra-abdominal extensions in 9 patients (69%). Symptoms were nonspecific with delayed presentation that averaged 22-month. The entire underwent combined open abdomino-perineal approach to widely en masse resect tumors plus infiltrated organs. No downsizing hormonal treatment was offered preoperative. Main outcome measures were disease free survival, recurrence pattern and salvage. Extensive pelvic and perineal tumor resection is tough and meticulous but straightforward with minor (Clavien-Dindo Classification (CDC) grade I &amp; II) early and delayed morbidity. Resection extends to hysterectomy, vaginectomy and vascular resection. Histopathology plus immunohistochemistry showed 9-aggressive angiomyxoid tumors (AA), 2-fibromatosis and 2-neurofibromas (NF). Margins of resection are all adequate (R0) except for 2 (Resection margin 1 (R1)). After 50-month median follow up, 8/13 total series (61.5%) were surviving free of disease. 4/9 of AA (44%) had local perineal and/or pelvic recurrences (13–37 months) and all were amenable to curative salvage resections; while, 1/2 patients with fibromatosis died of disseminated peritoneal relapses. No systemic metastases are noticed. Extensive tumors meticulous surgery with experienced pelvic dissection and resection could offer alone long term cure even after recurrences with minor morbidity in a good percent. Fertility sparing resection is not oncologically safe because of the frequent uterine and ovarian invasions.

Comparison of therapeutic features and oncologic outcome in patients with pN1 prostate cancer among robot-assisted, laparoscopic, or open radical prostatectomy.

To compare the therapeutic features and oncological outcomes of robot-assisted radical prostatectomy (RARP) with those of open radical prostatectomy (ORP) or laparoscopic radical prostatectomy (LRP) in lymph node (LN) positive prostate cancer patients in a retrospective observational multi-institutional study. We evaluated the clinical results of 561 patients across 33 institutions who underwent RARP, LRP, or ORP and who were diagnosed with LN-positive prostate cancer during RP with pelvic LN dissection (PLND). We determined the following survival outcomes: metastasis-free survival, overall survival, cancer-specific survival, and biochemical recurrence-free survival. The Kaplan-Meier method, log-rank test, and Cox proportional hazards regression model were used to evaluate the effect of treatment on oncological outcomes. Statistical significance was set atP < 0.05. There was no significant difference for any of the survival outcomes between the three surgical groups. However, RARP achieved a greater LN yield compared to that of ORP or LRP. When the extent of PLND was limited to the obturator LNs, the number of removed LNs (RLNs) was comparable between the three surgical groups. However, higher numbers of RLNs were achieved with RARP compared to the number of RLNs with ORP (P < 0.001) when PLND was extended to the external and/or internal iliac LNs. RARP, LRP, and ORP provided equal surgical outcomes for pN1 prostate cancer, and the prognosis was relatively good for all procedures. Increased numbers of RLNs may not necessarily affect the oncological outcome.

Patterns of Recurrence and Survival After Pelvic Treatment for Locally Advanced Penile Cancer

BackgroundPenile cancer (PeCa) is rare, and the survival of patients with advanced disease remains poor. A better understanding of where treatment fails could aid the development of new treatment strategies. ObjectiveTo describe the disease course after pelvic lymph node (LN) treatment for PeCa. Design, setting, and participantsWe retrospectively analysed 228 patients who underwent pelvic LN treatment with curative intent from 1969 to 2016. The main treatment modalities were neoadjuvant chemotherapy, chemoradiation, and pelvic LN dissection. Outcome measurements and statistical analysisIn the case of multiple recurrence locations, the most distant location was taken and recorded as follows: local (penis), regional (inguinal and pelvic LN), and distant (any other location). A competing risk analysis was used to calculate the time to recurrence per location, and a Kaplan-Meier analysis was used for overall survival (OS). Results and limitationsThe median follow-up of the surviving patients was 79 mo. The reason for pelvic treatment was pelvic involvement on imaging (29%), two or more tumour-positive inguinal LNs (61%), or inguinal extranodal extension (52%). More than half of the patients (61%) developed a recurrence. The median recurrence-free survival was 11 mo. The distribution was local in 9%, regional in 27%, and distant in 64% of patients. The infield control rate of nonsystemically treated patients was 61% (113/184). From the start of pelvic treatment, the median OS was 17 mo (95% confidence interval 12–22). After regional or distant recurrence, all but one patient died of PeCa with median OS after a recurrence of 4.4 (regional) and 3.1 (distant) mo. This study is limited by its retrospective nature. ConclusionsThe prognosis of PeCa patients treated on their pelvis who recur despite locoregional treatment is poor. The tendency for systemic spread emphasises the need for more effective systemic treatment strategies. Patient summaryIn this report, we looked at the outcomes of penile cancer patients in an expert centre undergoing various treatments on their pelvis. We found that survival is poor after recurrence despite locoregional treatment. Therefore, better systemic treatments are necessary.

A machine-learning-based combination of criteria to detect bladder cancer lymph node metastasis on [18F]FDG PET/CT: a pathology-controlled study.

Initial pelvic lymph node (LN) staging is pivotal for treatment planification in patients with muscle-invasive bladder cancer (MIBC), but [18F]FDG PET/CT provides insufficient and variable diagnostic performance. We aimed to develop and validate a machine-learning-based combination of criteria on [18F]FDG PET/CT to accurately identify pelvic LN involvement in bladder cancer patients. Consecutive patients with localized MIBC who performed preoperative [18F]FDG PET/CT between 2010 and 2017 were retrospectively assigned to training (n = 129) and validation (n = 44) sets. The reference standard was the pathological status after extended pelvic LN dissection. In the training set, a random forest algorithm identified the combination of criteria that best predicted LN status. The diagnostic performances (AUC) and interrater agreement of this combination of criteria were compared to a consensus of experts. The overall prevalence of pelvic LN involvement was 24% (n = 41/173). In the training set, the top 3 features were derived from pelvic LNs (SUVmax of the most intense LN, and product of diameters of the largest LN) and primary bladder tumor (product of diameters). In the validation set, diagnostic performance did not differ significantly between the combination of criteria (AUC = 0.59 95%CI [0.43-0.73]) and the consensus of experts (AUC = 0.64 95%CI [0.48-0.78], p = 0.54). The interrater agreement was equally good with Κ = 0.66 for both. The developed machine-learning-based combination of criteria performs as well as a consensus of experts to detect pelvic LN involvement on [18F]FDG PET/CT in patients with MIBC. • The developed machine-learning-based combination of criteria performs as well as experts to detect pelvic LN involvement on [18F]FDG PET/CT in patients with muscle-invasive bladder cancer. • The top 3 features to predict LN involvement were the SUVmax of the most intense LN, the product of diameters of the largest LN, and the product of diameters of the primary bladder tumor.

Targeted lateral pelvic lymph node excision in the setting of total neoadjuvant therapy for rectal cancer.

Targeted lateral pelvic node dissection in the era of total neoadjuvant therapy.

Starting a minimally invasive inguinal lymphadenectomy program: Initial learning experience and outcomes

BackgroundThere is promising data on minimally invasive inguinal lymphadenectomy indicating decreased wound complications compared with the standard open approach. We examined our institutional experience with starting a minimally invasive inguinal lymphadenectomy program. MethodsThis is a retrospective case series of consecutive patients undergoing videoscopic minimally invasive inguinal lymphadenectomy from August 2017 to March 2022 by a single surgeon. Patients meeting criteria for inguinal lymphadenectomy were considered for minimally invasive inguinal lymphadenectomy unless there was skin involvement by tumor or bulky disease. Data collected included patient characteristics, primary cancer, surgery, and postoperative complications. ResultsThere were 26 patients included. The mean age was 60.6 ± 16.2 years. Most patients were female (n = 17, 65.4%), and the primary diagnosis was melanoma (n = 21, 19.2%). In 6 cases (23.1%), minimally invasive inguinal lymphadenectomy was combined with deep pelvic node dissection, but most patients did not have a concurrent procedure (n = 15, 57.7%). The median operative time was 119.0 minutes (range, 89.0–160.0), or 130.5 minutes (range, 89.0–345.0) when including concurrent procedures. The mean number of nodes retrieved was 9.8 ± 3.7, with a positive node identified in 19 patients (73.1%) during minimally invasive inguinal lymphadenectomy. There were 12 (46.2%) patients experiencing at least one postoperative complication within 30 days of surgery, the most common being infection (n = 4, 15.4%). One patient required reoperation for infected hematoma washout. Postoperative intervention for seroma was undertaken in 3 patients (11.5%). ConclusionMinimally invasive inguinal lymphadenectomy is a safe approach to inguinal lymph node dissection, in terms of node retrieval and postoperative complications, and can feasibly be adopted into practice with minimal learning curve.

Combining staged laparoscopic colectomy with robotic completion proctectomy and ileal pouch–anal anastomosis (IPAA) in ulcerative colitis for improved clinical and cosmetic outcomes: a single-center feasibility study and technical description

Robotic proctectomy has been shown to lead to better functional outcomes compared to laparoscopic surgery in rectal cancer. However, in ulcerative colitis (UC), the potential value of robotic proctectomy has not yet been investigated, and in this indication, the operation needs to be adjusted to the total colectomy typically performed in the preceding 6 months. In this study, we describe the technique and analyze outcomes of a staged laparoscopic and robotic three-stage restorative proctocolectomy and compare the clinical outcome with the classical laparoscopic procedure. Between December 2016 and May 2021, 17 patients underwent robotic completion proctectomy (CP) with ileal pouch–anal anastomosis (IPAA) for UC. These patients were compared to 10 patients who underwent laparoscopic CP and IPAA, following laparoscopic total colectomy with end ileostomy 6 months prior by the same surgical team at our tertiary referral center. 27 patients underwent a 3-stage procedure for refractory UC (10 in the lap. group vs. 17 in the robot group). Return to normal bowel function and morbidity were comparable between the two groups. Median length of hospital stay was the same for the robotic proctectomy/IPAA group with 7 days [median; IQR (6–10)], compared to the laparoscopic stage II with 7.5 days [median; IQR (6.25–8)]. Median time to soft diet was 2 days [IQR (1–3)] vs. 3 days in the lap group [IQR 3 (3–4)]. Two patients suffered from a major complication (Clavien–Dindo ≥ 3a) in the first 90 postoperative days in the robotic group vs. one in the laparoscopic group. Perception of cosmetic results were favorable with 100% of patients reporting to be highly satisfied or satisfied in the robotic group. This report demonstrates the feasibility of a combined laparoscopic and robotic staged restorative proctocolectomy for UC, when compared with the traditional approach. Robotic pelvic dissection and a revised trocar placement in staged proctocolectomy with synergistic use of both surgical techniques with their individual advantages will likely improve overall long-term functional results, including an improved cosmetic outcome.

8244 Laparoscopic Approach to Endometriosis and Fibrosis in the Lateral Pelvic Sidewall

<h3>Study Objective</h3> To explore surgical techniques and anatomic spaces in the sidewall to assist with difficult pelvic sidewall dissections due to endometriosis and fibrosis. <h3>Design</h3> Surgical video. <h3>Setting</h3> Tertiary care hospital. <h3>Patients or Participants</h3> Patient is a 32-yo G0 with pelvic pain and known stage IV endometriosis desiring definitive surgical management. <h3>Interventions</h3> Patient underwent total laparoscopic hysterectomy, right oophorectomy, right ureterolysis and lysis of adhesions. Due to dense right sidewall endometriosis and fibrosis, the medial and lateral pararectal spaces were developed, the ureter was identified, and extensive ureterolysis was performed. Pre-operative ureteral stents were utilized to assist with ureter identification. <h3>Measurements and Main Results</h3> The ureteral stents were removed immediately post-operatively and patient was discharged home the same day. She had an uncomplicated post-operative course with improvement in her pain symptoms. <h3>Conclusion</h3> This video demonstrates the laparoscopic approach to endometriosis within the sidewall and demonstrates safe dissection techniques to avoid injury to key structures.

Strategies to Minimize Blood Loss during Laparoscopic Hysterectomy for Management of Cesarean Scar Ectopic Pregnancy

<h3>Study Objective</h3> Demonstrate techniques to minimize blood loss during laparoscopic hysterectomy for management of cesarean scar ectopic pregnancy. <h3>Design</h3> Stepwise demonstration using narrated video footage. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> 33-year-old G5P4004 with one prior cesarean delivery presented to the ER with abdominal pain and vaginal spotting in early pregnancy. Her vital signs were normal with a Hemoglobin of 8.9. Ultrasound revealed a ∼6-week cesarean scar ectopic pregnancy. She was counseled on management options including laparoscopic resection of the ectopic with repair of uterine defect or laparoscopic hysterectomy. The patient was satisfied with her parity and opted for hysterectomy. <h3>Interventions</h3> The patient underwent total laparoscopic hysterectomy, bilateral pelvic wall dissection, bilateral salpingectomy, and cystoscopy. Various considerations and techniques were used intraoperatively to minimize blood loss. 1. Major vasculature (uterine and utero-ovarian arteries) was interrupted before placement of uterine manipulator 2. Uterine manipulator was placed under laparoscopic guidance in a retroverted fashion to avoid disruption of pregnancy 3. The correct plane was identified during dissection between the bladder and pregnancy to avoid injury or bleeding 4. Additional bleeding was anticipated and encountered even after major blood supply was interrupted, likely related to collateral vasculature to the pregnancy <h3>Measurements and Main Results</h3> Successful management of cesarean scar ectopic pregnancy was performed via laparoscopic hysterectomy. Estimated blood loss was 100cc and the surgery was uncomplicated. <h3>Conclusion</h3> Cesarean scar ectopic pregnancy is more common with the rising rate of cesarean deliveries. Risk of hemorrhage in this scenario is higher due to possible trophoblastic involvement up to level of uterine arteries. However, various techniques may be used to decrease blood loss during definitive surgical treatment.

Upper Vaginectomy for Rectovaginal Endometriosis: Manual Guidance for Deep Rectovaginal Dissection

<h3>Study Objective</h3> The objective of this video is to demonstrate a robotic-assisted excision of a rectovaginal endometriosis nodule. <h3>Design</h3> This case involves a 31-year-old nulligravid patient with dysmenorrhea, dyschezia, and dyspareunia. <h3>Setting</h3> This surgery was performed at an academic tertiary care center. The patient was in the dorsal lithotomy position and the robot was docked from the patient's left side. <h3>Patients or Participants</h3> The patient had a palpable rectovaginal nodule, which was confirmed with magnetic resonance imaging. <h3>Interventions</h3> The patient underwent diagnostic laparoscopy which showed bilateral pelvic sidewall endometriosis and cul-de-sac obliteration. The ovaries and fallopian tubes were normal. Pelvic sidewall dissection with extensive peritoneal stripping was required to remove all of the endometriosis implants. Bilateral uterosacral ligaments were excised. Within the posterior cul-de-sac, the rectocervical nodule was not visible due to tethering of the rectum. The rectovaginal space was carefully dissected with monopolar scissors. Despite opening the left para-rectal space, the nodule was still not visible. An assistant placed a single digit into the posterior fornix to mobilize the nodule to guide the surgeon. The surgeon dissected the rectovaginal space until the fibrosis was visualized abdominally. Chocolate cyst fluid was expelled, consistent with deep infiltrating endometriosis. Full-thickness entry into the vagina was required, and the colpotomy was closed with running barbed suture. After complete excision of endometriosis, a flat-tire test was performed to confirm rectal integrity. The surgery was then completed. <h3>Measurements and Main Results</h3> The patient did well and was discharged home from the recovery room. She had significant improvement in her pain, and her recovery proceeded without complications. <h3>Conclusion</h3> This surgical video demonstrates the importance of careful pre-operative planning and intra-operative use of resources to accomplish complete excision of endometriosis. Surgeons often need to be creative when tissue planes are obscured, and the target pathology is not clearly visible.

Laparoscopic Left Ureteric Reimplantation for Post Caesarean Section Ureterovaginal Fistula

<h3>Study Objective</h3> To demonstrate laparoscopic ureteric implantation procedure in a case of ureterovaginal fistula. <h3>Design</h3> Stepwise demonstration of laparoscopic ureteric implantation in a case of ureterovaginal fistula with previous history of lower segment caesarean section with narrated video. <h3>Setting</h3> Tertiary care hospital. <h3>Patients or Participants</h3> A 22-year primipara, underwent lower segment caesarean section six weeks back, presented with watery discharge from vagina, fever and pain in abdomen from day five after caesarean section. Per speculum examination showed urinary leakage from left fornix. Methylene blue test revealed no leakage of dye from vagina. Abdominal ultrasound showed left sided moderate hydronephrosis, both kidneys normal, uterus bulky in size with no free fluid in abdomen. CT intravenous pyelography revealed left sided ureterovaginal fistula. Cystoscopy with left ureteric stenting tried stent did not pass beyond 2-3 cm. Percutaneous nephrostomy done for diversion of urine. <h3>Interventions</h3> Ureteric reimplantation done after six weeks of nephrostomy. Left lateral pelvic wall dissection done to identify the course of ureter from pelvic brim to fistula site. Bladder mobilised from anterior abdominal wall and hitched to the psoas muscle. Cystostomy done after creating tunnel over superior aspect of bladder. Lower end of ureter cut and spatulated. Ureteric stenting done with DJ stent. Lower end of ureter implanted over bladder with approximating sutures with 4-0 delayed absorbable sutures. Lower end of ureter covered by bladder muscle to create anti reflux mechanism. <h3>Measurements and Main Results</h3> Post operative recovery was uneventful. Bladder was catheterized with Foleys catheter for 14 days and ureteric stent removed after six weeks by cystoscopy. <h3>Conclusion</h3> Laparoscopic ureteric reimplantation can be done for ureterovaginal fistula with excellent outcome. Delaying the repair till three months allows healing of tissue edema and inflammation with healthy tissue for surgery.

TRANS-Peritoneal PARA-Aortic Node Dissection Two Different Technique

<h3>Study Objective</h3> Trans-peritoneal para-aortic node dissection two different approach. <h3>Design</h3> Prospective analysis. <h3>Setting</h3> Patient underwent 3D laparoscopy, all procedure done by experienced and qualified team. <h3>Patients or Participants</h3> CA Endometrium (> 50% invasion), CA cervix patients. <h3>Interventions</h3> Laparoscopic transperitoneal para-aortic lymph node dissection. <h3>Measurements and Main Results</h3> all patient reviewed at monthly interval followed by 3 monthly interval with USG (A+P). PET scan done at 6 months did not reveal any recurrence. median follow up 18 months. all patients are diseased free. <h3>Conclusion</h3> Two different approaches for transperitoneal para-aortic dissection possible laparoscopically. since para-aortic dissection is part of pelvic dissection in radical hysterectomy so without changing position of patient and surgeon (surgeon standing on right side of patient) we can achieve complete nodal dissection.

The Influence of Pelvic Lymph Node Dissection Volumes on Clinical Outcomes in NRG/RTOG 0534

<h3>Purpose/Objective(s)</h3> The use of radiation therapy (RT) and androgen deprivation therapy (ADT) following radical prostatectomy (RP) has been recently addressed by the NRG/RTOG 0534 phase III trial, which compared prostate bed RT alone (<i>arm 1</i>), prostate bed RT + short term (st-ADT) (<i>arm 2</i>), and prostate bed RT + st-ADT + pelvic lymph node (LN) RT (<i>arm 3)</i>. A wide range of LN volumes were removed at RP prior to enrollment. We sought to study the influence of LN dissection volumes on clinical outcomes. <h3>Materials/Methods</h3> Our hypothesis was that the number of LNs resected at RP on NRG/RTOG 0534 influences the benefit of pelvic LN RT (arm 3). Outcomes of interest included freedom from progression (FFP), time to distant metastasis (DM) and toxicity. Pretreatment characteristics were compared across quartiles of number of LNs dissected using the Kruskal Wallis test for categorical variables and the f-test from analysis of variance for continuous variables. Adjusted multivariable (MV) Cox proportional hazards models (cause-specific in the presence of competing risks) were used to assess the interaction between treatment arm and LNs dissected (0-1 vs. 2+ and as a continuous variable) with FFP and time to DM. <h3>Results</h3> 1,626 eligible patients had data on number of LNs dissected, 538 in <i>arm 1</i>, 543 in <i>arm 2</i>, and 545 in <i>arm 3</i>. 606 patients had 0 LNs removed, 228 had 1-2, 414 had 3-7, and 378 had over 7 LNs removed (max of 54). A higher number of LNs removed was associated with more adverse Gleason grade (p< 0.01), T-stage (p< 0.01), seminal vesicle invasion (p < 0.01), and academic medical center enrollment (p < 0.01). Controlling for differences in patient characteristics and continuous LN dissected, patients on arm 3 (vs. arm 2) did not demonstrate improvement in FFP (HR 1.19, 95% CI: 0.93-1.51, p = 0.2) nor was the interaction between treatment and LN dissected significant. Upon MV analysis for DM, there was a significant interaction between continuous number of LNs dissected and treatment arm. Specifically, patients with 0 LNs removed on arm 3 had a significant improvement in DM when compared with arms 1 and 2 (vs. arm 1 HR 2.49, 95% CI: 1.46-4.26; vs. arm 2 HR 1.75, 95% CI: 1.02-3.01). Patients with 1 node removed and on arm 3 had a significant improvement in DM when compared with arms 1 and 2 (vs. arm 1 HR 2.34, 95% CI: 1.42-3.85; vs. arm 2 HR 1.67, 95% CI: 1.00-2.77). The benefit of arm 3 vs. arm 2 was no longer significant in patients with 2+ LNs removed as the 95% CIs crossed 1.0. 2+ vs. 0-1 pelvic LNs removed and treatment on arm 3 vs. 1 exhibited higher rates of any grade renal/genitourinary toxicity (HR=1.16, 95% CI:1.02-1.31; HR=0.86, 95% CI: 0.75-0.99, respectively). <h3>Conclusion</h3> The extent of surgical pelvic LN dissections influences the benefit of post-operative pelvic LN RT on FFP and DM. Patients with 0-1 LNs removed, and randomized to pelvic LN RT and st-ADT, benefitted significantly from the addition of pelvic LN RT. Although no improvements with pelvic LN RT were seen in patients with 2+ nodes removed, these analyses had low statistical power.