Pelvic Lymph Node Dissection Templates Research Articles

A comparative analysis of perioperative complications and biochemical recurrence between standard and extended pelvic lymph node dissection in prostate cancer patients undergoing radical prostatectomy: a systematic review and meta-analysis.

Pelvic lymph node dissection (PLND) is commonly performed during radical prostatectomy (RP) for prostate cancer staging. This study aimed to comprehensively analyze existing evidence compare perioperative complications associated with standard (sPLND) versus extended PLND templates (ePLND) in RP patients. A meta-analysis of prospective studies on PLND complications was conducted. Systematic searches were performed on Web of Science, Pubmed, Embase, and the Cochrane Library until May 2023. Risk ratios (RRs) were estimated using random-effects models in the meta-analysis. The statistical analysis of the data was carried out using Review Manager software. Nine studies, including three randomized clinical trial and six prospective studies, with a total of 4962 patients were analyzed. The meta-analysis revealed that patients undergoing ePLND had a higher risk of partial perioperative complications, such as lymphedema ( I2 =28%; RR 0.05; 95% CI: 0.01-0.27; P <0.001) and urinary retention ( I2 =0%; RR 0.30; 95% CI: 0.09-0.94; P =0.04) compared to those undergoing sPLND. However, there were no significant difference was observed in pelvic hematoma ( I2 =0%; RR 1.65; 95% CI: 0.44-6.17; P =0.46), thromboembolic ( I2 =57%; RR 0.91; 95% CI: 0.35-2.38; P =0.85), ureteral injury ( I2 =33%; RR 0.28; 95% CI: 0.05-1.52; P =0.14), intraoperative bowel injury ( I2 =0%; RR 0.87; 95% CI: 0.14-5.27; P =0.88), and lymphocele ( I2 =0%; RR 1.58; 95% CI: 0.54-4.60; P =0.40) between sPLND and ePLND. Additionally, no significant difference was observed in overall perioperative complications ( I2 =85%; RR 0.68; 95% CI: 0.40-1.16; P =0.16). Furthermore, ePLND did not significantly reduce biochemical recurrence ( I2 =68%; RR 0.59; 95% CI: 0.28-1.24; P =0.16) of prostate cancer. This analysis found no significant differences in overall perioperative complications or biochemical recurrence between sPLND and ePLND, but ePLND may offer enhanced diagnostic advantages by increasing the detection rate of lymph node metastasis.

Different lymph node dissection ranges during radical prostatectomy for patients with prostate cancer: a systematic review and network meta-analysis

ObjectiveThe purpose of this network meta-analysis was to compare the effectiveness and adverse effects of limited, standard, extended, and super-extended pelvic lymph node dissection (PLND) following radical prostatectomy.MethodsThis study followed the PRISMA 2020 statement. Clinical trials were searched from three electronic databases, including PubMed, the Cochrane Library, and Embase from the database’s inception to April 5, 2022. The lymph node-positive rate, biochemical recurrence-free rate, lymphocele rate, thromboembolic rate, and overall complication rate were compared by meta-analysis. Data analyses were performed using R software based on the Bayesian framework.ResultsSixteen studies involving 15,269 patients were included. All 16 studies compared the lymph node-positive rate; 5 studies compared the biochemical recurrence-free rate; 10 studies compared the lymphocele rate; 6 studies compared the thromboembolic rate, and 9 studies compared the overall complication rate. According to Bayesian analysis, the lymph node-positive rate, lymphocele rate, and overall complication rate were significantly associated with the extension of the PLND range. The limited, extended, and super-extended PLND templates showed a similar but lower biochemical recurrence-free rate and a higher thromboembolic rate than the standard template.ConclusionsThe extension of the PLND range is associated with an elevated lymph node-positive rate; however, it does not improve the biochemical recurrence-free rate and correlates with an increased risk of complications, especially lymphocele. The selection of the PLND range in clinical practice should consider the oncological risk and adverse effects.Trial registrationPROSPERO (CRD42022301759).

Update of the Diagnostic and Therapeutic Role of the Pelvic Lymph Node Dissection Boundaries During Radical Cystectomy in Muscle Invasive Bladder Cancer

Radical cystectomy (RC) is the gold standard treatment option for muscle invasive bladder cancer (MIBC). However, up to 25% of patients who undergo RC show metastatic lymph node deposits during the procedure. In such cases, the 5-year survival rate is reported to be 25%–30%. Pelvic lymph node dissection (PLND) can also provide useful prognostic information, including data regarding the disease burden, lymph node density, and extracapsular extension of metastatic lymph nodes. Accordingly, the National Comprehensive Cancer Network guidelines recommend that PLND that includes the common iliac lymph node should be performed at the time of RC to allow reliable staging of MIBC. In addition to its diagnostic role, many studies have reported the potential therapeutic role of PLND. Data from clinical trials indicate a substantial oncological advantage in PLND cohorts compared to non-PLND cohorts, regardless of pathological nodal status, as a result of removal of metastatic and micrometastatic tumor cells nested in lymph nodes. As such, despite the diagnostic and therapeutic role of PLND in MIBC, the optimal PLND template remains controversial. Currently, extended PLND (E-PLND) is recommended for diagnostic purposes, however, E-PLND did not show therapeutic effectiveness in some recent preliminary randomized controlled trials. In this review, we will discuss the appropriate range of PLND for RC in terms of its diagnostic and therapeutic importance, and propose an appropriate range of PLNDs based on the evidence and randomized trials so far.

Prevalence of High-Risk Prostate Cancer Metastasis to Cloquet's Ilioinguinal Lymph Node.

Cloquet's node, located at the junction between the deep inguinal nodes and the external iliac chain, is easily accessible and commonly excised during pelvic lymph node dissection for prostate cancer. However, we hypothesize that Cloquet's node is not part of lymphatic metastatic spread of prostate cancer. Between September 2016 and June 2019, 105 consecutive patients with high-risk prostate cancer (cT3a or Grade Group 4/5, or prostate specific antigen >20 ng/ml) underwent a laparoscopic radical prostatectomy and pelvic lymph node dissection. First, Cloquet's node was identified, retrieved and submitted separately to pathology as right and left Cloquet's node. Next, a pelvic lymph node dissection was completed including the external iliac, obturator fossa and hypogastric nodal packets. Each lymph node was cut into 3 mm slices which were separately embedded in paraffin, stained with hematoxylin and eosin, and examined microscopically. The final analysis included 95 patients. In this high-risk population, the median number of nodes removed was 22 (IQR 18-29); 39/95 patients (41%) had lymph node metastasis. The median number of Cloquet's nodes removed was 2 (IQR 2-3). Cloquet's node was negative in all but 1 patient (1.1%), who had very high-risk features and high metastatic burden in the lymph nodes. In high-risk prostate cancer, metastasis to the ilioinguinal node of Cloquet is rare. Given this low prevalence, Cloquet's node can be safely excluded from the pelvic lymph node dissection template.

Is There an Oncological Benefit of Performing Bilateral Pelvic Lymph Node Dissection in Patients with Penile Cancer and Inguinal Lymph Node Metastasis?

We aim to review the literature for studies investigating the oncological outcomes of patients with penile cancer (PC) undergoing bilateral pelvic lymph node dissection (PLND) in the presence of inguinal lymph node metastasis (LNM) who are at risk of harboring pelvic metastasis. A search of English language literature was performed using the PubMed-MEDLINE database up to 3 December 2020 to identify articles addressing bilateral PLND in PC patients. Eight articles investigating bilateral PLND met our inclusion criteria. Patients with pelvic LNM have a dismal prognosis and, therefore, PLND has an important role in both the staging and treatment of PC patients. Ipsilateral PLND is recommended in the presence of ≥2 positive inguinal nodes and/or extranodal extension (ENE). Significant survival improvements were observed with a higher pelvic lymph node yield, in patients with pN2 disease, and in men treated with bilateral PLND as opposed to ipsilateral PLND. Nevertheless, the role of bilateral PLND for unilateral inguinal LNM remains unclear. Although the EAU guidelines state that pelvic nodal disease does not occur without ipsilateral inguinal LNM, metastatic spread from one inguinal side to the contralateral pelvic side has been reported in a number of studies. Further studies are needed to clarify the disseminative pattern of LNM, in order to establish PLND templates according to patients’ risk profiles and to investigate the benefit of performing bilateral PLND for unilateral inguinal disease.

Prediction of the Need for an Extended Lymphadenectomy at the Time of Radical Cystectomy in Patients with Bladder Cancer

BackgroundA prospective randomized trial (LEA AUO AB 25/02) found no survival benefit in extended compared with limited pelvic lymph node dissection (PLND) templates in bladder cancer (BCa) patients treated with radical cystectomy (RC). However, the rate of lymph node invasion (LNI) in the standard and extended templates was lower than estimated. ObjectiveTo assess the accuracy of preoperative clinical and pathological parameters to predict LNI and to develop a model to preoperatively select candidates for the extended PLND templates. Design, setting, and participantsA total of 903 BCa patients treated at a single institution were retrospectively identified. The primary outcome was to identify preoperatively the risk of LNI to tailor the type of PLND. The extended PLND templates consisted in the removal of pelvic lymph nodes together with the common iliac, presacral, para-aortocaval, interaortocaval, and paracaval sites up to the inferior mesenteric artery. InterventionA total of 903 BCa patients were treated with RC and bilateral extended PLND templates. Outcome measurements and statistical analysisSeveral models predicting LNI were evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots and decision curve analyses. A nomogram predicting LNI in the extended pattern was developed and validated internally. Results and limitationsOverall, 55 patients (6.1%) had LNI in the extended PLND templates at RC. The median number of nodes removed was 19 (interquartile range: 13–26). A model including age, clinical T stage, clinical node stage, lymphovascular invasion, and presence of carcinoma in situ at the last transurethral resection before RC was developed. The AUC of this model is 73%. Using a cutoff of 3%, 108 extended PLNDs (12%) would be spared and only two LNIs (3%) would be missed. The main limitations of our model are the retrospective nature of the data, lack of external validation, and low rate of LNI. ConclusionsThis is the first proposed model to predict LNI in the extended PLND templates. This model might help urologists identify which patients might benefit from an extended PLND at the time of RC, reserving a standard PLND for all the others. Patient summaryWe developed the first nomogram to predict lymph node invasion (LNI) in the extended pelvic lymph node dissection templates in bladder cancer patients treated with radical cystectomy. The adoption of our model to identify candidates for the extended pelvic lymph node dissection templates could avoid up to 12% of these procedures at the cost of missing only 3% of patients with LNI.

MP67-13 COMPARISON OF MORBIDITY BETWEEN LIMITED AND EXTENDED PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER: RESULTS FROM A LARGE, CLINICALLY-INTEGRATED, RANDOMIZED TRIAL

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy III (MP67)1 Apr 2020MP67-13 COMPARISON OF MORBIDITY BETWEEN LIMITED AND EXTENDED PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER: RESULTS FROM A LARGE, CLINICALLY-INTEGRATED, RANDOMIZED TRIAL Karim Touijer, Daniel D. Sjoberg, Nicole Benfante, Claudia Mercader Barrull*, Natalia Picola Brau, Inés Rivero Belenchón, Vincent Laudone, Behfar Ehdaie, James A. Eastham, Peter T. Scardino, and Andrew Vickers Karim TouijerKarim Touijer More articles by this author , Daniel D. SjobergDaniel D. Sjoberg More articles by this author , Nicole BenfanteNicole Benfante More articles by this author , Claudia Mercader Barrull*Claudia Mercader Barrull* More articles by this author , Natalia Picola BrauNatalia Picola Brau More articles by this author , Inés Rivero BelenchónInés Rivero Belenchón More articles by this author , Vincent LaudoneVincent Laudone More articles by this author , Behfar EhdaieBehfar Ehdaie More articles by this author , James A. EasthamJames A. Eastham More articles by this author , Peter T. ScardinoPeter T. Scardino More articles by this author , and Andrew VickersAndrew Vickers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000947.013AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pelvic lymph node dissection (PLND) in prostate cancer is controversial. Although it represents the most reliable procedure for lymph node staging, the extended PLND was reported to be associated with increased morbidity. METHODS: Between October 2011 and March 2017, men were consented to the trial and underwent radical prostatectomy at Memorial Sloan Kettering Cancer Center. The study design was a cluster randomization with crossover. Each surgeon was randomized to use a limited (external iliac nodal packet) vs. extended (external iliac, obturator fossa and hypogastric nodal packets) PLND template for a 3-month period. At the end of the 3-month period, surgeons were once again randomized. Morbidity data within 30 days of surgery was prospectively graded and collected in the clinical research database. RESULTS: A total of 1574 patients were randomized: 811 randomized to the extended and 763 to the limited template. Overall the rate of complication was 10.5% in the limited PLND group vs. 8.5% in the extended PLND group. There were no grade IV or V complications. Rates for grade II and III complications were similar (7.2% in limited vs. 6.3% in extended). CONCLUSIONS: In this large randomized trial the overall rate of grade II and III complications was low. There was no significant difference in complication rates between the limited and extended PLND. Source of Funding: None. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1030-e1030 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Karim Touijer More articles by this author Daniel D. Sjoberg More articles by this author Nicole Benfante More articles by this author Claudia Mercader Barrull* More articles by this author Natalia Picola Brau More articles by this author Inés Rivero Belenchón More articles by this author Vincent Laudone More articles by this author Behfar Ehdaie More articles by this author James A. Eastham More articles by this author Peter T. Scardino More articles by this author Andrew Vickers More articles by this author Expand All Advertisement PDF downloadLoading ...

Extended pelvic lymph node dissection during extraperitoneal laparoscopic or robotic assisted radical prostatectomy

Objective: Extraperitoneal access in endoscopic (laparoscopicic or robotic assisted) radical prostatectomy is a standard approach in the management of prostatic cancer with well-established advantages over transperitoneal access. Still, traditionally, extraperitoneal endoscopic radical prostatectomy (EERP) has been associated with an inability to offer an extended pelvic lymph node dissection (PLND). The former is due to the fact that in the extraperitoneal space, peritoneal folding covers the majority of common iliac vessels and as a result in extraperitoneal PLND, lymph nodes (LNs) located above the bifurcation of common iliac vessels cannot be dissected. We herein present a simple and easy technique to offer an extended PLND during EERP. Methods: After a conventional extraperitoneal PLND, a peritoneal fenestration cranially to extrernal iliac vessels is performed bilaterally exposing the common iliac vessels. Results: Upon peritoneal fenestration, PLND can be continued in a standard fashion as in transperitoneal approach until the uppermost limit of the extended PLND template which is the ureteral crossing over common iliac vessels. Following LN dissection, both peritoneal fenestrations are left open at both sides, as this approach has been found to decrease the incidence of postoperative lymphocele formation. Conclusions: Peritoneal fenestration over common iliac vessels during extraperitoneal PLND is an easy approach that allows surgeon to reach the uppermost limit of extended PLND template. The latter peritoneal dissection is not time consuming and is expected to decrease the morbidity of the operation reducing the incidence of postoperative lymphocele formation.

Pelvic lymph node dissection during radical cystectomy for muscle-invasive bladder cancer.

Radical cystectomy is the gold-standard treatment option for muscle-invasive and metastatic bladder cancer. At the time of cystectomy, up to 25% of patients harbour metastatic lymph node deposits. These deposits most frequently occur in the obturator fossa, but can be as proximal as the interaortocaval region. Thus, the use of concurrent pelvic lymph node dissection (PLND) with cystectomy has been increasingly reported. Data from studies including many patients suggest substantial oncological benefit in PLND cohorts versus non-PLND cohorts, irrespective of pathological nodal status. Additionally, PLND provides useful prognostic information, including disease burden, lymph node density, and extracapsular extension of metastatic lymph nodes. Accordingly, the National Comprehensive Cancer Network guidelines advocate the use of PLND during radical cystectomy for muscle-invasive bladder cancer. Despite this recommendation, a lack of consensus exists regarding the optimal PLND template. Comparative series suggest that extended PLND provides improved recurrence-free survival and cancer-specific survival compared with more limited PLND templates. More extensive templates (such as super-extended PLND) provide no additional survival benefit at the potential cost of increased operative time and patient morbidity. In addition to extended PLND templates, increased nodal harvest confers an oncological benefit in patients with node-positive disease or in patients with node-negative disease. Accordingly, recommendations for a minimum nodal yield have been proposed. Despite the growing body of evidence, formal recommendations by oncological and urological authoritative bodies have been limited owing to the lack of randomized data and level I evidence.

A Head-to-head Comparison of Four Prognostic Models for Prediction of Lymph Node Invasion in African American and Caucasian Individuals

BackgroundFour nomograms are available for the prediction of lymph node invasion (LNI) prior to radical prostatectomy (RP): the Cagiannos, the 2012-Briganti, the Godoy, and the online-Memorial Sloan Kettering Cancer Center (MSKCC). None was tested in African Americans (AAs). ObjectiveTo perform a validation and head-to-head comparison of four nomograms for the prediction of LNI in AAs. Design, setting, and participantsWithin the Surveillance Epidemiology and End Results database (2010–2014), we identified 14 077 Caucasians and 2668 AAs with clinically localised prostate cancer. InterventionRP and pelvic lymph node dissection (PLND). Outcome measurements and statistical analysisPredicted and observed LNI rates for the four nomograms were tested between AAs and Caucasians with Heagerty’s concordance index (C-index), calibration plots, decision curve analyses (DCAs), and nomogram-derived cut-offs for avoided PLND and missed LNI cases. Results and limitationsAll C-index values were lower in AAs than in Caucasians: Cagiannos (76.1% vs 79.5%), Godoy (73.0% vs 79.4%), 2012-Briganti (73.3% vs 81.3%), and MSKCC (72.6% vs 81.6%). All four nomogram calibration plots showed invariably worse performances in AAs. In DCAs focusing on AAs, the Cagiannos nomogram provided the highest net benefit relative to the remaining three nomograms. In nomogram cut-off analyses testing the number of avoided PLND against the number of missed LNI cases, the Cagiannos nomogram yielded the best results when tested in AAs. However, in DCAs and cut-off analyses that compared AAs with Caucasians, AAs yielded less favourable outcomes regardless of which nomogram was tested. We lack a central pathology review and standardisation of PLND templates. ConclusionsIn AAs, the Cagiannos nomogram provides the optimal results relative to the remaining three nomograms. Nonetheless, all tested nomograms yielded worse metrics in AAs than in Caucasians. Patient summaryAll four tested nomograms can be equally considered in Caucasians. Conversely, the Cagiannos nomogram should be preferred in African Americans.

Can Anterior Prostatic Fat Harbor Prostate Cancer Metastasis? A Prospective Cohort Study

Objectives: Traditionally anterior prostatic fat (APF) hasn't been included in pelvic lymph node (LN) dissection templates following radical prostatectomy. In this study we evaluate the incidence of lymphoid tissue in the APF and the incidence of LN metastasis in APF in patients who have undergone robotic-assisted laparoscopic radical prostatectomy (RALP). Methods: A prospective database of RALP has been maintained between January 2010 and September 2015. APF is routinely excised and sent separately for histopathological evaluation to identify lymphoid tissue and metastatic prostate cancer. Results: A total of 629 underwent RALP. Forty-six (7.3%) of the patients had lymphoid tissue on histopathological evaluation. Two patients had meta-static disease. Both patients with positive LNs were intermediate risk on pre-operative evolution (A-PSA 16.6 ng/ml, Gleason 3 + 4; B PSA 7.3 ng/ml, Gleason 4 + 3) and upgraded on final prostate pathological evaluation to high risk disease (A-Gleason 4 + 5, pT3b, B-Gleason 4 + 3, pT4). Conclusion: There appears to be lymphatic drainage to the APF from the prostate. Hence APF should be included in pelvic LN dissection templates when lymphadenectomy is contemplated in patients undergoing radical prostatectomy.

Development, validation and clinical application of Pelvic Lymphadenectomy Assessment and Completion Evaluation: intraoperative assessment of lymph node dissection after robot‐assisted radical cystectomy for bladder cancer

To develop a scoring tool, Pelvic Lymphadenectomy Appropriateness and Completion Evaluation (PLACE), to assess the intraoperative completeness and appropriateness of pelvic lymph node dissection (PLND) following robot-assisted radical cystectomy (RARC). A panel of 11 open and robotic surgeons developed the content and structure of PLACE. The PLND template was divided into three zones. In all, 21 de-identified videos of bilateral robot-assisted PLNDs were assessed by the 11 experts using PLACE to determine inter-rater reliability. Lymph node (LN) clearance was defined as the proportion of cleared LNs from all PLACE zones. We investigated the correlation between LN clearance and LN count. Then, we compared the LN count of 18 prospective PLNDs using PLACE with our retrospective series performed using the extended template (No PLACE). A significant reliability was achieved for all PLACE zones among the 11 raters for the 21 bilateral PLND videos. The median (interquartile range) for LN clearance was 468 (431-545). There was a significant positive correlation between LN clearance and LN count (R2 = 0.70, P < 0.01). The PLACE group yielded similar LN counts when compared to the No PLACE group. Pelvic Lymphadenectomy Appropriateness and Completion Evaluation is a structured intraoperative scoring system that can be used intraoperatively to measure and quantify PLND for quality control and to facilitate training during RARC.

Lymph node yield in node-negative patients predicts cancer specific survival following radical cystectomy for transitional cell carcinoma.

PurposeTo determine the oncological implications of increased nodal dissection in node-negative bladder cancer during radical cystectomy in a contemporary Australian series.Materials and MethodsWe performed a multicenter retrospective study, including more than 40 surgeons across 5 sites over a 10-year period. We identified 353 patients with primary bladder cancer undergoing radical cystectomy. Extent of lymphadenectomy was defined as follows; limited pelvic lymph node dissection (PLND) (perivesical, pelvic, and obturator), standard PLND (internal and external iliac) and extended PLND (common iliac). Multivariable cox proportional hazards and logistic regression models were used to determine LNY effect on cancer-specific survival.ResultsOver the study period, the extent of dissection and lymph node yield increased considerably. In node-negative patients, lymph node yield (LNY) conferred a significantly improved cancer-specific survival. Compared to cases where LNY of 1 to 5 nodes were taken, the hazard ratio (HR) for 6 to 15 nodes harvested was 0.78 (95% confidence interval [CI], 0.43–1.39) and for greater than 15 nodes the HR was 0.31 (95% CI, 0.17–0.57), adjusted for age, sex, T stage, margin status, and year of surgery. The predicted probability of cancer-specific death within 2 years of cystectomy was 16% (95% CI, 13%–19%) with 10 nodes harvested, falling to 5.5% (95% CI, 0%–12%) with 30 nodes taken. Increasing harvest in all PLND templates conferred a survival benefit.ConclusionsThe findings of the current study highlight the improved oncological outcomes with increased LNY, irrespective of the dissection template. Further prospective research is needed to aid LND data interpretation.

Patterns and prognostic significance of clinical recurrences after radical cystectomy for bladder cancer: A 20-year single center experience

ObjectivePatients treated with radical cystectomy (RC) due to bladder cancer (BCa) face high risk of clinical recurrence. The aim of our study was to describe recurrence patterns and characteristics related to survival in patients treated with RC due to BCa. MethodsYears 1992–2012 of a prospectively maintained institutional RC registry were queried for clinical localized urothelial BCa patients. Clinical recurrences were categorized as local, distant or secondary urothelial recurrences. Kaplan Meier analysis assessed time to cancer specific mortality (CSM). Multivariable Cox regression models were constructed to predict recurrence and CSM after recurrence. ResultsData from 1110 patients with urothelial non-metastatic BCa at RC were analyzed with 7.5 years of median follow up. Overall, 324 patients experienced recurrence and 200 (61.7%) were single site recurrence. The locations were: 43 local (22 cystectomy bed and 21 pelvic lymph node dissection template), 138 distant (36 lung, 19 liver, 52 bone, 17 extra pelvic LN, 7 peritoneal, 4 brain and 3 others) and 19 secondary urothelial carcinoma (11 upper urinary tract, 8 urethra). Significant independent predictors of overall recurrence were pathological stage pT3/T4 vs. pT0-2, pathological N positive status and positive surgical margin. Median overall survival after recurrence was 18 months. At multivariate analysis, pathological T3 (Hazard ratio [HR]: 1.62), T4 (HR: 1.58), interval from RC to recurrence (HR: 0.92) and distant (HR: 2.57) recurrences were independently associated with CSM (all p < 0.05). ConclusionsOverall, one out of three patients treated with RC face recurrence during follow up. Early and distant recurrences are associated with shortest survival expectancies.

Lymph node count at radical cystectomy does not influence long-term survival if surgeons adhere to a standardized template

IntroductionMultiple bladder cancer studies report that the number of removed lymph nodes (lymph node count [LNC]) at radical cystectomy (RC) is positively associated with survival. Although these reports suggest that LNC can be used as a proxy for surgical quality, all studies used variable or inconsistent pelvic lymph node dissection (PLND) templates. We therefore wished to establish whether LNC at RC influences survival if surgeons adhere to a standardized PLND template. Materials and methodsWe included 274 patients who underwent RC from January 2005 until December 2012. All RCs were performed in either one of 2 hospitals (hospital A or B) by the same 4 urologists (all from hospital A) and a standardized PLND template was applied. PLND specimens were processed by 2 independent pathology departments (hospital A and B). We used Cox regression analysis to investigate the prognostic value of LNC adjusted for patient characteristics. We also compared LNC between hospitals and surgeons and investigated the effect of both the variables on overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS). ResultsMedian LNC was 17 (interquartile range = 12). At a median follow-up of 64.3 months, there was no association between LNC and OS (P = 0.328), CSS (P = 0.645), or DFS (P = 0.450). Median LNC was higher in hospital B than in hospital A (20.0 vs. 16.0, P = 0.003). Median LNC varied significantly among surgeons (12–20, P<0.001). Neither the hospital of surgery nor the surgeon performing PLND influenced OS (P = 0.771 and P = 0.982, respectively), CSS (P = 0.310 and P = 0.691, respectively), or DFS (P = 0.256 and P = 0.296, respectively). ConclusionIf surgeons adhere to a standardized template, LNC at RC does not affect long-term survival.

Advances in sentinel node dissection in prostate cancer from a technical perspective.

The most important feature of sentinel node biopsy for prostate cancer procedure is that staging can be improved. Sentinel nodes might be found outside the extended pelvic lymph node dissection template what renders the sentinel node additive ofextended pelvic lymph node dissection. At the same time, staging within the template can be further refined. We reviewed the literature regarding the sentinel node biopsy procedure for prostate cancer. PubMed and Embase were searched for all English-languagepublications from January 1999 to September 2014 by using the keywords as "prostatecancer" and "sentinel lymph node" plus "biopsy" "dissection" and/or "procedure." The present review discusses step-by-step sentinel node biopsy for prostate cancer. Topics of discussion are: (i) preoperative sentinel node mapping (tracers and imaging); (ii) intraoperative sentinel node identification (surgical procedure and outcome); and (iii) novelties to improve sentinel node identification (pre- and intraoperative approaches). Conventional sentinel node mapping is carried out after the injection of a (99m) Tc-based tracer and subsequent preoperative imaging; for example, lymphoscintigraphy and single-photon emission computed tomography/computed tomography. This approach allowed the detection of sentinel nodes outside the extended lymph node dissection template in 3.6-36% of men with intermediate- and high-risk prostate cancer. Hereby, an overall false negative rate of sentinel nodes was reported between 0% and 24.4%. To further refine the intraoperative sampling procedure, novel imaging methods such as fluorescence imaging have been introduced. Prospective randomized comparison studies are required to confirm the added benefit of sentinel template directed nodal dissection. A proper and obtainable end-point of such a study could be the number of removed positive nodes for carrying out nodal dissection with or without sentinel template directed dissection. Similarly, the clinical impact of novel imaging technologies requires further investigation.

Fluorescence Guided Targeted Pelvic Lymph Node Dissection for Intermediate and High Risk Prostate Cancer

We investigated whether visualization of the drainage system of the prostate by free indocyanine green would lead to identification of all or even more lymph node metastases detected by super-extended pelvic lymph node dissection in an intermediate and high risk patient population with prostate cancer. A total of 38 consecutive men with intermediate or high risk prostate cancer according to the D'Amico criteria underwent fluorescence targeted pelvic lymph node dissection during laparoscopic radical prostatectomy. Super-extended pelvic lymph node dissection was added as the control. Patients with neoadjuvant hormonal therapy, macroscopic lymph node involvement or prior transurethral prostate resection were excluded from study. Statistical descriptive methods, and the chi-square test and independent t-test were used to analyze data. Mean patient age was 64.9 years (range 46 to 74) and mean preoperative prostate specific antigen was 13.8 ng/ml (range 0.3 to 44). A total of 23 (60.5%) and 15 cases (39.5%) were classified as intermediate and high risk, respectively. Fluorescence stained nodes were found on each side in all except 1 patient. A total of 700 lymph nodes (mean ± SD 18.4 ± 8.2 per patient) were removed, of which 531 (75% of all nodes) were fluorescence stained (mean 14 ± 8.07 per patient). Lymph node metastases were found in 15 patients (39.5%). Two patients (5.3%) had a solitary micrometastasis and 3 (7.9%) had nodes containing isolated tumor cells. Metastases were found outside the extended pelvic lymph node dissection template in 5 of 15 patients (33.3%). Three of those 5 patients attained a prostate specific antigen nadir of less than 0.1 ng/ml 6 weeks postoperatively. Fluorescence targeted pelvic lymph node dissection showed superior sensitivity and negative predictive value compared to extended and super-extended pelvic lymph node dissection to detect lymph node metastasis. Fluorescence targeted pelvic lymph node dissection allows for the lymphatic drainage of the prostate to be identified with great reliability. Since only the nodes draining the prostate are removed, the absolute number of removed nodes is decreased while diagnostic accuracy is increased.

Anatomic Basis for Lymph Node Counts as Measure of Lymph Node Dissection Extent: A Cadaveric Study

To determine the number, variability, and distribution of pelvic lymph nodes to better understand the utility of the node count as a surrogate for the dissection extent. Although pelvic lymph node dissection (PLND) at radical cystectomy for bladder cancer is critical for disease control and staging, debate regarding the measurement of dissection adequacy remains. Many have proposed minimum node counts, yet an anatomic study assessing the number and variability of lymph nodes in the PLND templates is lacking. Super-extended PLND was performed on 26 human cadavers, and the lymph nodes within each of 12 dissection zones were enumerated by a single pathologist. We calculated the mean, standard deviation, and range of nodal yield within each dissection region. The super-extended and standard dissection templates were compared using the paired t test. Super-extended PLND yielded a mean of 28.5 ± 11.5 lymph nodes, with a total node count range of 10-53 nodes. In contrast, the nodal yield within the standard template was 18.3 ± 6.3 nodes, with a range of 8-28 nodes (P <.001). No significant differences were seen in lymph node counts when stratified by age, sex, or cause of death. Using a cadaveric model and a single pathologist to eliminate many of the factors affecting the nodal yield in surgical series, we found substantial interindividual differences, with counts ranging from 10 to 53 nodes. These results have demonstrated the limited utility of lymph node count as a surrogate for the dissection extent and illustrated the challenges associated with implementing a surgical standard for minimum lymph node counts.

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

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

Extended lymphadenectomy in bladder cancer

Radical cystectomy with pelvic lymph node dissection (PLND) is the preferred treatment for invasive bladder cancer. It not only results in the best disease-free term survival rates, but also provides the most accurate disease staging and most effective local symptom control. Recent investigations have demonstrated a clinical benefit to performance of an extended PLND, including all lymphatic tissue to the level of the aortic bifurcation. This review will summarize recent findings regarding the clinical benefits of radical cystectomy with extended lymphadenectomy, and will also examine the latest surgical techniques for optimizing the performance of this technically demanding procedure. Recent studies have demonstrated increased recurrence-free survival and overall survival rates in patients undergoing radical cystectomy with extended PLND, even in cases of pathologically lymph node negative disease. The growing use of minimally invasive techniques has prompted interest in robotic radical cystectomy and extended PLND, and recent reports have demonstrated the feasibility of this technique. The standardization of extended PLND templates has also been a focus of contemporary research. Contemporary research strongly suggests that all patients undergoing radical cystectomy for bladder cancer should undergo concomitant extended PLND. Randomized trials are still needed to confirm the benefits of extended over 'standard' PLND, and to clarify which patients may receive the greatest benefit from this procedure.