Pelvic Lymphadenectomy For Prostate Cancer Research Articles

Extended pelvic lymphadenectomy for prostate cancer: should the Cloquet's nodes dissection be considered only an option?

The aim of this study was to assess the anatomical prevalence and secondary involvement of Cloquet's nodes in patients undergoing robotic radical prostatectomy (RRP) and extended pelvic lymph node dissection (ePLND) for prostate cancer (PCa). RRP and ePLND were performed by two expert surgeons (WA and VDM). Data were prospectively collected and retrospectively analyzed. Dissected pelvic lymph nodes were sampled according to an anatomical template as follows: external iliac, obturator, Marcille's, and Cloquet's. Node packages were sent to the dedicated pathologist separately. Baseline characteristics, perioperative and pathological outcomes were analyzed. Between January 2014 and December 2017 a total of 258 patients were evaluated. In aggregate 247 out of 258 patients (95.7%) presented at least a lymph node in the in the Cloquet's fossa tissue and 105 (40.6%) had more than one node. Patients with multiple nodes in Cloquet fossa presented higher median lymph node amount (27 vs. 33; P<0.0001). 13.5% of patients had lymph node invasion Pathological evaluation of the Cloquet's nodes showed metastatic PCa in 3 out of 35 (8.6%) pN+ patients. No differences were found when patients with metastatic Cloquet's nodes were compared with the pN+ population in terms of demographics, PSA, D'Amico classification, biopsy and pathological Gleason Grouping, clinical and pathological stage and complications. To the best of our knowledge this is the first study that analyses specifically the quantitative prevalence of Cloquet's nodes and the incidence of malignancy involvement in patients undergoing RRP and ePLND for PCa. The occurrence of multiple lymph nodes in the Cloquet fossa is a rare event. Our series showed that Cloquet involvement seems to be associated with multiple nodes cohabitation and contemporarily multiple lymph node metastases in other template locations. Related morbidity rate is sporadic and cannot justify the Cloquet preservation. Wider series are required to comprehend predictor factors of Cloquet nodes involvement. Until then the Cloquet lymphadenectomy would be recommended and should not be an option.

P165 - Extended pelvic lymphadenectomy for prostate cancer: Should the Cloquet’s nodes dissection be considered only an option?

P165 - Extended pelvic lymphadenectomy for prostate cancer: Should the Cloquet’s nodes dissection be considered only an option?

Lymph node parameters and complications following laparoscopic extended pelvic lymphadenectomy for prostate cancer in 1000 consecutive patients

Objective: The purpose of this study was to investigate the short-term results of extended pelvic lymphadenectomy (ePLND) during laparoscopic radical prostatectomy (LRP). Patients and methods: Of 1330 consecutive patients undergoing LRP during a 90-month period 1000 (75%) had an ePLND for d’Amico intermediate- or high-risk prostate cancer. Results: Operating time, blood loss, conversion and transfusion rates and hospital stay were similar in patients having standard pelvic lymphadenectomy (sPLND) and ePLND. Median lymph node count was significantly greater following ePLND vs sPLND (17 vs 6; p⩽0.0001). Complication rates were also similar but trended ( p=0.06) towards a greater rate after ePLND vs sPLND: 9.0% and 5.5%. Lymph node involvement (LNI) was detected more frequently following ePLND in patients with: prostate specific antigen (PSA)=0–9.9 ( p=0.01) and PSA=10–19.9 ( p⩽0.0001); biopsy Gleason sum ⩽8 ( p⩽0.0001 to 0.03); intermediate- ( p⩽0.0001) and high-risk ( p⩽0.0001) cancer; pathological Gleason grade 7 ( p⩽0.0001) and pathological stage T3 ( p=0.0009 for pT3a and p⩽0.0001 for pT3b). Conclusion: ePLND is a more effective tool than sPLND in detecting LNI for patients in all prognostic clinical groups. This can be achieved without significant penalty with respect to operating time or complication rates.

Extended pelvic lymphadenectomy in prostate cancer: Practice makes perfect.

Extended pelvic lymphadenectomy in prostate cancer: Practice makes perfect.

Blood Type, Lymphadenectomy and Blood Transfusion Predict Venous Thromboembolic Events Following Radical Prostatectomy with Pelvic Lymphadenectomy

Venous thromboembolic events are the most common nonoperative complication after radical prostatectomy and they represent the most common cause of death within 30 days of surgery. While effective mechanical and chemoprophylaxis exists, such prophylaxis may also be associated with increased complications. To identify venous thromboembolic event risk factors and, thereby, facilitate targeted prophylaxis we characterized clinicopathological variables associated with these events in patients undergoing radical prostatectomy. We reviewed the records of 18,472 consecutive patients who underwent radical prostatectomy with pelvic lymphadenectomy for prostate cancer at our institution from 1987 to 2010. Patients were followed postoperatively for complications. Venous thromboembolic events within 30 days of surgery were recorded. Logistic regression models were used to analyze clinicopathological variables associated with venous thromboembolic events. We identified symptomatic venous thromboembolic events in 271 patients (1.4%). This diagnosis was not associated with preoperative body mass index, prostate specific antigen, Gleason score or cancer recurrence. However, the diagnosis was significantly associated with nonO blood type (OR 1.98, p = 0.004), an increasing number of lymph nodes removed (OR 1.05, p = 0.035) and blood transfusion (OR 1.30, p = 0.02). Patients with venous thromboembolic events were significantly more likely to die within 30 days of surgery (3.0% vs 0%, p <0.001). Blood type, pelvic lymphadenectomy extent and blood transfusion are significant risk factors for symptomatic venous thromboembolic event before radical prostatectomy plus pelvic lymph node dissection. These data should be used for patient counseling, particularly in regard to obviating lymphadenectomy in patients at low risk and for individualizing prophylaxis for venous thromboembolic event in patients at higher risk.

Standardized comparison of robot‐assisted limited and extended pelvic lymphadenectomy for prostate cancer

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Extended pelvic lymphadenectomy is the present standard of care according to European Association of Urology guidelines. Extended dissection improves staging, removes more metastatic lymph nodes, and potentially has therapeutic benefits. Previous reports have examined the morbidity of extended dissection compared with a more limited dissection in the open and laparoscopic setting. While some have suggested an increased complication rate with extended node dissection, others have not. This represents the first study focused on comparing the complications associated with the extent of node dissection using the modified Clavien system and Martin criteria in the literature on robot-assisted surgery. In a single surgeon series, we found no statistically significant differences in complications. With careful anatomic dissection, robot-assisted extended lymph node dissection can be performed safely and effectively, although operating time and length of hospital of stay are slightly increased. To compare the perioperative course of patients undergoing robot-assisted limited lymph node dissection (LLND) or extended lymph node dissection (ELND) for prostate cancer. To examine the differential lymph node counts and rates of detection of lymph node metastases. Between 2008 and 2012, 406 consecutive patients with D'Amico intermediate- or high-risk prostate cancer underwent either bilateral LLND (n = 204) or ELND (n = 202) and robot-assisted laparoscopic radical prostatectomy by a single surgeon. The region of dissection was the obturator fossa for LLND, while ELND included, in addition, the common iliac, external iliac and internal iliac lymph nodes. All complications within 90 days of surgery were recorded according to a modified Clavien system. Clinical variables were summarized and compared. Logistic regression was used to identify predictors of complications. There were no differences in demographics when comparing patients who underwent ELND with those who underwent LLND. The median operating time was 3.0 h for the ELND cohort and 2.8 h in the LLND cohort (P < 0.001). Intraoperative blood loss was 200 mL in both cohorts. Hospital stay was longer for a small percentage of patients in the ELND cohort, with 75% of ELND patients and 85% of LLND patients staying 1 day (P = 0.004). No significant difference was found in the overall or major complication rates between LLND (21.6% overall; 6.9% major) and ELND (22.8% overall; 4.5% major). No difference was seen in the symptomatic lymphocele rate between LLND and ELND, 2.9 vs 2.5%, respectively. Overall, the lymph-node-positive rate was 12% compared with 4% for the ELND and LLND groups, respectively (P = 0.002). A higher Charlson comorbidity index score was associated with the development of major complications. ELND at the time of robot-assisted radical prostatectomy can be performed safely with minimal additional morbidity. Long-term oncological and functional outcomes require further study.

Technique of Pelvic Lymphadenectomy After Robot-Assisted Laparoscopic Prostatectomy for Prostate Cancer

Pelvic lymphadenectomy for prostate cancer is an important tool in the prognostication of the disease in selected patients who are at risk of occult lymph node metastases. This procedure, usually performed in conjunction with radical prostatectomy, had progressed successfully from an open approach to the current robot-assisted approach. The following article and accompanying video describe the surgical technique of robot-assisted pelvic lymphadenectomy for prostate cancer. We also discuss the indications, patient selection, preparation, complications, and tips to avoid the major pitfalls in the procedure.

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.

UP-02.235 Robotic Extended Pelvic Lymphadenectomy for Prostate Cancer

Accurate staging of prostate cancer is dependent on a sufficient evaluation of the pelvic lymph nodes. We examine our experience with performing robotic extended pelvic lymphadenectomy.

912 ROBOTIC LIMITED AND EXTENDED PELVIC LYMPHADENECTOMY FOR PROSTATE CANCER

You have accessJournal of UrologyTechnology & Instruments: Robotics/Laparoscopy/Ureteroscopy II1 Apr 2010912 ROBOTIC LIMITED AND EXTENDED PELVIC LYMPHADENECTOMY FOR PROSTATE CANCER Hugh Lavery and Ronney Abaza Hugh LaveryHugh Lavery More articles by this author and Ronney AbazaRonney Abaza More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1668AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The optimal extent of lymphadenectomy for prostate cancer is unknown. More extensive dissections have shown increased overall nodal yields as well as more frequent identification of positive nodes. With the advent of robot-assisted laparoscopic prostatectomy (RALP), the ability to achieve adequate lymph node dissections with this approach has been questioned with many series reporting lower nodal yields than historical series or lower nodal positivity than expected based upon the biology of the disease. We reviewed our experience with both extended (ePLND) and limited pelvic lymphadenectomy (PLND) to determine nodal yield, complications, and rate of node positivity. METHODS We reviewed 250 consecutive RALP procedures with PLND from Feb 2008 to Jan 2009 by a single surgeon (RA). Nodal packets were dissected en bloc and nodes counted before paraffin-embedding to prevent double counting from cutting of nodes. Pathology processing was without knowledge of the study. ¡°Low-risk¡± patients underwent a limited PLND including the external iliac and obturator lymph nodes. An extended dissection was performed in ¡°high-risk¡± patients with preoperative PSA >10ng/dl, cT3 disease, Gleason ¡Ý8, or cancer in ¡Ý50% of biopsy tissue extending the template to all nodes medial to the genitofemoral nerve including the hypogastric nodes and common iliac nodes up to the crossing of the ureter. Patient and pathologic outcomes were evaluated. RESULTS Of 250 patients, 173 underwent limited PLND while 77 underwent ePLND. Mean nodal yield for all patients was 11 nodes, with 8.6 and 16.4 nodes for limited and extended PLND, respectively. A total of 17 (7%) node-positive (N+) patients were identified overall, with 2 (1.1%) in the limited group and 15 (19.5%) in the ePLND group. Of the 183 organ-confined (OC) tumors, only 1 was N+ (0.5%), compared to 16 of 67 (24%) non-OC tumors. Complications of the lymphadenectomy included four symptomatic lymphoceles requiring percutaneous drainage, one ureteral injury requiring a temporary stent, and one transient obturator nerve palsy for an overall complication rate of 2.4% (0.5% of limited and 8% of ePLND). CONCLUSIONS Pelvic lymphadenectomy for prostate cancer can be adequately performed in robot-assisted laparoscopic fashion with nodal yields and rate of positivity comparable to published open surgical series. The role of limited PLND remains unclear, but ePLND appears warranted for high risk cancers. Columbus, OH© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byAbaza R, Dangle P, Gong M, Bahnson R and Pohar K (2018) Quality of Lymphadenectomy is Equivalent With Robotic and Open Cystectomy Using an Extended TemplateJournal of Urology, VOL. 187, NO. 4, (1200-1205), Online publication date: 1-Apr-2012. Volume 183Issue 4SApril 2010Page: e356 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hugh Lavery More articles by this author Ronney Abaza More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Extended pelvic lymphadenectomy for prostate cancer: Will the previously reported benefits be reproduced in hospitals with lower surgical volumes?

In the European Association of Urology guidelines on prostate cancer an extended pelvic lymphadenectomy (ePLND) is now recommended, instead of a dissection limited to the obturator fossae (lPLND). This recommendation relies on studies reporting that metastatic disease is identified twice as often with ePLND as with lPLND, with only moderately increased complications. However, these studies were from high-volume centres. This study investigated whether these results could be repeated in a hospital with lower surgical volume, more typical for the Nordic countries. From January 2002 to September 2007 172 patients underwent radical prostatectomy and PLND at the University Hospital of Lund, 108 with ePLND and 64 with lPLND. Perioperative complications and the number of lymph-node metastases found were registered. A median of 17 lymph nodes was identified with ePLND compared with seven with lPLND. Metastases were identified in four out of 64 patients in the lPLND group (6%), versus 22 out of 108 in the ePLND group (20%). In the ePLND group 10 of the patients with metastases had such exclusively outside the obturator fossae. Complications were significantly more common after ePLND (p=0.007): lymphoceles (18 vs 9%), pulmonary embolism (4.6 vs 1.6%), deep venous thrombosis (1 vs 1.5%) and other (haematomas and infectious including sepsis (8 vs 0%). Almost half of the patients with metastases are misclassified by lPLND. Complications are significantly more common after ePLND. This implies that ePLND should be performed, but in selected patients and by high-volume surgeons only.

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.

Results of robotic limited and extended pelvic lymphadenectomy for prostate cancer

Results of robotic limited and extended pelvic lymphadenectomy for prostate cancer

Comparison of Open and Robot-Assisted Pelvic Lymphadenectomy for Prostate Cancer

We evaluated whether there were differences in the lymph node yield and incidence of nodal metastasis among patients undergoing robot-assisted radical prostatectomy with pelvic lymphadenectomy (LAD) and open radical retropubic prostatectomy with either a standard or extended node dissection. Data were collected retrospectively on all patients undergoing radical prostatectomy with pelvic LAD at our institution between January 2006 and December 2008. Patients in group 1 (n = 60) underwent robot-assisted standard LAD, those in group 2 (n = 64) had open standard LAD, and group 3 patients (n = 43) were treated with open extended LAD. Statistical comparison was then made between the three groups stratified by histologic grade and pathologic stage. The mean lymph node yield was 8.2 for group 1, 7.6 for group 2, and 14.8 for group 3. The overall incidence of positive nodes in each group was 3.3%, 1.6%, and 18.6%, respectively. There were no differences between the node counts (P = 0.84) and probability of finding positive nodes between the robot-assisted and open standard dissections. The extended LAD identified patients with positive nodes at a greater frequency, although those patients were more likely to have adverse pathologic features. Complications related to the lymphadenectomy were not different between the groups. The lymph node yield obtained during robot-assisted pelvic lymphadenectomy for prostate cancer is comparable to an open approach using a similar template. An open extended node dissection yields more nodes and identifies a greater number of patients with lymph node involvement.

Commentary on: Validation of sentinel lymph node dissection in prostate cancer: experience in more than 2,000 patients

Lymph node metastases are one of the most important prognostic factors in prostate cancer. N staging directly influences the treatment decision in patients for whom potentially curative treatments are planned. However, the authors [1] provide a reminder that there is an ongoing debate about which patients require lymph node resection and how the dissection should be extended [2]. The Augsburg group first developed and described sentinel lymphadenectomy (SLNE) in prostate cancer. They have demonstrated through some studies that the majority of sentinel lymph node (SLN) and non-SLN metastases were found along the internal iliac vessels and that limited lymphadenectomy to obturator fossa was clearly insufficient for accurate lymph node staging. These findings are sustained by the majority of studies reporting on extended pelvic lymphadenectomy in prostate cancer. In this study, they reported the largest series with more than 2,000 patients who underwent SLNE alone or in combination with either standard or extended lymphadenectomy. It is the most important published manuscript in the literature. However, this study gathers heterogeneous subgroups of patients. The first goal of the study was to evaluate the

Extended pelvic lymphadenectomy for prostate cancer: Will the previously reported benefits be reproduced in hospitals with lower surgical volumes?

Extended pelvic lymphadenectomy for prostate cancer: Will the previously reported benefits be reproduced in hospitals with lower surgical volumes?

Pelvic lymphadenectomy in prostate cancer

This review analyzes the anatomy of the prostate gland's lymphatic drainage, the optimal anatomic extend of pelvic lymph node dissection (PLND) and which dissection may be superior, who should undergo a PLND during prostatectomy, and its potential therapeutic benefits and complications. The prostate gland's lymphatic drainage can be variable, but frequently metastatic disease is found in the internal iliac chain. We conclude that the extended PLND yields the most lymph nodes and therefore may be superior. Some have demonstrated an unproven survival benefit after performing an extended PLND, possibly from removal of occult disease or from more accurate staging.

Radical Cystectomy for Carcinoma of the Bladder: 2,720 Consecutive Cases 5 Years Later

We performed a critical analysis of the results of radical cystectomy for invasive bladder carcinoma treated at 1 center. Between 1970 and 2000, 2,090 men and 630 women with invasive bladder cancer were treated with 1-stage radical cystectomy and urinary diversion. Followup ranged from 0 to 34.2 years with a mean of 5.5 +/- 5.7. Survival data were correlated to patient and tumor characteristics using univariate and multivariate analysis. Postoperative mortality was 2.6%. Squamous tumors accounted for 49.4% of cases, transitional cell carcinoma for 36.4% and adenocarcinoma for 9.6%. Regional lymph nodes were involved in 20.4% of cases. The 5 and 10-year disease-free survival rates were 55.5% and 50.03%, respectively. Evidence was provided that tumor stage, histological grade and lymph node status are the only independent variables which affect survival probability. Contemporary cystectomy can be performed with minimal mortality. Radical cystectomy for organ confined disease is followed by good therapeutic results and enhances the possibilities for functional restoration. With stage progression there is a stepwise reduction in survival probability. The radical operation can provide disease-free survival for an important subgroup of node positive cases (27.3%). Additional therapy is needed to improve the oncological outcome for advanced locoregional disease.

Extended lymph node dissection for prostate cancer

Lymph node status is an important determinant for the management of patients with newly diagnosed prostate cancer. Given the significant limitations of cross-sectional and functional preoperative imaging in the detection of small metastases, pelvic lymph node dissection remains the only reliable staging method in clinically localized prostate cancer. Although lymph node dissection is a well-established form of staging in prostate cancer, controversy remains about indications and the surgical extent of the procedure. Reported practices vary from omitting pelvic lymph node dissection in low-risk disease to routine pelvic lymph node dissection in all radical prostatectomy patients. This review highlights the recent literature concerning pelvic lymphadenectomy in prostate cancer with respect to anatomical extent and oncologic outcome.

Sentinel Lymph Node Dissection for Prostate Cancer: Experience With More Than 1,000 Patients

We determined the incidence of positive pelvic lymph nodes in men undergoing radical retropubic prostatectomy and describe the correlation with prostate specific antigen, histological grade and stage. We examined whether tumor cells are localized in the sentinel nodes only or also in other nonsentinel lymph nodes. A total of 1,055 men with prostate cancer underwent radio guided pelvic lymph node dissection and radical retropubic prostatectomy. In men with prostate specific antigen 20 ng/ml or less and biopsy Gleason score 7 or less only sentinel nodes were removed. In men with prostate specific antigen more than 20 ng/ml or Gleason score greater than 7 extended pelvic lymph node dissection was also performed. Positive lymph nodes were found in 207 men (19.6%). In 63.3% of the men these lymph nodes were detected outside of the region of standard lymphadenectomy. The percent of patients with positive nodes was greater than predicted by currently used nomograms. The higher the preoperative prostate specific antigen, pathological stage and grade, the greater the percent of men with positive sentinel and nonsentinel lymph nodes (p<0.001). When deciding on pelvic lymph node dissection, sentinel or extended lymphadenectomy should be performed since more than half of patients have positive nodes outside of the region of standard lymphadenectomy. In cases of positive sentinel nodes extended lymph node dissection should be performed since tumor cells are also detectable in nonsentinel lymph nodes.