Robot-assisted Pelvic Lymph Node Dissection Research Articles

Japanese expert consensus on the standardization of robot-assisted pelvic lymph node dissection in urological surgery: Extent of pelvic lymph node and surgical technique.

Pelvic lymph node dissection (PLND) is important for accurate staging and prognosis of prostate and/or bladder cancer. Several guidelines recommend extended PLND for patients with these cancers. However, the therapeutic benefits of extended PLND are unclear. One major reason is that the extent of PLND is not clearly defined. Thus, the working group for standardization of robot-assisted PLND, including nine experienced urologists for PLND in Japan, was launched in January 2023 by the Japanese Society of Endourology and Robotics. This study summarized the discussions to define the individual extent of PLND in urological surgery in a consensus meeting among these experienced urologists. The consensus meeting determined the extent of PLND based on arteries (veins) and anatomical membrane structures rather than a vague concept or approach toward PLND. This concept is expected to allow surgeons to implement the same extent of PLND. Finally, after a total of 10 online web conferences were held, we determined the extent of PLND for the obturator lymph node (LN) area, the internal iliac LN area, the external and common iliac LN area, and the presacral LN area according to the above rules. The extent of PLND suggested here currently does not have a clear therapeutic rationale. Therefore, the extent of our proposed PLND is by no means mandatory. We hope our definition of the extent of PLND will be supported by further evidence of therapeutic benefits for urologic cancers.

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).

Neoadjuvant Chemotherapy Followed by Vaginal Radical Trachelectomy as Fertility-Preserving Treatment for Patients with FIGO 2018 Stage 1B2 Cervical Cancer.

BackgroundStandard treatment for International Federation of Gynecology and Obstetrics (FIGO) 2018 stage 1B2 cervical cancer (i.e., tumor size between 2 and 4 cm) is a radical hysterectomy (RH) with pelvic lymph node dissection (PLND). We evaluated the oncological and fertility outcomes treatment in patients receiving a fertility‐sparing alternative consisting of neoadjuvant chemotherapy (NACT) followed by vaginal radical trachelectomy (VRT).MethodsPatients with stage 1B2 cervical cancer who wished to preserve fertility were included from September 2009 to September 2018. NACT consisted of 6‐week cycles of cisplatin or carboplatin with paclitaxel. If tumor size decreased to 2 cm or smaller, NACT was followed by a robot‐assisted PLND and VRT.ResultsEighteen patients were included. Median follow‐up time was 49.7 months (range 11.4–110.8). Median tumor size was 32 mm (range 22–40 mm). Complete remission after NACT occurred in seven women. Four women had a poor response on NACT. Three underwent RH with PLND; one received chemoradiation after PLND instead of VRT because of positive lymph nodes. The remaining 14 patients received VRT 3–4 weeks after NACT. Four recurrences occurred: three after NACT and VRT and one after NACT and RH. Median time to recurrence was 20.8 months (range 17.0–105.7). Three recurrences occurred in women with adenocarcinoma with lymph vascular space invasion (LVSI). In four women fertility could not be preserved. To date, four women had six pregnancies, including three live births born at term, two first trimester miscarriages, and one currently ongoing pregnancy. ConclusionNACT and VRT in women with stage 1B2 cervical cancer showed promising results. In 78% fertility was preserved. However, patients with poor response on NACT and with adenocarcinoma and/or LVSI were possibly at risk for recurrence. Long‐term results in relation to fertility and oncological outcome are needed to corroborate these findings.Implications for PracticeStandard treatment for women with International Federation of Gynecology and Obstetrics (FIGO) 2018 stage 1B2 cervical cancer (tumor size 2–4 cm) is a radical hysterectomy and pelvic lymph node dissection (PLND). However, many of these women are young and wish to preserve fertility. Data on fertility‐sparing treatment options are sparse, but neoadjuvant chemotherapy followed by a vaginal radical trachelectomy and PLND could be an alternative. Since 2009 we performed an observational cohort study in which 18 women opted for this treatment in our center. In 14 women fertility could be preserved. In four patients the tumor recurred. In four women six pregnancies occurred. After careful selection this treatment could be a good fertility‐sparing treatment option.

Strangulated Internal Hernia Behind the Common Iliac Artery Following Pelvic Lymph Node Dissection

We report a rare case of a strangulated internal hernia behind the common iliac artery after robot-assisted pelvic lymph node dissection. Internal hernias involving the retroperitoneal vascular axis have been reported four times in medical literature. This is the first time it has been seen after robotic surgery.

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

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

V72 Robot-assisted pelvic lymph node dissection during radical cystectomy. The OLV Vattikuti Robotic Surgery Institute technique

V72 Robot-assisted pelvic lymph node dissection during radical cystectomy. The OLV Vattikuti Robotic Surgery Institute technique

Robot‐assisted nerve‐sparing radical cystectomy with bilateral extended pelvic lymph node dissection (PLND) and intracorporeal urinary diversion for bladder cancer: initial experience in 27 cases

• To report the outcomes of 27 patients whom we performed robot-assisted radical cystoprostatectomy and cystectomy (RARC) with intracorporeal urinary diversion (Studer pouch and ileal conduit) for bladder cancer. • Between December 2009 and December 2010, we performed RARC in 25 men (intrafascial bilateral [22], unilateral [one], non-neurovascular bundle [NVB] sparing [two]), NVB-sparing RARC with anterior pelvic exenteration in two women, bilateral extended robot-assisted pelvic lymph node dissection (RAPLND) (25), intracorporeal Studer pouch (23), ileal conduit (two), and extracorporeal Studer pouch (two) construction. • Patient demographics, operative and postoperative variables, pathological variables, complications (according to modified Clavien system) and functional outcomes were evaluated. • The mean (sd, range) operative duration, intraoperative estimated blood loss and mean lymph node (LN) yield were 9.9 (1.4, 7.1-12.4) h, 429 (257, 100-1200) mL and 24.8 (9.2, 8-46), respectively. • The mean (sd, range) hospital stay was 10.5 (6.8, 7-36) days, there was one perioperative death (3.7%), lodge drains were removed at a mean of 11.3 (5.6, 9-35) days and surgical margins were negative in all but one patient who had pT4b disease. • The postoperative pathological stages were: pT0 (five), pTis (one), pT1 (one), pT2a (five), pT2b (three), pT3a (six), pT3b (two), pT4a (three) and pT4b (one). • Positive LNs and incidental prostate cancer were detected in six and nine patients, respectively and at a mean follow-up of 6.3 (2.9, 1.8-11.3) months, three patients died from metastatic disease and one from cardiac disease. • According to the modified Clavien system, there were nine minor (Grade 1 and 2) and four major (Grade 3-5) complications in the perioperative (0-30 days) period; four minor and three major complications in the postoperative (31-90 days) period. Of the available 18 patients, 11 were fully continent, four had mild and two had severe day-time incontinence. • Bilateral NVB-sparing RARC with RAPLND and intracorporeal Studer pouch or ileal conduit reconstruction are complex procedures with acceptable morbidity, excellent short-term surgical and pathological outcomes and satisfactory functional results. • Studies with more patients and longer follow-ups are required to evaluate the feasibility of these RA totally intracorporeal complex procedures.

Editorial Comment to Risk factors for pelvic lymphoceles post‐radical prostatectomy

Pelvic lymph node dissection (PLND) might account for perioperative morbidity and complications, including lymphoceles and lymphorrhea.1 Lymphoceles can lead to infection, nerve injury, prolonged drain stay and, consequently, prolonged hospital stay. Furthermore, in some series, lymphoceles and lymphorrhea have been associated with increased risk of deep venous thrombosis and pulmonary embolism. Venous thromboembolism, for example, occurred in up to 1.5% of patients who underwent laparoscopic radical prostatectomy plus PLND relative to virtually no risk in patients treated with prostatectomy only.2 Although PLND has never been proven to be beneficial for the outcome of low-risk prostate cancer patients, an extended PLND (ePLND) should not be omitted in intermediate- to high-risk prostate cancer patients.1,3 Even in the presence of such a recommendation, many urologists are reluctant to take such an extensive surgical approach in all patients with more aggressive cancer variants. This reticence is because of the lack of a proven prospective benefit of ePLND for cancer control, as well as to the potential exposure of patients to the risk of lymphoceles and their potentially related complications. This argument has been based on previous studies reporting higher rates of lymphoceles in patients treated with ePLND.1,4 Some points, however, need to be considered. First, reports from the literature are hardly comparable as a result of the heterogeneous definition of lymphocele, as well as to the different approaches used to determine the presence and extent of this complication. Second, several recent reports showed that PLND and its extent are only some of the potential risk factors for lymphocele development.5–7 Several other variables have been suggested to promote lymphoceles and lymphorrhea, such as locally advanced disease, clinical patient characteristics (i.e. old age and obesity) and prophylactic therapy with low molecular weight heparin. In addition, surgical aspects have been thought to correlate with the risk of harboring a lymphocele postoperatively. External iliac lymphadenectomy, for example, was associated with higher risk of lymphoceles and lymphorrhea relative to obturator node removal.5 For this reason, all lymphatics lateral to the external iliac artery should be saved. The type of surgical approach was also thought to represent a determinant of lymphocele formation. Theoretically, the use of a transperitoneal approach (i.e. laparoscopic and robot-assisted PLND) might reduce the rate of lymphocele formation. Unfortunately, it has been shown that up to 51% of patients treated with laparoscopic or robot-assisted prostatectomy also might develop a lymphocele.7 This finding is even more significant considering that the vast majority of patients treated with a minimally invasive approach are treated with a limited PLND; however, not all lymphoceles translate into a significant clinical condition. Indeed, <10% of lymphoceles are usually symptomatic, and only approximately 2% require intervention.7 That said, are lymphoceles and lymphorrhea something to worry about? In the current issue of the International Journal of Urology, Khoder et al. confirmed that lymphoceles after prostatectomy are more common than thought, although they rarely necessitated intervention.6 Given the relatively low prevalence of complications that are clinically significant, and that can affect patients' quality of life and morbidity, the main effort should focus on preventing lymphocele development during surgery, especially in those patients at higher risk for lymphocele formation. In the first setting, many authors suggested technical tips that might decrease patients' risk of harboring a symptomatic lymphocele: closed suction drain, sclerotherapy, talc poudrage, fibrin sealant, intramuscular injection of octeotride, pressure dressings, careful ligation of lymphatic vessels and avoidance of electrocautery.8–10 In a prospective randomized clinical trial, Simonato et al. showed that a surgical patch located after PLND reduces drainage volume and prevents lymphocele development after extraperitoneal radical retropubic prostatectomy with pelvic lymphadenectomy.10 Furthermore, Waldert et al. evaluated the efficacy and cost-effectiveness of FloSeal hemostatic matrix in preventing lymphocele development after laparoscopic and robot-assisted pelvic lymphadenectomy.9 Although not prospectively randomized, such matched cost analysis suggested that the use of FloSeal after lymphadenectomy might reduce the number of symptomatic lymphoceles in a cost-effective manner. In conclusion, lymphoceles and lymphorrhea are not negligible when patients undergo pelvic lymphadenectomy, even in the hands of the most experienced surgeons. Exposure of patients at risk of lymphocele formation should be balanced with the proven benefit of PLND of accurate nodal staging and improved cancer control in highly selected patients. Prevention of lymphoceles begins with a meticulous surgical approach in which surgeons should be extremely careful in ligating or clipping all of the distal ends of the lymphatic vessels. Use of additional devices should still be considered investigational at this time.

Da Vinci S robotic surgery in the treatment of benign and malignant gynecologic tumors

The objective of this work is to present and analyze our da Vinci S robotic surgery results in the treatment of gynecologic tumors for a 1-year period. Fifty-one patients underwent da Vinci S (Intuitive Surgical, USA) robotic surgery at the Medical University—Pleven Gynecologic Oncology Clinic from January 2008 to January 2009. Robot-assisted radical hysterectomy with total pelvic lymph node dissection was performed in 28 (54.9%) of them, robot-assisted total hysterectomy in 21 (41.2%), and robot-assisted pelvic lymph node dissection in two (3.9%). The average length of the operative intervention, from the beginning of the CO2 insufflation of the abdomen to closing trocar skin incision was 119.89 min (± 43.441) and mean console time was 76.56 min (± 32.904). The average patient body weight was 70.56 kg (± 18.272; range, 41–114) with mean body mass index (BMI) of 27.30 (± 6.938). No significant difference was observed between the BMI and operative time (p = 0.49). No significant intra-operative complications were registered. An ureterovaginal fistula was diagnosed on the 10th postoperative day in one of the patients (2%). Robot-assisted endoscopic gynecologic surgery is a modern and advanced method for operative treatment of benign and malignant gynecological tumors. It is appropriate for obese patients as the obesity is not related to a prolonged operative time.

Lymph node dissection during robot-assisted radical prostatectomy: where do we stand?

Since the initial report of robot-assisted laparoscopic prostatectomy (RALP) in 2001, the technique has gained rapid acceptance and utilization. When compared with more traditional forms of surgical intervention, there is still much debate with respect to cost, and impact on potency and continence. Less often is the focus on oncologic outcomes. Pelvic lymph node dissection (PLND) at the time of prostatectomy is an important part of the surgical intervention for prostate cancer and is currently underreported during robotic procedures. Herein, we review the current controversies on the value and extent of PLND and the status of emerging data regarding robot-assisted PLND.