Robotic Pelvic Lymph Node Dissection Research Articles

Early drainage removal in the management of lymphatic leakage after robotic pelvic lymph node dissection

AbstractBackgroundRadical prostatectomy (RP) and radical cystectomy (RC) with concurrent pelvic lymph node dissection (PLND) are considered as the curative surgical treatment options for localized prostate cancer (PC) or muscle‐invasive bladder cancer (BC). Regarding lymphatic leakage management after PLND, there is no standard of care, with different therapeutic approaches having been reported with varying success rates.MethodsSeventy patients underwent pelvic lymphadenectomy during robotic RP and RC with postoperative pelvic drainage volume more than 50 mL/day before the removal of drainage tube, were retrospectively evaluated in this study between August 2015 and June 2023. If the pelvic drainage volume on postoperative Day 2 was more than 50 mL/day, a drainage fluid creatinine was routinely tested to rule out urine leakage. We removed the drainage if the patient had no significant abdominal free fluid collection, no abdominal distension or pain, no fever, and no abdominal tenderness. After 1‐day observation of the vital signs and abdominal symptoms, the patient was discharged and followed‐up in clinic for 2 weeks after surgery.ResultsForty‐one cases underwent the early drainage removal even if the pelvic drainage volume was more than 50 mL/day. Among these forty‐one cases, twenty‐five drainage tubes were removed when drainage volume was more than 100 mL/day. All the forty‐one cases with pelvic drainage volume greater than 50 mL/day were successfully managed with the early drainage removal. No paracentesis or drainage placement was required. No re‐admission occured during the follow‐up period.ConclusionIt is safe to manage the high‐volume pelvic lymphatic leakage by early clamping of the drainage tube, ultrasonography assessment of no significant residual fluid in the abdominal and pelvic cavity, and then the early removal of the drainage tube.

Arterial and venous hemorrhage during robotic pelvic lymph node dissection. Management of intraoperative vascular injuries

Arterial and venous hemorrhage during robotic pelvic lymph node dissection. Management of intraoperative vascular injuries

Robotic Vessel Sealer Device for Lymphocele Prevention After Pelvic Lymphadenectomy: Results of a Randomized Trial.

Introduction: Pelvic lymph node dissection (PLND) during robotic prostatectomy is associated with potential complications. The most common complication of PLND is lymphoceles, occurring in up to 50% of patients in studies with screening imaging but usually asymptomatic. We performed a prospective randomized trial to evaluate whether using advanced bipolar energy for PLND via the robotic vessel sealer can prevent lymphoceles. Methods: A total of 120 patients were enrolled in the trial with each patient serving as their own control. Robotic PLND was randomly performed using the vessel sealer on one side and standard PLND using clips on the other side. All patients underwent screening computed tomography scan 3 months postoperatively with radiologists blinded to the assigned technique. Significant lymphoceles were defined as fluid collections ≥3 cm in any plane. Results: Of those enrolled, 114 completed the study. The mean nodal yield was 6.5 nodes, with 3.1 versus 3.4 nodes for vessel sealer side versus standard technique (P = .35), respectively. The mean operative time for PLND was 11.3 versus 11.1 minutes (P = .62), respectively. Twenty-two lymphoceles were identified. Ten occurred on the vessel sealer side versus 12 on the standard side (8.8% versus 10.5%, P = .412). All lymphoceles were asymptomatic. Conclusions: While the robotic advanced bipolar device did not appear to prevent lymphoceles, the vessel sealer also did not increase the rate of lymphoceles compared with a standard technique using clips. Both techniques were equally efficacious, efficient, and safe for PLND such that surgeons who prefer to avoid clips can reasonably use the vessel sealer, although at increased cost. Clinical Trial Registration number: NCT02035475.

ASO Author Reflections: Robotic Pelvic Lymph Node Dissection for Metastatic Melanoma-A Minimally Invasive Approach to a Difficult Problem.

ASO Author Reflections: Robotic Pelvic Lymph Node Dissection for Metastatic Melanoma-A Minimally Invasive Approach to a Difficult Problem.

Robotic perineal radical prostatectomy and robotic pelvic lymph node dissection via a perineal approach: The Tugcu Bakirkoy Technique.

To describe The Tugcu Bakirkoy robotic perineal radical prostatectomy and pelvic lymph node dissection technique, and present the results of seven patients. We performed seven robotic perineal radical prostatectomy and pelvic lymph node dissection operation using Da Vinci Xi HD Surgical System (Intuitive Surgical, Inc., Sunnyvale, California, USA) on single Gel-port platform. The operation is completed in 4 stages: stage 1 open perineal dissection and gel port placement, stage 2 robotic perineal radical prostatectomy, stage 3 robotic pelvic lymph node dissection, stage 4 vesico-urethral anastomosis. In addition to describing the operation technique step by step, we aimed to present the perioperative and postoperative findings of the seven patients who underwent The Tugcu Bakirkoy Technique. All operations were successfully completed without any complications in fully the robotic procedure by a single surgeon. Demographic data of the patients were as follows: Mean age (62.1±8 years), mean body mass index (28.2±0.7 kg/m2), mean prostate specific antigen value (10.7±3 ng/mL), and mean prostate volume (64.2±15.3 cc). Mean operative time (184.1±20.2 mins), blood loss (64.2±15.3 cc), hospitalization time (2.1±0.6 days), and time to withdrawal of the urethral catheter (7.8±0.8 days) were also estimated. According to the pathology results, lymph node metastasis was detected in 3 patients while the surgical margin was positive in one. We demonstrated for the first time that a new The Tugcu Bakirkoy robotic perineal radical prostatectomy technique which was previously tested in a cadaveric model, can be safely applied for the first time in vivo, and presented our results. On the basis of this, for problems that can not be overcome by traditional methods, this method is a good alternative as a way out. In this regard, it is necessary to carry out advanced studies so that this method can be applied to daily practice.

P.L.E.A.T.—Preventing Lymphocele Ensuring Absorption Transperitoneally: A Robotic Technique

To reduce the risk of symptomatic lymphocele after robotic pelvic lymph node dissection (PLND), we present a technique, preventing lymphocele ensuring absorption transperitoneally (P.L.E.A.T.), where the peritoneum is "pleated" along its midline, leaving 2 lateral openings and allowing lymphatic fluid to drain away from the pelvis and into the abdomen. We analyzed a single-surgeon series of PLNDs during robotic radical prostatectomy, comparing 195 "standard" PLNDs (in which the peritoneum was "re-approximated" or left completely open) with 176 cases in which P.L.E.A.T. was performed. In the group without P.L.E.A.T., 8 cases of symptomatic (grade ≥3, according to the Clavien-Dindo Classification) lymphoceles (4.1%) were recorded. Only 1 patient in the P.L.E.A.T. group complained of symptoms because of a lymphocele (P = .039). No patient reported complications because of the procedure. The P.L.E.A.T. technique is a fast, easy-to-perform, and safe method of reducing the risk of symptomatic lymphocele after transperitoneal robotic PLND.

Near-infrared Intraoperative Molecular Imaging Can Identify Metastatic Lymph Nodes in Prostate Cancer

To propose a novel method to perform indocyanine green (ICG) based near-infrared (NIR) fluorescence imaging during pelvic lymph node dissection (PLND) for prostate cancer patients with lymph node metastasis (LNM). A prostate cancer cell line PC3 was used to establish xenograft model in NOD/SCID mice. After tumor growth, the mice were injected with ICG through the tail vein. Xenografts and surrounding tissues were imaged with NIR camera 24 hours after intravenous ICG, and tumor-to-background ratios were calculated. We then performed a pilot human study to evaluate the role of NIR imaging in robotic PLND after systemic ICG in 4 patients with prostate cancer and preoperative lymphadenopathy. ICG localized to PC3 xenografts in the mice and all xenografts were highly fluorescent compared with surrounding tissues, with a median tumor-to-background ratio of 2.85 (interquartile range = 2.64-3.90). In the human study, intraoperative in vivo NIR imaging identified 3 of the 4 preoperative lymphadenopathies as fluorescence-positive, and back table ex vivo NIR imaging identified all 4 lymphadenopathies as fluorescence-positive. All the lymphadenopathies were found to be LNMs by pathologic examination. Two of the four cases had additional LNMs, all of which were fluorescence-positive with intraoperative in vivo NIR imaging. Intravenously administered ICG accumulates in prostate cancers in both a murine model and human patients. NIR fluorescence based on intravenous ICG may serve as a useful tool to facilitate the identification of positive nodes during PLND in patients with higher risk of LNMs.

Editorial Comment

Pelvic lymph node dissection (PLND) and its extent during radical prostatectomy (RRP) continue to be hotly debated. PLND is performed infrequently during RRP, with open and minimally invasive surgeries, especially in low-risk patients, owing to low yield of positive nodes, longer operative time, and the risk of vascular injury or lymphoceles. That trend seems to be shifting toward performing PLND in patients with high-risk prostate cancer, because PLND provides accurate staging, indicating patients who should be considered for adjuvant therapy or at least followed up closely, 1 Touijer K. Rabbani F. Otero J.R. et al. Standard versus limited pelvic lymph node dissection for prostate cancer in patients with a predicted probability of nodal metastasis greater than 1%. J Urol. 2007; 178: 120-124 Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar and because PLND during RRP seems to cure, or is at least associated with, long-term survival in some patients with positive nodes. 2 Schumacher M.C. Burkhard F.C. Thalmann G.N. et al. Good outcomes for patients with few lymph node metastases after radical retropubic prostatectomy. Eur Urol. 2008; 54: 344-349 Abstract Full Text Full Text PDF PubMed Scopus (175) Google Scholar The current debate is about what is the necessary template (limit) of a PLND during RRP, and what should we call it? And can PLND be done in a timely and complete fashion using the robot? Pelvic Lymphadenectomy During Robot-assisted Radical Prostatectomy: Assessing Nodal Yield, Perioperative Outcomes, and ComplicationsUrologyVol. 74Issue 2PreviewTo describe our pelvic lymphadenectomy (PLND) technique during robot-assisted radical prostatectomy and to evaluate the nodal yield and perioperative outcomes. PLND is commonly performed with radical prostatectomy for localized prostate cancer. Because of the limitations of the robotic arm pitch in accessing the pelvic sidewall and undersurface of the iliac bifurcation, uro-oncologists have questioned the adequacy of robotic PLND. Full-Text PDF Editorial CommentUrologyVol. 74Issue 2PreviewThe preceding article is a timely report that addresses an important aspect of robotic radical prostatectomy, namely, the need for, and, most importantly, the adequacy of, nodal dissection. This has, for the most part, been overlooked in high-volume robotic series and only recently emphatically emphasized in high-volume open radical prostatectomy series. The recent report by Schumacher et al.1 is appropriately cited in the present report. It presents sobering data and survival outcomes in favor of extended pelvic lymphadenectomy, even in the prostate-specific antigen era. Full-Text PDF ReplyUrologyVol. 74Issue 2PreviewIt has been well demonstrated in non-neurologic malignancies (breast, lung, gastric, and colorectal) as well as in bladder cancer that regional lymphadenectomy is both diagnostic and therapeutic, and that the added survival benefit depends on the number of lymph nodes removed. Although it is universally accepted that pelvic lymph node dissection (PLND) during radical prostatectomy is a reliable staging tool, its role and potential benefit for patients with prostate cancer are still controversial. Full-Text PDF