Transperitoneal Lymphadenectomy Research Articles

Sophisticated Dissection without Monopolar Scissors

<h3>Study Objective</h3> To demonstrate how the bipolar method allows for pinpoint dissection with minimal thermal spread in a variety of challenging operative scenarios in gynecology. <h3>Design</h3> Case presentations. <h3>Setting</h3> Urban general hospital in Japan. <h3>Patients or Participants</h3> From December 2018 to April 2021, we performed 485 robotic surgeries using the double bipolar method in a variety of procedures such as hysterectomy for benign pathology, robotic sacro-colpopexy and para-aortic and pelvic lymphadenectomy for cervical and endometrial cancer. <h3>Interventions</h3> Pinpoint dissection in the case of severe Douglas Pouch adhesion or bladder adhesion, transperitoneal lymphadenectomy and extraperitoneal para-aortic and pelvic lymphadenectomy and nerve-sparing radical trachelectomy is a great advantage. These challenging procedures require the elucidation of fine structures and well as accurate separation of adhered organs. The double bipolar method is accurate, powerful and efficient with minimal thermal spread. <h3>Measurements and Main Results</h3> Only one patient who had extensive adhesion due to previous surgery required surgery from postoperative peritonitis. All other patients recovered quickly and without complications. <h3>Conclusion</h3> Monopolar scissors are a standard robotic equipment, used by the majority of surgeons. Although monopolar scissors allow for good quality dissection, thermal spread is always a concern. The thermal spread is known to be source of intraoperative complications and reducing this problem is an important concern. As a result, we implemented the double bipolar method. Not only because of its pinpoint accuracy, but also because the cutting mechanism has minimal thermal spread which is desirable especially when dissection ultra-fine structures.

Comparison of surgical and pathological parameters after laparoscopic transperitoneal pelvic/para-aortic lymphadenectomies

ObjectiveLymphadenectomy is an integral part of surgical staging and treatment for patients with gynecologic malignancies. Since its introduction, laparoscopic lymphadenectomy has proved feasible, safe, and oncologically adequate compared with open...

Laparoscopic Transperitoneal Para-Aortic Lymphadenectomy in 10 Steps

Study ObjectiveLaparoscopic transperitoneal lymphadenectomy has a few advantages. First, it is a minimally invasive approach, and the transperitoneal approach is also the best option when intra-abdominal surgery is indicated. Although the procedure was described more than 2 decades ago, there is a lack of diffusion of the technique. The main objective of this video is standardization and a simple description of the technique. We described this procedure in 10 logical steps, which should help to understand and perform this procedure. MethodsThis video presents a systematic approach to transperitoneal lumboaortic lymphadenectomy, which is clearly divided in 10 steps ordered in a counterclockwise direction. ResultsThe 10 steps are as follows: step 1, retroperitoneal access; step 2, creating a space for subsequent lymphadenectomy and identification of anatomic landmarks; step 3, left common iliac lymph node dissection; step 4, right common iliac lymph node dissection; step 5, presacral lymph node dissection; step 6, lateroaortal lymph node dissection; step 7, laterocaval lymph node dissection; step 8, aortocaval lymph node dissection; step 9, vaginal extraction of bags with specimens; and step 10, vaginal suture. ConclusionsLaparoscopic transperitoneal access to lumboaortic lymph nodes is an effective method of lymphadenectomy, which may bring benefits to a patient and physician. The presented 10 steps help to perform each part of surgery in a logical sequence, making the procedure ergonomic and easier to adopt and learn. Standardization of laparoscopic techniques could help to reduce the learning curve.

Less Invasive Endometrial Cancer Surgery with Extraperitoneal Pelvic and Para-aortic Lymphadenectomy via a Small Midline Abdominal Incision and the Retroperitoneal Approach.

[Objective] To achieve less invasive lymphadenectomy in endometrial cancer patients, we performed extraperitoneal pelvic and para-aortic lymphadenectomy via a small midline abdominal incision with retroperitoneal approach. The feasibility and safety of this method were investigated.[Methods] Inclusion criteria were 1) endometrioid adenocarcinoma diagnosed by preoperative biopsy, 2) myometrial invasion by magnetic resonance imaging, and 3) no peritoneal dissemination or distant metastasis by computed tomography. Systematic extraperitoneal dissection of pelvic and para-aortic lymph nodes was performed via an approximately 12-cm midline lower abdominal incision, after which hysterectomy and bilateral salpingo-oophorectomy were done (extraperitoneal group). The historical control group was patients who underwent standard transperitoneal lymphadenectomy followed by hysterectomy and bilateral salpingo-oophorectomy. The two groups were compared for demographic characteristics, perioperative factors, and complications.[Results] A total of 62 patients were enrolled. Demographic and clinicopathological factors showed no differences between the extraperitoneal group (n = 34) and the historical control group (n = 28). The median number of pelvic (30 vs. 28) and para-aortic (14 vs. 17) nodes dissected was also similar. However, median intraoperative blood loss was significantly smaller in the extraperitoneal group than the control group (220 vs. 573 g). Median operating time (265 vs. 323.5 min), median laparotomy time (60 vs. 295 min), and median initial flatus time (8 vs. 32 hours) were all significantly shorter in the extraperitoneal group, while complications and severe postoperative pain were significantly less frequent.[Conclusions] Our new technique was feasible, safe, and less invasive than standard laparotomy. It is an alternative to laparoscope-assisted or robotic procedures.

Infrarenal lymphadenectomy for gynecological malignancies: Two laparoscopic approaches

ObjectiveCompare two approaches for laparoscopic infrarenal lymphadenectomy. MethodsRetrospective chart review. Statistical analyses with SPSS. ResultsPatients: 4 stage II/III cervical carcinoma, 75 clinical stage I/II endometrial carcinoma, 36 clinically stage I/II tubal/ovarian cancer. 36 transperitoneal approaches; 79 extraperitoneal approaches. Both groups had similar age, 58years (range 29–80), BMI of 25 (range 18–41), blood loss, 150cm3 (range 25–1500), and hospital stay, 1day (range 1–6). The extraperitoneal surgery took longer (240 v 202min; p=.001); yielded more nodes (50 v 41; p=.004). Extraperitoneal approach yielded more inframesenteric (14 v 10; p=.036), and infrarenal nodes (14 v 9; p=.001). 25% of cervical, 19% of endometrial and 14% of ovarian cancer patients had metastases in radiographically negative infrarenal nodes. 50% of cervical, 33% of endometrial and 17% of ovarian cancer patients had therapy altered by aortic lymphadenectomy. When the inframesenteric nodes were positive, 63% of endometrial and 80% of ovarian cancer patients had infrarenal metastases. More metastases were identified with increasing aortic node count. Extraperitoneal lymphadenectomy had no learning curve (p=0.320), while transperitoneal lymphadenectomy did (p=0.016). Higher BMI patients had lower aortic node yields by transperitoneal (p=.057) but not extraperitoneal approach (p=.578). Among the 14 patients whose BMI was 35–41, mean extraperitoneal total aortic nodal yield was 30; transperitoneal yield was 6. ConclusionsInfrarenal aortic lymphadenectomy may offer higher aortic nodal yields, even in patients with BMI's of 45. Larger prospective studies are needed to confirm whether this dissection in high-risk patients ensures more accurate therapy, and possibly improves cure rates.

Surgical Experience Affects Harvested Lymph-Node Count But Not Detection Rate of Metastatic Nodes During Endometrial and Ovarian Cancer Surgery

Abstract Background: It has previously reported that harvested lymph-node count may be influenced by various factors that may be surgeon-, instutition-, or patient-dependent. Objective: The goal of this research was to investigate the effect of surgical experience on the number of lymph nodes harvested at laparotomy for endometrial- and ovarian-cancer staging. Materials and Methods: The current authors retrospectively reviewed 70 patients with endometrial and ovarian cancer who underwent transperitoneal laparotomy and lymphadenectomy by the same surgeon as a part of staging surgery at the Kahramanmaras Sutcu Imam University School of Medicine, in Kahramanmaras, Turkey. Data were extracted from instutional medical records. Results: The mean number of pelvic lymph nodes was 20.7 (8–47) and the mean number of para-aortic lymph nodes was 13.6 (1–67). No statistical difference was noted between corpus and ovarian cancers in terms of mean node counts. The retrieved pelvic, para-aortic, and total numbers of lymp...

Prevention of lymphoceles using FloSeal and CoSeal after laparoscopic lymphadenectomy in patients with gynecologic malignancies.

Pelvic ± para-aortic lymphadenectomy (LAE) is an essential element of staging and treatment of different gynecologic malignancies. However, LAE can induce asymptomatic and symptomatic pelvic lymphoceles (LCs) in a considerable percentage of patients. Therapy of symptomatic LCs may cause additional morbidity. The best strategy to reduce the rate of LCs has not established yet. Between January 2011 and May 2012, transperitoneal laparoscopic pelvic ± para-aortic LAE was performed at the Department of Gynecology at Charité University Hospital Berlin in 238 patients with cervical, endometrial, ovarian, or groin-positive vulvar cancer. The application of FloSeal (Baxter, Deerfield, IL) and CoSeal (Baxter) was used in 25 patients (group A) as an alternative to routine pelvic drainage after LAE. A case-control comparison was performed on 25 patients (group B) with bilateral drainage after complete LAE. The primary objective of this pilot study was to evaluate the feasibility and safety of the method. As a secondary objective, we evaluated the incidence of LCs and symptomatic LCs in both groups. The detection of LCs was performed during oncologic follow-up by sonography, computed tomographic imaging, or magnetic resonance imaging. Pelvic (n = 50) or pelvic + para-aortic (n = 42) LAE was performed in 44 patients with cervical, 2 with endometrial, 1 with ovarian, and 2 with groin-positive vulvar cancer, respectively. In group B (n = 25), systematic bilateral pelvic drainage was placed after finishing LAE, whereas in group A (n = 25) LAE areas were sealed with 5 mL FloSeal on each side and sprayed with CoSeal afterward without placing drains. In 14 of 50 patients (28%), LCs were detected. In a subgroup of patients with cervical cancer (88% of the cohort), symptomatic LCs occurred in 11% in group A and 18% in group B. Operative revision of symptomatic LCs was necessary in 5% and 18% in groups A and B, respectively (p = .66). Mean Hospital stay was significant shorter in group A (6 days) versus B (8 days) (p = .027). The results of this case-controlled pilot study indicate that the application of FloSeal and CoSeal after transperitoneal LAE is feasible and safe, may reduce hospital stay, and may potentially decrease the rate of symptomatic LCs in patients with gynecologic malignancies.

Robotic extraperitoneal paraaortic lymphadenectomy in gynecological cancers: feasibility, safety, and short-term outcomes of isolated and combined procedures.

The aim of our study was to report the technique, the feasibility, and perioperative results of robotic extraperitoneal paraaortic lymphadenectomy in gynecological cancers performed for isolated or combined procedures. This is a retrospective study of 24 consecutive patients undergoing robotic extraperitoneal paraaortic lymphadenectomy using the Da Vinci Surgical system (Intuitive Inc, Sunnyvale, CA) (cervical cancer, n = 15; high-risk endometrial cancer, n = 8; and ovarian cancer, n = 2, including 1 synchronous tumor). Extraperitoneal paraaortic lymphadenectomy was performed using the surgical technique previously described by laparoscopy. Of the 24 included patients, 12 patients had isolated robotic extraperitoneal paraaortic lymphadenectomy, whereas the others underwent the following associated procedures: total hysterectomy with bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and omentectomy (n = 7); pelvic transperitoneal lymphadenectomy (n = 3), laparotomic Bricker procedure (n = 1), and colpectomy (n = 1). The median age of patients was 55 (42-64) years, and body mass index was 24.1 kg/m (20.9-26.1). The operation was completed in all patients except three with associated procedures. Perioperative difficulties were encountered in 9 patients (gas leakage, n = 7; adhesions, n = 2; and dissection difficulties, n = 1). The number of removed paraaortic lymph nodes was 18 (14-25). The operating times were 180 (150-210) minutes for isolated extraperitoneal paraaortic lymphadenectomy and 240 (180-300) minutes in case of associated procedures. There were 2 intraoperative (pneumothorax and renal artery injury) and 5 postoperative (3 grades 1-2 and 2 grade 3) complications. If robotic-assisted extraperitoneal paraaortic lymphadenectomy seems feasible in case of isolated procedure, further studies are required to prove its benefit compared with conventional laparoscopy.

Robotic-Assisted Transperitoneal Aortic Lymphadenectomy as Part of Staging Procedure for Gynaecological Malignancies: Single Institution Experience

Introduction. This study was designed to confirm the feasibility and safety of robotic-assisted transperitoneal aortic lymphadenectomy as part of staging procedure for gynecologic malignancies. Methods. Chart review of 51 patients who had undergone robotic staging with aortic lymphadenectomy for different gynaecologic malignancies was performed. Results. The primary diagnosis was as follows: 6 cases of endometrial cancer, 31 epithelial ovarian cancer, 9 nonepithelial ovarian cancer, 4 tubal cancer, and 1 cervical cancer. Median BMI was 23 kg/m2. Except for a single case of aortic lymphadenectomy only, both aortic and pelvic lymphadenectomies were performed at the time of the staging procedure. All the para-aortic lymphadenectomies were carried out to the level of the renal veinl but 6 cases were carried out to the level of the inferior mesenteric artery. Hysterectomy was performed in 24 patiens (47%). There was no conversion to LPT. The median console time was 285 (range 195–402) with a significant difference between patients who underwent hysterectomy and those who did not. The median estimated blood loss was 50 mL (range 20–200). The mean number of removed nodes was 29 ± 9.6. The mean number of pelvic nodes was 15 ± 7.6, whereas the mean number of para-aortic nodes was 14 ± 6.6. Conclusions. Robotic transperitoneal infrarenal aortic lymphadenectomy as part of staging procedure is feasible and can be safely performed. Additional trocars are needed when pelvic surgery is also performed.

Laparoscopic Transperitoneal Infrarenal Para-Aortic Lymphadenectomy in Patients with FIGO Stage IB1-II B Cervical Carcinoma

This study aimed to evaluate the safety, feasibility, and clinical outcomes of laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy in patients with FIGO stage IB1-IIB cervical carcinoma. Between August 1999 and April 2009, we performed 59 laparoscopic transperitoneal lymphadenectomies; specifically, 12 procedures were performed up to the level of the left renal vessels, and 47 procedures were performed up to the level of the inferior mesenteric artery. We retrospectively analyzed the pathology reports and clinical data and compared the 2 groups. The data were analyzed with a nonparametric Mann-Whitney test, Kaplan-Meier log-rank test, and Pearson's correlation analysis. The 2 groups did not significantly differ with respect to histologic type (P = .093), clinical stage (P = .053), tumor size (P = .383), time interval to start adjuvant therapy postoperatively (P = .064), and type of adjuvant therapy (P = .407). The blood loss (P = .131), operative time (P = .200), mean hospital stay (P = .417), and postoperative self-voiding (P = .306) did not significantly differ between the groups, with the exception of the number of harvested lymph nodes (P = .001). The disease-free survival was better in the group that underwent infrarenal para-aortic lymphadenectomy than the group that did not (P = .017); however, the 2 groups did not differ with respect to overall survival (P = .115). We suggest that laparoscopic transperitoneal infrarenal lymphadenectomy for cervical cancer is feasible and safe. The rate of positive lymph nodes in infrarenal lymphadenectomy is very rare in patients with locally advanced cervical carcinoma. Infrarenal lymphadenectomy in patients with cervical cancer did not provide additional survival benefits in this study.

Laparoscopic pelvic lymphadenectomy: experience of a Gynaecological Cancer Centre in the UK

The role of laparoscopic lymphadenectomy in the management of gynaecological cancers has been established over the last two decades, having been first described in Dargent and Selvat (L'envahissement ganglionnaire pelvin. Medsi-Mcgraw Hill, Paris, 1989). It has been shown that laparoscopic lymphadenectomy can be performed in the majority of patients and is associated with a low complication rate. However, the technique continues to be undertaken in only a relatively small number of Gynaecological Cancer Centres in the UK owing to the long learning curve and wide variations in training. At the Royal Wolverhampton NHS Trust Gynaecological Cancer Centre in the Greater Midlands Cancer Network laparoscopic lymphadenectomy has been performed since 1999 in the management of early cervical and high grade endometrial cancers. We have undertaken a retrospective audit (1999-2009) of these 42 cases to assess the feasibility of the procedure as well as to assess the complication rate. We are presenting the first reported series of exclusive laparoscopic transperitoneal lymphadenectomies from a Gynaecological Cancer Centre in the UK.

Voie d’abord cœlioscopique du curage lombo-aortique

The idea that pelvic cancers can be treated by laparoscopy is now commonly admitted among gynaecological surgeons. Literature shows a lower morbidity than laparotomy, with similar prognostic results. Metastatic invasion of para-aortic lymph nodes is a major prognostic factor in gynaecological malignancies. It modifies the therapeutic plan and requires retroperitoneal lymphadenectomy in many indications. Laparoscopy is an interesting technical procedure in this situation: it allows both staging and curative surgery. Two laparoscopic ways are eligible: transperitoneal lymphadenectomy and retroperitoneal lymphadenectomy.

VID.13: Laparoscopic Retroperitoneal Lymphadenectomy for Stage I Non-Seminomatous Germ Cell Cancer: Better Results with the Same Template as Open Surgery?

Laparoscopic transperitoneal lymphadenectomy is a minimally invasive procedure and a feasible option to open retroperitoneal lymph node dissection. Our purpose was to demonstrate that endoscopic technique can duplicate the open procedure.

Extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of fallopian tube carcinoma

The endoscopic retroperitoneal approach is a minimally invasive method for surgical staging of cervical cancer. A 57-year-old woman had an intraoperative diagnosis of carcinoma of the left fallopian tube and undergone a retroperitoneal pelvic and para-aortic lymphadenectomy with no peritonization during surgical staging. Small suspicious nodes in the serous membrane of the sigmoid colon and peritoneal washings were positive for malignancy. A total of 12 nodes were obtained, all of which were negative. She received six cycles of paclitaxel and platinum-based chemotherapy and showed a complete clinical response. Thirty-two months after surgery, the abdominal computed tomography scan showed a left para-aortic lymph node, 19 mm in diameter, which was successfully removed through an extraperitoneal laparoscopic approach. The extraperitoneal laparoscopic approach of the para-aortic region is a feasible procedure after previous transperitoneal lymphadenectomy and chemotherapy.

Extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of fallopian tube carcinoma

The endoscopic retroperitoneal approach is a minimally invasive method for surgical staging of cervical cancer. A 57-year-old woman had an intraoperative diagnosis of carcinoma of the left fallopian tube and undergone a retroperitoneal pelvic and para-aortic lymphadenectomy with no peritonization during surgical staging. Small suspicious nodes in the serous membrane of the sigmoid colon and peritoneal washings were positive for malignancy. A total of 12 nodes were obtained, all of which were negative. She received six cycles of paclitaxel and platinum-based chemotherapy and showed a complete clinical response. Thirty-two months after surgery, the abdominal computed tomography scan showed a left para-aortic lymph node, 19 mm in diameter, which was successfully removed through an extraperitoneal laparoscopic approach. The extraperitoneal laparoscopic approach of the para-aortic region is a feasible procedure after previous transperitoneal lymphadenectomy and chemotherapy.

The use of harmonic shears (Ultracision) for laparoscopic lymphadenectomies in women with gynaecological malignancies

The purpose of this paper is to evaluate the safety and efficacy of the harmonic scalpel for laparoscopic pelvic and para-aortic lymphadenectomy in the management of gynaecologic cancers. A prospective study of 21 consecutive patients with gynaecologic cancer, including cervical (11), endometrial (3), ovarian (6) and tubal (1). Eleven patients had pelvic nodes retrieval only, two had para-aortic nodes retrieval only and eight had both. Eighteen patients had transperitoneal lymphadenectomies, one had extraperitoneal and two had both. Eleven patients had a hysterectomy or salpingo-oophorectomy in addition to the laparoscopic lymphadenectomy. In all cases, the harmonic scalpel was used as the only instrument to achieve haemostasis. Average nodal yields were 21.4 for bilateral pelvic lymphadenectomies. The mean estimated blood loss was 132.7 ml. There were no intraoperative complications. Laparoscopic pelvic and para-aortic lymphadenectomy using the harmonic scalpel appears to be both safe and efficient in the management of patients with gynaecologic cancers. Its main advantage is that it enables simultaneous and safe tissue dissection, haemostasis and cutting, avoiding the exchange of several instruments. It could become the first choice instrument for this procedure.

Laparoscopic paraaortic left-sided transperitoneal infrarenal lymphadenectomy in patients with gynecologic malignancies: technique and results

Laparoscopic paraaortic left-sided transperitoneal infrarenal lymphadenectomy in patients with gynecologic malignancies: technique and results

Laparoscopic paraaortic left-sided transperitoneal infrarenal lymphadenectomy in patients with gynecologic malignancies: technique and results

Laparoscopic paraaortic left-sided transperitoneal infrarenal lymphadenectomy in patients with gynecologic malignancies: technique and results

Surgical treatment of low stage cervical carcinoma: Back to the old days?

Radical hysterectomies for the treatment of cervical carcinoma are being performed laparoscopically by some surgeons. Others combine the laparoscopic lymphadenectomy with a radical vaginal hysterectomy or a radical trachelectomy, like in the Schauta procedure. In this way the procedure resembles the AVRUEL-procedure (Abdominal Vaginal Radical Uterus Extirpation with transperitoneal Lymphadenectomy), as developed in 1957 by Sindram who combined the Wertheim and the Schauta procedure together with abdominal lymphadenectomy in one single operation. Because of the high complication rate in the form of voiding problems and sexual impairment caused by the Schauta part, this operation is no longer performed. In order to pay attention to the morbidity associated in the past with the combined abdomino-vaginal approach compared to the single abdominal approach, we reassembled the data of several large Dutch centers where patients were treated either by the AVRUEL or the abdominal radical hysterectomy.A total of 730 patients underwent an AVRUEL procedure, all carried out between 1957 and 1981. Fistulas occurred in 57 patients (7.8%), long-term urologic complications in 233 patients (32%), and sexual dysfunction in 71 (9.7%) were found. A total of 928 patients underwent an abdominal radical hysterectomy, of whom in 511 cases the complication rates have been described. Twelve fistulas occurred (2%), long-term micturition problems in 55 (10%), and sexual problems in 11 (2%). There was no difference in 5-year survival rates in both groups. From the abovementioned data it is clear, that returning to the old days in terms of a re-introduction of the Schauta procedure is not to be preferred. In order to conclude if the laparoscopically assisted radical vaginal hysterectomy or the trachelectomy are an improvement, they should be carried out according to clearly defined prospective protocols in which data can be compared to those of other techniques with special attention to late complications including micturition and sexual sequelae.

Staging laparoscopic pelvic lymphadenectomy in prostate cancer

To assess the results of transperitoneal laparoscopic pelvic lymphadenectomy as a separate staging procedure in patients with early prostate cancer. The results were reviewed from the first 27 patients with prostate cancer admitted for laparoscopic lymphadenectomy between January 1994 and March 1998. Initially, all patients with a negative bone scan and either a negative computed tomography or negative magnetic resonance scan were admitted for laparoscopic staging. After several reports detailing ways of reducing the number of negative lymphadenectomy operations, from July 1996 only those patients with a preoperative prostate specific antigen (PSA) serum level of >10 ng/mL were admitted to the study. All procedures were performed by one experienced laparoscopic surgeon. A radical retropubic prostatectomy was performed as a separate procedure by a consultant urologist within 2 weeks. The effectiveness of the staging operation was analysed by assessing the nodal yield, and the results, including operative duration, complications and length of stay, were compared with other published series. Further analysis was provided by reviewing the PSA levels, Gleason grade sum and clinical digital staging. The nodal yield was similar to that published in series from other institutions, with a median (range) of 6.5 (0-12). However, the operation was significantly quicker, at a median (range) of 55 (40-110) min for a bilateral dissection. There were only minor complications, with no detectable reduction in complications with experience; the median (range) postoperative stay was 1 (1-4) days. Two of the 27 patients had metastatic disease within the lymph nodes. If a PSA level of >10 ng/mL had been instituted as an entry criteria at the start of the study, six patients would have been excluded and thus the positive lymphadenectomy rate would have been two of 21 patients (10%). Of 54 patients eligible to enter the study, half did not require a lymphadenectomy. Laparoscopic transperitoneal lymphadenectomy can be performed expeditiously and safely. A two-stage procedure in some patients with prostate cancer is the management of choice. Attention to carefully closing the peritoneum with sutures minimizes any retropubic adhesions and no problems associated with the staging procedure were encountered during subsequent radical retropubic prostatectomy. In efforts to reduce negative staging lymphadenectomies, the exclusion values for staging should not be set too high (PSA and Gleason grading sum). Such practice, despite a relatively safe staging procedure, would lead to unnecessary radical prostatectomy.