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International Journal of Urology (2014) 21, 1138–1143
doi: 10.1111/iju.12534
Original Article: Clinical Investigation
Contemporary minimally-invasive extended pelvic lymph node dissection for prostate cancer before curative radiotherapy: Prospective standardized analysis of complications Charles Van Praet,1 Karel Decaestecker,1 Valérie Fonteyne,2 Piet Ost,2 Pieter De Visschere,3 Stephanie Verschuere,4 Sylvie Rottey5 and Nicolaas Lumen1 Departments of 1Urology, 2Radiotherapy, 3Radiology, 4Pathology and 5Medical Oncology, Ghent University Hospital, Ghent, Belgium
Abbreviations & Acronyms LMWH = low-molecular weight heparin LN = lymph nodes LNI = lymph node involvement MI = minimally invasive O-PLND = open pelvic lymph node dissection OR = odds ratio PCa = prostate cancer PLND = pelvic lymph node dissection RP = radical prostatectomy RT = radiotherapy SD = standard deviation Correspondence: Charles Van Praet M.D., Department of Urology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium. Email: [email protected] Received 17 January 2014; accepted 18 May 2014. Online publication 25 June 2014
Objectives: To prospectively assess contemporary complication rates of minimallyinvasive staging pelvic lymph node dissection before curative radiotherapy for prostate cancer using a standardized classification. Methods: A total of 100 prostate cancer patients underwent laparoscopic or robotassisted 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. Results: 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). Conclusions: 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.
Key words: laparoscopy, lymph node excision, lymph nodes, prostatic neoplasms, robotics.
Introduction PLND at the time of RP is the gold standard for nodal staging in PCa, given the lack of sensitive imaging techniques.1 However, most PCa patients treated with RT undergo prostate-only or whole-pelvis RT based on their risk of LNI, as calculated by one of several nomograms.2–4 Alternatively, these patients can undergo prior staging PLND to reliably determine nodal status. Whole-pelvis RT can then be limited to patients with LNI, thus reducing overtreatment.5 Apart from staging, PLND might also be therapeutic, as it improves biochemical recurrence-free and cancer-specific survival in intermediate- and high-risk PCa patients with or without LNI.6,7 PLND can be carried out open or MI with laparoscopy or robot-assisted surgery. Contemporary PLND complication rates vary between 2–38%, with development of a symptomatic lymphocele being the main complication (0–11%).8–12 Overall, (asymptomatic) lymphoceles have been reported in 18–61% of patients.13–15 To our knowledge, only one study prospectively assessed the complication rate after laparoscopic staging PLND using a standardized classification.12 The goal of the present study was to assess complications of staging MI-PLND by reporting on surgical outcome and compare this with O-PLND. Additionally, we analyzed overall and symptomatic lymphocele formation rate.
Methods Patient selection Between July 2005 and May 2013, 154 patients underwent staging PLND without RP at Ghent University Hospital, Ghent, Belgium. Patients undergoing salvage PLND after previous RP 1138
© 2014 The Japanese Urological Association
Minimally-invasive staging PLND
(n = 11) were excluded from this analysis. PLND was carried out in the case of D’Amico high-risk PCa (n = 111),1 intermediate-risk PCa with chance of LNI ≥15% according to Roach’s formula (n = 28)3 or physician’s preference (n = 4). PLND was carried out open (n = 43) or MI (n = 100) either laparoscopically (n = 86) or robot-assisted (n = 14). Reasons for an open approach were standard of care by the surgeon (n = 31), multiple previous laparotomies (n = 2), concomitant ureter reimplantation (n = 1) or initially planned with open RP (n = 9) that was aborted after PLND as a result of extensive intraoperative adhesions and/or previous mesh placement (n = 3), LNI on frozen section (n = 3), intraoperative finding of a T3 tumor (n = 2) or excessive bleeding at the start of RP (n = 1). The study was approved by the local ethics committee (EC UZG 2011/495).
Surgical details MI-PLND was carried out transperitoneally by two surgeons (NL and KD). O-PLND was carried out extraperitoneally by two different surgeons. PLND extent was determined by the surgeon, but the following definitions were always applied. Extended PLND (n = 109) includes bilateral removal of all fatty, fibrous and lymphatic tissue medially from the lateral border of the external iliac artery, laterally from the hypogastric artery, from the obturator fossa with complete deskeletonization of the obturator nerve caudally up to and including the node of Cloquet, and cranially up to the crossing of the ureter over the common iliac artery. Limited PLND is defined either by removal of lymph nodes solely in the obturator fossa (n = 5) or in the obturator fossa, and laterally from the hypogastric artery, but not up to the bifurcation of the common iliac artery (n = 29). In the case of suspect LN presacrally or along common iliac vessels on preoperative imaging, these regions were also dissected (n = 4). Main distal lymphatic vessels were sealed using titanium clips before transection.16 Finally, one drain was placed on each side in the obturator fossa, and was usually removed when it produced 40 mL was considered to be of significant size.15 Lymphoceles were considered symptomatic when they caused local pain, fever, bladder neck obstruction, thrombo-embolism or if the patient suffered lymphorrea >5 days through the drain or percutaneously. Treatment of a symptomatic lymphocele was at the treating physician’s discretion. RT started a median 54 days (range 26–169 days) post-surgery either to the prostate alone (pN0) or whole-pelvis RT (pN1).5 Two patients did not receive RT because of metastases on postoperative imaging.
Statistical analysis All statistical analyses were carried out with SPSS version 20.0 (IBM, Armonk, NY, USA). Normally and not normally distributed variables are presented as mean ± SD and median (range) respectively, and analyzed using Student’s t-test and Mann– Whitney U-test, respectively. For categorical variables, χ2-test or Fisher’s exact test were used. Predictors for lymphoceles, symptomatic lymphoceles and lymphoceles >40 mL were identified with logistic regression and quantified using OR with 95% confidence interval. Covariates with a P-value 40 mL, n (%) Paravesical Prevesical Pelvic with retroperitoneal extension Symptomatic lymphocele, n (%) Suprapubic pain Prolonged lymphorrea Fever Dysuria
All patients (n = 143)
MI-PLND (n = 100)
O-PLND (n = 43)
P-value
91 (64%) 59 (41%) 32 (22%) 15.0 (1.5–561) 29 (20%) 26 (18%) 3 (2%)
71 (71%) 45 (45%) 26 (26%) 14.5 (1.5–451) 22 (22%) 19 (19%) 3 (3%)
20 (47%) 14 (33%) 6 (14%) 26.8 (5.3–561) 7 (16%) 7 (16%) 0
0.009*
26 (90%) 2 (7%) 1 (3%) 18 (13%)
20 (91%) 1 (5%) 1 (5%) 10 (10%) 2 4 4 0
6 (86%) 1 (14%) 0 8 (19%) 3 4 0 1
0.415 0.580
1 0.251
*P-values 5 days postoperatively” as having a symptomatic lymphocele, which is not the case in most other reports.8–10,12 Additionally, complication rates are known to be higher when data is gathered prospectively.22 Although we found no significant difference between the type of surgery, in a series of 331 patients Danuser et al. recently reported significantly less symptomatic lymphoceles after transperitoneal robot-assisted RP + extended PLND (1%) versus extraperitoneal open RP + extended PLND (5%; P = 0.06).23 Several additional techniques have been proposed to reduce the number of (symptomatic) lymphoceles: incising the peritoneum at the end of extraperitoneal PLND,24 the use of haemostatic agents22,25 or a vessel sealing device.15 Up to 64% of patients developed lymphoceles, which is the highest number reported in the literature.13–15 To our surprise, significantly more patients developed lymphoceles after MI-PLND (71%) compared with O-PLND (47%). We have no clear explanation for this surprise finding, as one would 1142
expect the transperitoneal approach in the MI group to allow drainage of lymph fluid into the peritoneal cavity. Multivariate regression shows this increased lymphocele rate cannot be fully attributed to the fact that most MI cases underwent extended PLND, as MI surgery was an independent risk factor for lymphocele development (OR 3.99). We could not add weight to previous reports identifying extended PLND,10 increased number of LN removed11 or number of positive LN,26 LNI,14 extracapsular extension,14 increased age,11 hypoalbuminemia, impaired renal function and diabetes27 as predictors for lymphocele development. Contrary to the present findings, Solberg et al. found fewer lymphoceles after laparoscopic PLND versus O-PLND (37% vs 61% respectively; P = 0.013).13 This is possibly because in the former study, unlike O-PLND patients, men undergoing laparoscopic PLND did not receive prophylactic LMWH. Use of LMWH is associated with increased lymph leakage, and it is recommended to inject LMWH into the upper arm rather than the abdomen.28 However, most lymphoceles after MI-PLND were small, as just 22% of patients had a lymphocele >40 mL, which corresponds to a sphere of approximately 4 cm in diameter.13,15 Approximately 90% of significant lymphoceles present paravesically in the dissected region. In 105 patients presenting with symptomatic lymphoceles, Khoder et al. concordantly found these 94% paravesically, 4% prevesically and 2% extending retroperitoneally.29 There were some limitations to the present study. Although most data (surgical/pathological details, complications) were gathered prospectively, some data were gathered retrospectively, most notably lymphocele rates and size, and long-term development of lymphedema. More O-PLND patients had LNI (49%) compared with MI-PLND (24%). This is probably as a result of the inclusion of patients with aborted RP because of LNI on frozen section (n = 3) or a peroperative T3 tumor (n = 3), and the presence of more patients with locally advanced PCa (cT3b–4) in the open group. This makes it difficult to compare both groups, additionally because O-PLND and MI-PLND was carried out by different surgeons. However, such bias is inherent to most surgical studies. In conclusion, MI staging extended PLND is a safe procedure with low morbidity that allows nodal staging before curative radiotherapy. MI-PLND is associated with increased asymptomatic lymphocele development. © 2014 The Japanese Urological Association
Minimally-invasive staging PLND
Conflict of interest None declared.
References 1 Heidenreich A, Bellmunt J, Bolla M et al. EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease. Eur. Urol. 2011; 59: 61–71. 2 Pommier P, Chabaud S, Lagrange JL et al. Is there a role for pelvic irradiation in localized prostate adenocarcinoma? Preliminary results of GETUG-01. J. Clin. Oncol. 2007; 25: 5366–73. 3 Roach M III, Marquez C, Yuo HS et al. Predicting the risk of lymph node involvement using the pre-treatment prostate specific antigen and Gleason score in men with clinically localized prostate cancer. Int. J. Radiat. Oncol. Biol. Phys. 1994; 28: 33–7. 4 Briganti A, Larcher A, Abdollah F et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores. Eur. Urol. 2012; 61: 480–7. 5 Fonteyne V, Lumen N, Ost P et al. Hypofractionated intensity-modulated arc therapy for lymph node metastasized prostate cancer: early late toxicity and 3-year clinical outcome. Radiother. Oncol. 2013; 109: 229–34. 6 Ji J, Yuan H, Wang L, Hou J. Is the impact of the extent of lymphadenectomy in radical prostatectomy related to the disease risk? A single center prospective study. J. Surg. Res. 2012; 178: 779–84. 7 Withrow DR, DeGroot JM, Siemens DR, Groome PA. Therapeutic value of lymph node dissection at radical prostatectomy: a population-based case-cohort study. BJU Int. 2011; 108: 209–16. 8 Bader P, Burkhard FC, Markwalder R, Studer UE. Is a limited lymph node dissection an adequate staging procedure for prostate cancer? J. Urol. 2002; 168: 514–18. 9 Briganti A, Chun FK, Salonia A et al. Complications and other surgical outcomes associated with extended pelvic lymphadenectomy in men with localized prostate cancer. Eur. Urol. 2006; 50: 1006–13. 10 Musch M, Klevecka V, Roggenbuck U, Kroepfl D. Complications of pelvic lymphadenectomy in 1,380 patients undergoing radical retropubic prostatectomy between 1993 and 2006. J. Urol. 2008; 179: 923–8. 11 Capitanio U, Pellucchi F, Gallina A et al. How can we predict lymphorrhoea and clinically significant lymphocoeles after radical prostatectomy and pelvic lymphadenectomy? Clinical implications. BJU Int. 2011; 107: 1095–101. 12 Liedberg F, Kjolhede H, Sundqvist P. Laparoscopic extended pelvic lymphadenectomy for staging can be performed with limited morbidity and short hospital stay in patients with prostate cancer. Scand. J. Urol. Nephrol. 2012; 46: 332–6. 13 Solberg A, Angelsen A, Bergan U, Haugen OA, Viset T, Klepp O. Frequency of lymphoceles after open and laparoscopic pelvic lymph node dissection in patients with prostate cancer. Scand. J. Urol. Nephrol. 2003; 37: 218–21. 14 Orvieto MA, Coelho RF, Chauhan S, Palmer KJ, Rocco B, Patel VR. Incidence of lymphoceles after robot-assisted pelvic lymph node dissection. BJU Int. 2011; 108: 1185–90.
© 2014 The Japanese Urological Association
15 Yasumizu Y, Miyajima A, Maeda T et al. How can lymphocele development be prevented after laparoscopic radical prostatectomy? J. Endourol. 2013; 27: 447–51. 16 Heidenreich A, Ohlmann CH, Polyakov S. Anatomical extent of pelvic lymphadenectomy in patients undergoing radical prostatectomy. Eur. Urol. 2007; 52: 29–37. 17 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann. Surg. 2004; 240: 205–13. 18 Umbehr MH, Muntener M, Hany T, Sulser T, Bachmann LM. The role of 11C-choline and 18F-fluorocholine positron emission tomography (PET) and PET/CT in prostate cancer: a systematic review and meta-analysis. Eur. Urol. 2013; 64: 106–17. 19 Lawenda BD, Mondry TE, Johnstone PA. Lymphedema: a primer on the identification and management of a chronic condition in oncologic treatment. CA Cancer J. Clin. 2009; 59: 8–24. 20 Bodin T, Boutin JM, Haillot O, Bruyere F. Pelvic lymphadenectomy in prostate cancer: should it be realized by laparoscopy? Prog. Urol. 2011; 21: 463–9. 21 Eden CG, Zacharakis E, Bott S. The learning curve for laparoscopic extended pelvic lymphadenectomy for intermediate- and high-risk prostate cancer: implications for compliance with existing guidelines. BJU Int. 2013; 112: 346–54. 22 Simonato A, Varca V, Esposito M, Venzano F, Carmignani G. The use of a surgical patch in the prevention of lymphoceles after extraperitoneal pelvic lymphadenectomy for prostate cancer: a randomized prospective pilot study. J. Urol. 2009; 182: 2285–90. 23 Danuser H, Di Pierro GB, Stucki P, Mattei A. Extended pelvic lymphadenectomy and various radical prostatectomy techniques: is pelvic drainage necessary? BJU Int. 2013; 111: 963–9. 24 Stolzenburg JU, Wasserscheid J, Rabenalt R et al. Reduction in incidence of lymphocele following extraperitoneal radical prostatectomy and pelvic lymph node dissection by bilateral peritoneal fenestration. World J. Urol. 2008; 26: 581–6. 25 Waldert M, Remzi M, Klatte T, Klingler HC. FloSeal reduces the incidence of lymphoceles after lymphadenectomies in laparoscopic and robot-assisted extraperitoneal radical prostatectomy. J. Endourol. 2011; 25: 969–73. 26 Lee JY, Diaz RR, Cho KS et al. Lymphocele after extraperitoneal robot-assisted radical prostatectomy: a propensity score-matching study. Int. J. Urol. 2013; 20: 1169–76. 27 Ulrich F, Niedzwiecki S, Fikatas P et al. Symptomatic lymphoceles after kidney transplantation – multivariate analysis of risk factors and outcome after laparoscopic fenestration. Clin. Transplant. 2010; 24: 273–80. 28 Tomic R, Granfors T, Sjodin JG, Ohberg L. Lymph leakage after staging pelvic lymphadenectomy for prostatic carcinoma with and without heparin prophylaxis. Scand. J. Urol. Nephrol. 1994; 28: 273–5. 29 Khoder WY, Gratzke C, Haseke N, Herlemann A, Stief CG, Becker AJ. Laparoscopic marsupialisation of pelvic lymphoceles in different anatomic locations following radical prostatectomy. Eur. Urol. 2012; 62: 640–8.
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International Journal of Urology (2014) 21, 1138–1143
doi: 10.1111/iju.12534
Original Article: Clinical Investigation
Contemporary minimally-invasive extended pelvic lymph node dissection for prostate cancer before curative radiotherapy: Prospective standardized analysis of complications Charles Van Praet,1 Karel Decaestecker,1 Valérie Fonteyne,2 Piet Ost,2 Pieter De Visschere,3 Stephanie Verschuere,4 Sylvie Rottey5 and Nicolaas Lumen1 Departments of 1Urology, 2Radiotherapy, 3Radiology, 4Pathology and 5Medical Oncology, Ghent University Hospital, Ghent, Belgium
Abbreviations & Acronyms LMWH = low-molecular weight heparin LN = lymph nodes LNI = lymph node involvement MI = minimally invasive O-PLND = open pelvic lymph node dissection OR = odds ratio PCa = prostate cancer PLND = pelvic lymph node dissection RP = radical prostatectomy RT = radiotherapy SD = standard deviation Correspondence: Charles Van Praet M.D., Department of Urology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium. Email: [email protected] Received 17 January 2014; accepted 18 May 2014. Online publication 25 June 2014
Objectives: To prospectively assess contemporary complication rates of minimallyinvasive staging pelvic lymph node dissection before curative radiotherapy for prostate cancer using a standardized classification. Methods: A total of 100 prostate cancer patients underwent laparoscopic or robotassisted 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. Results: 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). Conclusions: 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.
Key words: laparoscopy, lymph node excision, lymph nodes, prostatic neoplasms, robotics.
Introduction PLND at the time of RP is the gold standard for nodal staging in PCa, given the lack of sensitive imaging techniques.1 However, most PCa patients treated with RT undergo prostate-only or whole-pelvis RT based on their risk of LNI, as calculated by one of several nomograms.2–4 Alternatively, these patients can undergo prior staging PLND to reliably determine nodal status. Whole-pelvis RT can then be limited to patients with LNI, thus reducing overtreatment.5 Apart from staging, PLND might also be therapeutic, as it improves biochemical recurrence-free and cancer-specific survival in intermediate- and high-risk PCa patients with or without LNI.6,7 PLND can be carried out open or MI with laparoscopy or robot-assisted surgery. Contemporary PLND complication rates vary between 2–38%, with development of a symptomatic lymphocele being the main complication (0–11%).8–12 Overall, (asymptomatic) lymphoceles have been reported in 18–61% of patients.13–15 To our knowledge, only one study prospectively assessed the complication rate after laparoscopic staging PLND using a standardized classification.12 The goal of the present study was to assess complications of staging MI-PLND by reporting on surgical outcome and compare this with O-PLND. Additionally, we analyzed overall and symptomatic lymphocele formation rate.
Methods Patient selection Between July 2005 and May 2013, 154 patients underwent staging PLND without RP at Ghent University Hospital, Ghent, Belgium. Patients undergoing salvage PLND after previous RP 1138
© 2014 The Japanese Urological Association
Minimally-invasive staging PLND
(n = 11) were excluded from this analysis. PLND was carried out in the case of D’Amico high-risk PCa (n = 111),1 intermediate-risk PCa with chance of LNI ≥15% according to Roach’s formula (n = 28)3 or physician’s preference (n = 4). PLND was carried out open (n = 43) or MI (n = 100) either laparoscopically (n = 86) or robot-assisted (n = 14). Reasons for an open approach were standard of care by the surgeon (n = 31), multiple previous laparotomies (n = 2), concomitant ureter reimplantation (n = 1) or initially planned with open RP (n = 9) that was aborted after PLND as a result of extensive intraoperative adhesions and/or previous mesh placement (n = 3), LNI on frozen section (n = 3), intraoperative finding of a T3 tumor (n = 2) or excessive bleeding at the start of RP (n = 1). The study was approved by the local ethics committee (EC UZG 2011/495).
Surgical details MI-PLND was carried out transperitoneally by two surgeons (NL and KD). O-PLND was carried out extraperitoneally by two different surgeons. PLND extent was determined by the surgeon, but the following definitions were always applied. Extended PLND (n = 109) includes bilateral removal of all fatty, fibrous and lymphatic tissue medially from the lateral border of the external iliac artery, laterally from the hypogastric artery, from the obturator fossa with complete deskeletonization of the obturator nerve caudally up to and including the node of Cloquet, and cranially up to the crossing of the ureter over the common iliac artery. Limited PLND is defined either by removal of lymph nodes solely in the obturator fossa (n = 5) or in the obturator fossa, and laterally from the hypogastric artery, but not up to the bifurcation of the common iliac artery (n = 29). In the case of suspect LN presacrally or along common iliac vessels on preoperative imaging, these regions were also dissected (n = 4). Main distal lymphatic vessels were sealed using titanium clips before transection.16 Finally, one drain was placed on each side in the obturator fossa, and was usually removed when it produced 40 mL was considered to be of significant size.15 Lymphoceles were considered symptomatic when they caused local pain, fever, bladder neck obstruction, thrombo-embolism or if the patient suffered lymphorrea >5 days through the drain or percutaneously. Treatment of a symptomatic lymphocele was at the treating physician’s discretion. RT started a median 54 days (range 26–169 days) post-surgery either to the prostate alone (pN0) or whole-pelvis RT (pN1).5 Two patients did not receive RT because of metastases on postoperative imaging.
Statistical analysis All statistical analyses were carried out with SPSS version 20.0 (IBM, Armonk, NY, USA). Normally and not normally distributed variables are presented as mean ± SD and median (range) respectively, and analyzed using Student’s t-test and Mann– Whitney U-test, respectively. For categorical variables, χ2-test or Fisher’s exact test were used. Predictors for lymphoceles, symptomatic lymphoceles and lymphoceles >40 mL were identified with logistic regression and quantified using OR with 95% confidence interval. Covariates with a P-value 40 mL, n (%) Paravesical Prevesical Pelvic with retroperitoneal extension Symptomatic lymphocele, n (%) Suprapubic pain Prolonged lymphorrea Fever Dysuria
All patients (n = 143)
MI-PLND (n = 100)
O-PLND (n = 43)
P-value
91 (64%) 59 (41%) 32 (22%) 15.0 (1.5–561) 29 (20%) 26 (18%) 3 (2%)
71 (71%) 45 (45%) 26 (26%) 14.5 (1.5–451) 22 (22%) 19 (19%) 3 (3%)
20 (47%) 14 (33%) 6 (14%) 26.8 (5.3–561) 7 (16%) 7 (16%) 0
0.009*
26 (90%) 2 (7%) 1 (3%) 18 (13%)
20 (91%) 1 (5%) 1 (5%) 10 (10%) 2 4 4 0
6 (86%) 1 (14%) 0 8 (19%) 3 4 0 1
0.415 0.580
1 0.251
*P-values 5 days postoperatively” as having a symptomatic lymphocele, which is not the case in most other reports.8–10,12 Additionally, complication rates are known to be higher when data is gathered prospectively.22 Although we found no significant difference between the type of surgery, in a series of 331 patients Danuser et al. recently reported significantly less symptomatic lymphoceles after transperitoneal robot-assisted RP + extended PLND (1%) versus extraperitoneal open RP + extended PLND (5%; P = 0.06).23 Several additional techniques have been proposed to reduce the number of (symptomatic) lymphoceles: incising the peritoneum at the end of extraperitoneal PLND,24 the use of haemostatic agents22,25 or a vessel sealing device.15 Up to 64% of patients developed lymphoceles, which is the highest number reported in the literature.13–15 To our surprise, significantly more patients developed lymphoceles after MI-PLND (71%) compared with O-PLND (47%). We have no clear explanation for this surprise finding, as one would 1142
expect the transperitoneal approach in the MI group to allow drainage of lymph fluid into the peritoneal cavity. Multivariate regression shows this increased lymphocele rate cannot be fully attributed to the fact that most MI cases underwent extended PLND, as MI surgery was an independent risk factor for lymphocele development (OR 3.99). We could not add weight to previous reports identifying extended PLND,10 increased number of LN removed11 or number of positive LN,26 LNI,14 extracapsular extension,14 increased age,11 hypoalbuminemia, impaired renal function and diabetes27 as predictors for lymphocele development. Contrary to the present findings, Solberg et al. found fewer lymphoceles after laparoscopic PLND versus O-PLND (37% vs 61% respectively; P = 0.013).13 This is possibly because in the former study, unlike O-PLND patients, men undergoing laparoscopic PLND did not receive prophylactic LMWH. Use of LMWH is associated with increased lymph leakage, and it is recommended to inject LMWH into the upper arm rather than the abdomen.28 However, most lymphoceles after MI-PLND were small, as just 22% of patients had a lymphocele >40 mL, which corresponds to a sphere of approximately 4 cm in diameter.13,15 Approximately 90% of significant lymphoceles present paravesically in the dissected region. In 105 patients presenting with symptomatic lymphoceles, Khoder et al. concordantly found these 94% paravesically, 4% prevesically and 2% extending retroperitoneally.29 There were some limitations to the present study. Although most data (surgical/pathological details, complications) were gathered prospectively, some data were gathered retrospectively, most notably lymphocele rates and size, and long-term development of lymphedema. More O-PLND patients had LNI (49%) compared with MI-PLND (24%). This is probably as a result of the inclusion of patients with aborted RP because of LNI on frozen section (n = 3) or a peroperative T3 tumor (n = 3), and the presence of more patients with locally advanced PCa (cT3b–4) in the open group. This makes it difficult to compare both groups, additionally because O-PLND and MI-PLND was carried out by different surgeons. However, such bias is inherent to most surgical studies. In conclusion, MI staging extended PLND is a safe procedure with low morbidity that allows nodal staging before curative radiotherapy. MI-PLND is associated with increased asymptomatic lymphocele development. © 2014 The Japanese Urological Association
Minimally-invasive staging PLND
Conflict of interest None declared.
References 1 Heidenreich A, Bellmunt J, Bolla M et al. EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease. Eur. Urol. 2011; 59: 61–71. 2 Pommier P, Chabaud S, Lagrange JL et al. Is there a role for pelvic irradiation in localized prostate adenocarcinoma? Preliminary results of GETUG-01. J. Clin. Oncol. 2007; 25: 5366–73. 3 Roach M III, Marquez C, Yuo HS et al. Predicting the risk of lymph node involvement using the pre-treatment prostate specific antigen and Gleason score in men with clinically localized prostate cancer. Int. J. Radiat. Oncol. Biol. Phys. 1994; 28: 33–7. 4 Briganti A, Larcher A, Abdollah F et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores. Eur. Urol. 2012; 61: 480–7. 5 Fonteyne V, Lumen N, Ost P et al. Hypofractionated intensity-modulated arc therapy for lymph node metastasized prostate cancer: early late toxicity and 3-year clinical outcome. Radiother. Oncol. 2013; 109: 229–34. 6 Ji J, Yuan H, Wang L, Hou J. Is the impact of the extent of lymphadenectomy in radical prostatectomy related to the disease risk? A single center prospective study. J. Surg. Res. 2012; 178: 779–84. 7 Withrow DR, DeGroot JM, Siemens DR, Groome PA. Therapeutic value of lymph node dissection at radical prostatectomy: a population-based case-cohort study. BJU Int. 2011; 108: 209–16. 8 Bader P, Burkhard FC, Markwalder R, Studer UE. Is a limited lymph node dissection an adequate staging procedure for prostate cancer? J. Urol. 2002; 168: 514–18. 9 Briganti A, Chun FK, Salonia A et al. Complications and other surgical outcomes associated with extended pelvic lymphadenectomy in men with localized prostate cancer. Eur. Urol. 2006; 50: 1006–13. 10 Musch M, Klevecka V, Roggenbuck U, Kroepfl D. Complications of pelvic lymphadenectomy in 1,380 patients undergoing radical retropubic prostatectomy between 1993 and 2006. J. Urol. 2008; 179: 923–8. 11 Capitanio U, Pellucchi F, Gallina A et al. How can we predict lymphorrhoea and clinically significant lymphocoeles after radical prostatectomy and pelvic lymphadenectomy? Clinical implications. BJU Int. 2011; 107: 1095–101. 12 Liedberg F, Kjolhede H, Sundqvist P. Laparoscopic extended pelvic lymphadenectomy for staging can be performed with limited morbidity and short hospital stay in patients with prostate cancer. Scand. J. Urol. Nephrol. 2012; 46: 332–6. 13 Solberg A, Angelsen A, Bergan U, Haugen OA, Viset T, Klepp O. Frequency of lymphoceles after open and laparoscopic pelvic lymph node dissection in patients with prostate cancer. Scand. J. Urol. Nephrol. 2003; 37: 218–21. 14 Orvieto MA, Coelho RF, Chauhan S, Palmer KJ, Rocco B, Patel VR. Incidence of lymphoceles after robot-assisted pelvic lymph node dissection. BJU Int. 2011; 108: 1185–90.
© 2014 The Japanese Urological Association
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