Staging Laparoscopic Pelvic Lymph Experience and
Node Dissection
Indications
Raul O. Parra, MD; Charles H. Andrus, MD; John A. Boullier, MD
Laparoscopic pelvic lymph node dissection has proven to reliable, less-invasive method for staging prostate cancer. Presently, no clear indications for its performance prior to radical retropubic prostatectomy are available. With the purpose of identifying clinical parameters by which to better select patients who would benefit from laparoscopic pelvic lymph node dissection, we chose to perform the procedure only in patients considered at high risk for nodal metastasis: clinical stages B2 or C, poorly differentiated tumors, and/or a serum prostatic-specific antigen level of more than 20 ng/dL. We compared the results with those of patients not meeting such parameters. Of 80 men receiving treatment for clinically localized disease, 30 (38%) fulfilled one or more of the criteria. When considering the individual clinical parameters, clinical stage was predictive of nodal involvement in five (26%) of 19 patients, grade was predictive in three (37.5%) of eight patients, and prostatic\x=req-\ specific antigen level was predictive in six (40%) of 15 patients. Statistical analysis confirmed that the prostatic\x=req-\ specific antigen level was the single best predictor of nodal involvement. However, better predictive values were ob\s=b\
be a
tained when the different criteria were combined. Nodal involvement was predicted most consistently by a combination of clinical stage and prostatic-specific antigen level.
(Arch Surg. 1992;127:1294-1297)
nodes
the pelvic lymph Thepelling ofparameter deciding of status
in
represents
a com¬
treatment and deter¬
men with clinically local¬ ized prostate cancer.1-2 Noninvasive imaging and/or biochemical studies cannot be relied on to accurately pre¬ dict lymph node involvement.37 Consequently, direct his¬ nodes is the only tologie assessment of the regional undeniable means of corroborating malignant spread. This can be achieved with percutaneous needle biopsy of sus¬ picious nodes under radiologie guidance. Unfortunately, only radiographically positive nodes can be sampled,
mining long-term prognosis
lymph
Accepted for publication July 9, 1992. From the Division of Urology, Department of Surgery,
University School of Medicine.
St Louis (Mo)
Presented at the 45th Annual Cancer Symposium of the Society of New York, NY, March 16, 1992. Reprint requests to the St Louis University Medical Center, 3635 Vista at Grand, St Louis, MO 63110-0210 (Dr Parra).
Surgical Oncology,
which
potentially lead to missing microscopic mé¬ routinely not visualized with this technique.8 Open-staging lymphadenectomy is, without doubt, the most precise means to assess disease spread to the regional however, significant complications are not lymph nodes;The advent of operative laparoscopy has al¬ uncommon.9 lowed the performance of a lymph node dissection equal to the standard method, but with the added advantages of decreased morbidity, hospital stay, and possibly costs.1011 The usefulness of laparoscopie pelvic lymph node dissec¬ tion (LPLND) prior to radical perineal prostatectomy or radiation therapy is unequivocal. However, clear indica¬ tions for LPLND preceding radical retropubic prostatec¬ tomy are lacking despite the potential to spare men with positive nodes an unnecessary open surgical procedure. We report herein the results of a prospective study un¬ can
tastases
dertaken at our institution to evaluate different preopera¬ tive parameters individually and with respect to each other as possible selection criteria for LPLND prior to radical
retropubic prostatectomy.
MATERIALS AND METHODS
Patient
Population and Selection Criteria
From August 1990 to January 1991, 80 men were seen at our in¬ stitution with the diagnosis of clinically localized prostate cancer. Eighteen patients (22%) treated with interstitial radiation therapy were excluded from the study since complete staging data were not available. The age range of the remaining 62 patients was from 54 to 80 years, with a mean (±SD) age of 67.5±6.74 years. Clin¬ ical staging consisted of digital rectal examination, transrectal ultrasonography, radionuclide bone scanning, and determination of serum levels of prostate-specific antigen (PSA), as determined by the tandem hybritech assay (reference range, 0 to 4 ng/dL). Patients were assigned to one of two groups by strict selection criteria. Those patients with clinical stage B2 or C lesions; serum PSA levels greater than 20 ng/dL; or poorly differentiated tumors, defined as a Gleason score of 8-10 on the preoperative needle biopsy, were designated to undergo a staging LPLND (group A). If the frozen-section diagnosis of the pelvic nodes was negative, a radical prostatectomy (retropubic or perineal) was performed. However, when faced with a positive frozen-section diagnosis, no further surgery was pursued, with most patients proceeding to treatment via hormonal ablative therapy. In those patients who did not meet the above criteria, a standard open pelvic lymphadenectomy was performed, and, in the presence of benign lymph nodes, followed by a radical retropubic prostatec¬
tomy (group B).
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/02/2015
Table 1.—Patient
Populations Mean±SD
Mean±SD Age, y
Mean±SD Gleason Score
(Range)
(Range)
A (n=30)
66.7±6.1
6.17±1.9
(54-79)
(2-9)
(0.6-228)
B (n=32)
68.5±7.8
4.41 ±1.6
8.31 ±5.6
(54-80)
(2-7)
(0.7-20)
Group
*PSA indicates
Preoperative PSA Level, ng/dL* (Range)
35.2±49.0
prostatic-specific antigen.
Table 2.—Clinical and Clinical
Pathologic Stage*
Stage
Group A
*Data
B1
A2
B2
C
1
10
0
15
4
7
20
5
0
0
A1
are
-1
B1
1.—Correlation between clinical stage and nodal involvement (P=.02 by 2 analysis).
Fig
Pathologic Stage
-1
B2
C
D1
2
6
16
6
11
18
3
0
numbers of patients.
Surgical Technique The technique used for LPLND has been previously de¬ scribed.11 It consists of a standard 10- or 11-mm three-port laparoscopie access. The margins of dissection are delineated by the area encompassed by the external iliac artery laterally, the obliterated umbilical artery and pelvic floor medially, the pubic rami distally, and the bifurcation of the common iliac artery proximally. With a combination of sharp and blunt dissection, all of the lymphatic tissue encompassed by these boundaries is removed and the material submitted for step frozen-section assessment.
The approach to an open lymphadenectomy is through a low, midline incision. After the prevesical space is developed, the peritoneal envelope is retracted cephalad, which is facilitated by performing a bilateral vasectomy. The entire dissection is per¬ formed extraperitoneally, with the margins of dissection identi¬ cal to those used in the LPLND group. Once again, the nodal tis¬ sue is removed and submitted for frozen-section examination. Radical retropubic prostatectomy is then performed in the stan¬ dard fashion, and two closed-suction drains are brought out through separate stab wounds to drain the surgical field at the end of the procedure.
Statistical
Analysis
Data for the two study groups are means (±SDs). Comparisons of means were performed with unmatched two- tailed Student's t test. The predictive value of individual parameters for nodal in¬ volvement was assessed with stepwise linear regression analysis. Incidence of nodal metastasis with respect to each study param¬ eter and combinations of the parameters were examined with 2 analysis. Differences were considered significant at Yates' cor¬ rected P
Node Dissection
Indications
Raul O. Parra, MD; Charles H. Andrus, MD; John A. Boullier, MD
Laparoscopic pelvic lymph node dissection has proven to reliable, less-invasive method for staging prostate cancer. Presently, no clear indications for its performance prior to radical retropubic prostatectomy are available. With the purpose of identifying clinical parameters by which to better select patients who would benefit from laparoscopic pelvic lymph node dissection, we chose to perform the procedure only in patients considered at high risk for nodal metastasis: clinical stages B2 or C, poorly differentiated tumors, and/or a serum prostatic-specific antigen level of more than 20 ng/dL. We compared the results with those of patients not meeting such parameters. Of 80 men receiving treatment for clinically localized disease, 30 (38%) fulfilled one or more of the criteria. When considering the individual clinical parameters, clinical stage was predictive of nodal involvement in five (26%) of 19 patients, grade was predictive in three (37.5%) of eight patients, and prostatic\x=req-\ specific antigen level was predictive in six (40%) of 15 patients. Statistical analysis confirmed that the prostatic\x=req-\ specific antigen level was the single best predictor of nodal involvement. However, better predictive values were ob\s=b\
be a
tained when the different criteria were combined. Nodal involvement was predicted most consistently by a combination of clinical stage and prostatic-specific antigen level.
(Arch Surg. 1992;127:1294-1297)
nodes
the pelvic lymph Thepelling ofparameter deciding of status
in
represents
a com¬
treatment and deter¬
men with clinically local¬ ized prostate cancer.1-2 Noninvasive imaging and/or biochemical studies cannot be relied on to accurately pre¬ dict lymph node involvement.37 Consequently, direct his¬ nodes is the only tologie assessment of the regional undeniable means of corroborating malignant spread. This can be achieved with percutaneous needle biopsy of sus¬ picious nodes under radiologie guidance. Unfortunately, only radiographically positive nodes can be sampled,
mining long-term prognosis
lymph
Accepted for publication July 9, 1992. From the Division of Urology, Department of Surgery,
University School of Medicine.
St Louis (Mo)
Presented at the 45th Annual Cancer Symposium of the Society of New York, NY, March 16, 1992. Reprint requests to the St Louis University Medical Center, 3635 Vista at Grand, St Louis, MO 63110-0210 (Dr Parra).
Surgical Oncology,
which
potentially lead to missing microscopic mé¬ routinely not visualized with this technique.8 Open-staging lymphadenectomy is, without doubt, the most precise means to assess disease spread to the regional however, significant complications are not lymph nodes;The advent of operative laparoscopy has al¬ uncommon.9 lowed the performance of a lymph node dissection equal to the standard method, but with the added advantages of decreased morbidity, hospital stay, and possibly costs.1011 The usefulness of laparoscopie pelvic lymph node dissec¬ tion (LPLND) prior to radical perineal prostatectomy or radiation therapy is unequivocal. However, clear indica¬ tions for LPLND preceding radical retropubic prostatec¬ tomy are lacking despite the potential to spare men with positive nodes an unnecessary open surgical procedure. We report herein the results of a prospective study un¬ can
tastases
dertaken at our institution to evaluate different preopera¬ tive parameters individually and with respect to each other as possible selection criteria for LPLND prior to radical
retropubic prostatectomy.
MATERIALS AND METHODS
Patient
Population and Selection Criteria
From August 1990 to January 1991, 80 men were seen at our in¬ stitution with the diagnosis of clinically localized prostate cancer. Eighteen patients (22%) treated with interstitial radiation therapy were excluded from the study since complete staging data were not available. The age range of the remaining 62 patients was from 54 to 80 years, with a mean (±SD) age of 67.5±6.74 years. Clin¬ ical staging consisted of digital rectal examination, transrectal ultrasonography, radionuclide bone scanning, and determination of serum levels of prostate-specific antigen (PSA), as determined by the tandem hybritech assay (reference range, 0 to 4 ng/dL). Patients were assigned to one of two groups by strict selection criteria. Those patients with clinical stage B2 or C lesions; serum PSA levels greater than 20 ng/dL; or poorly differentiated tumors, defined as a Gleason score of 8-10 on the preoperative needle biopsy, were designated to undergo a staging LPLND (group A). If the frozen-section diagnosis of the pelvic nodes was negative, a radical prostatectomy (retropubic or perineal) was performed. However, when faced with a positive frozen-section diagnosis, no further surgery was pursued, with most patients proceeding to treatment via hormonal ablative therapy. In those patients who did not meet the above criteria, a standard open pelvic lymphadenectomy was performed, and, in the presence of benign lymph nodes, followed by a radical retropubic prostatec¬
tomy (group B).
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/02/2015
Table 1.—Patient
Populations Mean±SD
Mean±SD Age, y
Mean±SD Gleason Score
(Range)
(Range)
A (n=30)
66.7±6.1
6.17±1.9
(54-79)
(2-9)
(0.6-228)
B (n=32)
68.5±7.8
4.41 ±1.6
8.31 ±5.6
(54-80)
(2-7)
(0.7-20)
Group
*PSA indicates
Preoperative PSA Level, ng/dL* (Range)
35.2±49.0
prostatic-specific antigen.
Table 2.—Clinical and Clinical
Pathologic Stage*
Stage
Group A
*Data
B1
A2
B2
C
1
10
0
15
4
7
20
5
0
0
A1
are
-1
B1
1.—Correlation between clinical stage and nodal involvement (P=.02 by 2 analysis).
Fig
Pathologic Stage
-1
B2
C
D1
2
6
16
6
11
18
3
0
numbers of patients.
Surgical Technique The technique used for LPLND has been previously de¬ scribed.11 It consists of a standard 10- or 11-mm three-port laparoscopie access. The margins of dissection are delineated by the area encompassed by the external iliac artery laterally, the obliterated umbilical artery and pelvic floor medially, the pubic rami distally, and the bifurcation of the common iliac artery proximally. With a combination of sharp and blunt dissection, all of the lymphatic tissue encompassed by these boundaries is removed and the material submitted for step frozen-section assessment.
The approach to an open lymphadenectomy is through a low, midline incision. After the prevesical space is developed, the peritoneal envelope is retracted cephalad, which is facilitated by performing a bilateral vasectomy. The entire dissection is per¬ formed extraperitoneally, with the margins of dissection identi¬ cal to those used in the LPLND group. Once again, the nodal tis¬ sue is removed and submitted for frozen-section examination. Radical retropubic prostatectomy is then performed in the stan¬ dard fashion, and two closed-suction drains are brought out through separate stab wounds to drain the surgical field at the end of the procedure.
Statistical
Analysis
Data for the two study groups are means (±SDs). Comparisons of means were performed with unmatched two- tailed Student's t test. The predictive value of individual parameters for nodal in¬ volvement was assessed with stepwise linear regression analysis. Incidence of nodal metastasis with respect to each study param¬ eter and combinations of the parameters were examined with 2 analysis. Differences were considered significant at Yates' cor¬ rected P
