Platinum Priority – Collaborative Review – Prostate CancerEditorial by Alexandre Mottrie and Alessandro Volpe on pp. 17–19 of this issuePelvic Lymph Node Dissection During Robot-assisted Radical Prostatectomy: Efficacy, Limitations, and Complications—A Systematic Review of the Literature
Introduction
Pelvic lymph node dissection (PLND) in prostate cancer (PCa) is the most effective method for detecting lymph node metastases. Appropriate staging allows for more precise prognostication and it may help guide postsurgical follow-up and guide selection of either adjuvant or salvage therapy. However, a decline in the rate of PLND during radical prostatectomy (RP) has been noted, likely due to PCa stage migration that has occurred in the prostate-specific antigen (PSA) screening era and the introduction of minimally invasive approaches. Although the first reports of PLND during robot-assisted radical prostatectomy (RARP) demonstrated the technical feasibility of PLND, patients undergoing open RP were more likely to have concomitant PLND than patients undergoing minimally invasive radical prostatectomy [1], [2], [3], [4]. Among surgeons performing both open and robotic approaches, one-fifth reported that the indication for and extent of PLND differed based on surgical approach [5]. Various factors such as surgical volume, learning curve of RARP, and increased operative room time and costs have been suggested to account for the lower likelihood of performing PLND during minimally invasive RP. Thus, the adequacy of robotic PLND during RARP has been questioned. Both open and RARP should have identical indications for and extent of PLND. Recent reports have demonstrated the feasibility of PLND during the robotic procedure. This review assesses the efficacy, limitations, and complications of PLND during RARP.
Section snippets
Evidence acquisition
A review of the literature was performed using the Medline, Scopus, and Web of Science databases according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines [6]. We identified original articles, reviews, and editorials with no restriction of language from January 1990 to December 2012. All published retrospective or prospective full articles were included. Congress communications and abstracts were not included. The literature search used the following terms:
Anatomic landmarks: prostate cancer drainage
Historically, the levels of lymph node drainage have been segregated into internal iliac, obturator, external iliac, and presacral [7]. Autopsy studies suggest that the predominant region for lymph node metastasis is the external iliac region [8]. Nevertheless, various studies support primary spread of PCa to the internal iliac chain rather than the ilio-obturator lymph nodes [9], [10], [11], [12]. The presacral region has also been identified as the initial site of lymphatic drainage in a
Conclusions
PLND during RARP can be performed effectively and safely. The extended template is technically feasible with minimal morbidity. Types and rates of complications with the robot-assisted approach are similar to pure laparoscopic and open retropubic procedures. As seen in open RP, the extended template increases the number of nodes removed and the lymph node positivity rate. Findings from this systematic review suggest (1) the potential benefits of PLND outweigh its morbidity, (2) limited PLND
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