Elsevier

European Urology

Volume 65, Issue 1, January 2014, Pages 7-16
European Urology

Platinum Priority – Collaborative Review – Prostate Cancer
Editorial by Alexandre Mottrie and Alessandro Volpe on pp. 17–19 of this issue
Pelvic Lymph Node Dissection During Robot-assisted Radical Prostatectomy: Efficacy, Limitations, and Complications—A Systematic Review of the Literature

https://doi.org/10.1016/j.eururo.2013.03.057Get rights and content

Abstract

Context

Pelvic lymph node dissection (PLND) in prostate cancer is the most effective method for detecting lymph node metastases. However, a decline in the rate of PLND during radical prostatectomy (RP) has been noted. This is likely the result of prostate cancer stage migration in the prostate-specific antigen-screening era, and the introduction of minimally invasive approaches such as robot-assisted radical prostatectomy (RARP).

Objective

To assess the efficacy, limitations, and complications of PLND during RARP.

Evidence acquisition

A review of the literature was performed using the Medline, Scopus, and Web of Science databases with no restriction of language from January 1990 to December 2012. The literature search used the following terms: prostate cancer, radical prostatectomy, robot-assisted, and lymph node dissection.

Evidence synthesis

The median value of nodal yield at PLND during RARP ranged from 3 to 24 nodes. As seen in open and laparoscopic RP series, the lymph node positivity rate increased with the extent of dissection during RARP. Overall, PLND-only related complications are rare. The most frequent complication after PLND is symptomatic pelvic lymphocele, with occurrence ranging from 0% to 8% of cases. The rate of PLND-associated grade 3–4 complications ranged from 0% to 5%. PLND is associated with increased operative time. Available data suggest equivalence of PLND between RARP and other surgical approaches in terms of nodal yield, node positivity, and intraoperative and postoperative complications.

Conclusions

PLND during RARP can be performed effectively and safely. The overall number of nodes removed, the likelihood of node positivity, and the types and rates of complications of PLND are similar to pure laparoscopic and open retropubic procedures.

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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