Investig Clin Urol.  2016 Dec;57(Suppl 2):S155-S164. 10.4111/icu.2016.57.S2.S155.

Current technique and results for extended pelvic lymph node dissection during robot-assisted radical prostatectomy

Affiliations
  • 1Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. johndavis@mdanderson.org
  • 2Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, TX, USA.

Abstract

The practice of extended pelvic lymph node dissection (ePLND) remains one of the most controversial topics in the management of clinically localized prostate cancer. Although most urologists agree on its benefit for staging and prognostication, the role of the ePLND in cancer control continues to be debated. The increased perioperative morbidity makes it unpalatable, especially in patients with low likelihood of lymph node disease. With the advent of robotic assisted laparoscopic prostatectomy, many surgeons were slow to adopt ePLND in the robotic setting. In this study, we summarize the evidence for the prognostic and therapeutic roles of ePLND, review the clinical tools used for lymph node metastasis prediction and survey the numerous experiences of ePLND compiled by robotic urologic surgeons over the years.

Keyword

Lymph node excision; Prostate neoplasms; Prostatectomy; Robotic surgical procedures

MeSH Terms

Humans
Lymph Node Excision*
Lymph Nodes*
Neoplasm Metastasis
Prostatectomy*
Prostatic Neoplasms
Robotic Surgical Procedures
Surgeons

Figure

  • Fig. 1 For a left side extended pelvic lymph node dissection, the space of Retzius is opened and the urachus left intact to facilitate exposure of the hypogastric planes. The third arm grasper (top) will push the urachus up and contralaterally to facilitate exposure. Scan this QR code to see the accompanying video, or visit http://www.icurology.org or https://youtu.be/4Pyz8FBB7Jg.

  • Fig. 2 The hypogastric (HG) identified from the takeoff from the external iliac (Ex Il) and cleared medially above and under the obliterated (OB) branch including the sub-branches headed medially towards the bladder. These areas often have to come out separately from the larger en bloc nodes from the iliac/obturator spaces. Scan this QR code to see the accompanying video, or visit http://www.icurology.org or https://youtu.be/vsLNewh99-o.

  • Fig. 3 The Triangle Marcille is an important space to clear. It can be accessed between the external iliac artery and vein (A) or lateral to the external iliac artery (B). The obturator nerve (B; at tip of scissors) should be identified and the surround lymphatics become the proximal extent of dissection. Scan this QR code to see the accompanying video, or visit http://www.icurology.org or https://youtu.be/OTGMRWOb1W8.

  • Fig. 4 Completed right side dissection: 1, obliterated branch; 2, obturator nerve; 3, hypogastric artery; 4, external iliac vein; 5, external iliac artery; 6, pelvic side wall.


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