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Kato M, Shiota M, Kimura T, Hanazawa R, Hirakawa A, Takamatsu D, Tashiro K, Matsui Y, Hashine K, Saito R, Yokomizo A, Yamamoto Y, Narita S, Hashimoto K, Matsumoto H, Akamatsu S, Nishiyama N, Eto M, Kitamura H, Tsuzuki T. Validation study on the 2 mm diameter cutoff in lymph node-positive cases following radical prostatectomy in accordance with the AJCC/UICC TNM 8th edition: Real-world data analysis from a Japanese cohort. Int J Urol 2024; 31:662-669. [PMID: 38424729 DOI: 10.1111/iju.15434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES The American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) 8th edition has proposed micrometastasis as a lymph node metastasis (LN+) of diameter ≤2 mm in prostate cancer. However, supporting evidence has not described. We evaluated LN+ patients' survival after radical prostatectomy (RP) based on the LN maximum tumor diameter (MTD). METHODS Data from 561 LN+ patients after RP and pelvic LN dissection (PLND) treated between 2006 and 2019 at 33 institutions were retrospectively investigated. Patients were stratified by a LN+ MTD cutoff of 2 mm. Outcomes included castration resistance-free survival (CRFS), metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS). RESULTS In total, 282 patients were divided into two groups (LN+ MTD >2 mm [n = 206] and ≤2 mm [n = 76]). Patients of LN+ status >2 mm exhibited significantly decreased CRFS and MFS, and poorer CSS and OS. No patients developed CRPC in the LN+ status ≤2 mm group when the PLND number was ≥14. Multivariate analysis showed the number of LN removed, RP Gleason pattern 5, and MTD in LN+ significantly predicted CRFS. CONCLUSIONS Patients of LN+ status ≤2 mm showed better prognoses after RP. In all the patients in the ≤2-mm group, the progression to CRPC could be prevented with appropriate interventions, particularly when PLND is performed accurately. Our findings support the utility of the pN substaging proposed by the AJCC/UICC 8th edition; this will facilitate precision medicine for patients with advanced prostate cancer.
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Affiliation(s)
- Masashi Kato
- Department of Urology, Nagoya University, Nagoya, Japan
| | - Masaki Shiota
- Department of Urology, Kyushu University, Fukuoka, Japan
| | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryoichi Hanazawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Dai Takamatsu
- Department of Urology, Kyushu University, Fukuoka, Japan
| | - Kojiro Tashiro
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshiyuki Matsui
- Department of Urology, National Cancer Center Hospital, Tokyo, Japan
| | - Katsuyoshi Hashine
- Department of Urology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Ryoichi Saito
- Department of Urology and Andrology, Kansai Medical University, Osaka, Japan
| | - Akira Yokomizo
- Department of Urology, Harasanshin Hospital, Fukuoka, Japan
| | - Yoshiyuki Yamamoto
- Department of Urology, Osaka International Cancer Institute, Osaka, Japan
| | | | - Kohei Hashimoto
- Department of Urology, Sapporo Medical University, Sapporo, Japan
| | | | | | | | - Masatoshi Eto
- Department of Urology, Kyushu University, Fukuoka, Japan
| | | | - Toyonori Tsuzuki
- Department of Surgical Pathology, Aichi Medical University, Nagakute, Japan
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Goßler C, May M, Weikert S, Lenart S, Ponholzer A, Dreissig C, Stojanoski G, Anzinger I, Riester J, Burger M, Gilfrich C, Mayr R, Bründl J. Long-Term Follow-Up of Peritoneal Interposition Flap in Symptomatic Lymphocele Reduction following Robot-Assisted Radical Prostatectomy: Insights from the PIANOFORTE Trial. Cancers (Basel) 2024; 16:1932. [PMID: 38792010 PMCID: PMC11119833 DOI: 10.3390/cancers16101932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/09/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024] Open
Abstract
The available randomised controlled trials (RCTs) assessing the influence of peritoneal interposition flaps (PIF) on the reduction of symptomatic lymphoceles (sLCs) post robot-assisted radical prostatectomy (RARP) do not constitute a sufficient follow-up (FU) to assess the long-term effects. The PIANOFORTE trial was the first of these RCTs, showing no sLC reduction at the 3-month FU. Therefore, all 232 patients from the PIANOFORTE trial were invited for long-term FU. One hundred seventy-six patients (76%) presented themselves for FU and constituted the study group (SG). The median FU duration was 43 months. No significant differences in group allocation or LC endpoints at 90 days were observed between SG patients and patients not presenting themselves for the FU. During the FU period, four patients (2.3%) in the SG developed sLCs, and six patients (3.4%) developed asymptomatic lymphoceles (aLCs), which persisted in five patients (2.9%). There were no significant differences between PIF and non-PIF regarding sLC/aLC formation or persistence, newly developed complications, stress urinary incontinence or biochemical/clinical tumour recurrence. Therefore, this long-term FU confirms the primary outcomes of the PIANOFORTE trial that, while PIF does not impact complications or functionality, it does not reduce sLC/aLC rates. Furthermore, it shows the potential occurrence of LC after the third postoperative month.
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Affiliation(s)
- Christopher Goßler
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, 93053 Regensburg, Germany; (J.R.); (M.B.); (R.M.); (J.B.)
| | - Matthias May
- Department of Urology, St. Elisabeth Hospital Straubing, Brothers of Mercy Hospital, 94315 Straubing, Germany; (M.M.); (C.G.)
| | - Steffen Weikert
- Department of Urology, Alexianer Hospital St. Hedwig, 10115 Berlin, Germany; (S.W.); (C.D.)
| | - Sebastian Lenart
- Department of Urology and Andrology, St. John of God Hospital Vienna, Brothers of Mercy Hospital, 1020 Vienna, Austria; (S.L.); (A.P.)
| | - Anton Ponholzer
- Department of Urology and Andrology, St. John of God Hospital Vienna, Brothers of Mercy Hospital, 1020 Vienna, Austria; (S.L.); (A.P.)
| | - Christina Dreissig
- Department of Urology, Alexianer Hospital St. Hedwig, 10115 Berlin, Germany; (S.W.); (C.D.)
| | - Gjoko Stojanoski
- Department of Urology, Varisano Hospital Frankfurt Höchst, 65929 Frankfurt am Main, Germany;
| | - Isabel Anzinger
- Department of Urology, Mallersdorf Hospital, 84066 Mallersdorf, Germany;
| | - Josef Riester
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, 93053 Regensburg, Germany; (J.R.); (M.B.); (R.M.); (J.B.)
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, 93053 Regensburg, Germany; (J.R.); (M.B.); (R.M.); (J.B.)
| | - Christian Gilfrich
- Department of Urology, St. Elisabeth Hospital Straubing, Brothers of Mercy Hospital, 94315 Straubing, Germany; (M.M.); (C.G.)
| | - Roman Mayr
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, 93053 Regensburg, Germany; (J.R.); (M.B.); (R.M.); (J.B.)
| | - Johannes Bründl
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, 93053 Regensburg, Germany; (J.R.); (M.B.); (R.M.); (J.B.)
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Gamal A, Moschovas MC, Jaber AR, Saikali S, Sandri M, Patel E, Patel E, Rogers T, Patel V. Peritoneal Flap Following Lymph Node Dissection in Robotic Radical Prostatectomy: A Novel "Bunching" Technique. Cancers (Basel) 2024; 16:1547. [PMID: 38672629 PMCID: PMC11049471 DOI: 10.3390/cancers16081547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Pelvic lymph node dissection (PLND) is recommended while performing robot-assisted radical prostatectomy (RARP) for patients with localized intermediate or high-risk prostate cancer. However, symptomatic lymphoceles can occur after surgery, adding significant morbidity to patients. Our objective is to describe a novel Peritoneal Bladder Flap Bunching technique (PBFB) to reduce the risk of clinically significant lymphoceles in patients undergoing RARP and PLND. METHODS We evaluated 2267 patients who underwent RARP with PLND, dividing them into two groups: Group 1, comprising 567 patients who had the peritoneal flap (PBFB), and Group 2, comprising 1700 patients without the flap; propensity score matching carried out at a 1:3 ratio. Variables analyzed included estimated blood loss (EBL), operative time, postoperative complications, lymphocele formation, and the development of symptomatic lymphocele. RESULTS The two groups exhibited similar preoperative characteristics after matching. There was no statistically significant difference in the occurrence of lymphoceles between the flap group and the non-flap group, with rates of 24% and 20.9%, respectively (p = 0.14). However, none of the patients in the flap group (0%) developed symptomatic lymphoceles, whereas 2.2% of patients in the non-flap group experienced symptomatic lymphoceles (p = 0.01). CONCLUSION We have demonstrated a modified technique for a peritoneal flap (PBFB) with the initial elimination of postoperative symptomatic lymphoceles and promising short-term outcomes.
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Affiliation(s)
- Ahmed Gamal
- AdventHealth Global Robotics Institute, Celebration, FL 34747, USA (A.R.J.)
| | - Marcio Covas Moschovas
- AdventHealth Global Robotics Institute, Celebration, FL 34747, USA (A.R.J.)
- Urology Department, University of Central Florida (UCF), Orlando, FL 32816, USA
| | - Abdel Rahman Jaber
- AdventHealth Global Robotics Institute, Celebration, FL 34747, USA (A.R.J.)
| | - Shady Saikali
- AdventHealth Global Robotics Institute, Celebration, FL 34747, USA (A.R.J.)
| | - Marco Sandri
- Big and Open Data Innovation Laboratory (BODaI-Lab) and Data Methods and Systems Statistical, 25123 Brescia, Italy;
| | - Ela Patel
- Stanford University, Palo Alto, CA 94305, USA
| | - Evan Patel
- AdventHealth Global Robotics Institute, Celebration, FL 34747, USA (A.R.J.)
| | - Travis Rogers
- AdventHealth Global Robotics Institute, Celebration, FL 34747, USA (A.R.J.)
| | - Vipul Patel
- AdventHealth Global Robotics Institute, Celebration, FL 34747, USA (A.R.J.)
- Urology Department, University of Central Florida (UCF), Orlando, FL 32816, USA
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Hinojosa-González DE, Saffati G, Kronstedt S, La T, Chiu C, Wahlstedt E, Jones JA, Kadmon D, Badal J, Taylor JM, Slawin JR. Comparison of peritoneal interposition flaps and sealants for prevention of lymphocele after robotic radical prostatectomy and pelvic lymph node dissection: a systematic review, meta-analysis, Bayesian network meta-analysis, and meta-regression. J Robot Surg 2024; 18:177. [PMID: 38630430 DOI: 10.1007/s11701-024-01918-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/19/2024] [Indexed: 04/19/2024]
Abstract
Lymphocele is one of the most common complications after radical prostatectomy. Multiple authors have proposed the use of vessel sealants or peritoneal interposition techniques as preventive interventions. This study aimed to aggregate and analyze the available literature on different interventions which seek to prevent lymphocele through a Bayesian Network. A systematic review was performed to identify prospective studies evaluating strategies for lymphocele prevention after robot assisted laparoscopic prostatectomy + pelvic lymph node dissection. Data was inputted into Review Manager 5.4 for pairwise meta-analysis. Data was then used to build a network in R Studio. These networks were used to model 200,000 Markov Chains via MonteCarlo sampling. The results are expressed as odds ratios (OR) with 95% credible intervals (CrI). Meta-regression was used to determine coefficient of change and adjust for pelvic lymph node dissection extent. Ten studies providing data from 2211 patients were included. 1097 patients received an intervention and 1114 patients served as controls. Interposition with fenestration had the lowest risk of developing a lymphocele (OR 0.14 [0.04, 0.50], p = 0.003). All interventions, except sealants or patches, had significant decreased odds of lymphocele rates. Meta-analysis of all the included studies showed a decreased risk of developing a lymphocele (OR 0.42 [0.33, 0.53], p < 0.00001) for the intervention group. Perivesical fixation and interposition with fenestration appear to be effective interventions for reducing the overall incidence of lymphocele.
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Affiliation(s)
- David E Hinojosa-González
- Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge St., Floor 10, Suite C, Houston, TX, 77030, USA.
| | - Gal Saffati
- Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge St., Floor 10, Suite C, Houston, TX, 77030, USA
| | - Shane Kronstedt
- Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge St., Floor 10, Suite C, Houston, TX, 77030, USA
| | - Troy La
- Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge St., Floor 10, Suite C, Houston, TX, 77030, USA
| | | | - Eric Wahlstedt
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - Jeffrey A Jones
- Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge St., Floor 10, Suite C, Houston, TX, 77030, USA
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Dov Kadmon
- Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge St., Floor 10, Suite C, Houston, TX, 77030, USA
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Justin Badal
- Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge St., Floor 10, Suite C, Houston, TX, 77030, USA
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Jennifer M Taylor
- Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge St., Floor 10, Suite C, Houston, TX, 77030, USA
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Jeremy R Slawin
- Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge St., Floor 10, Suite C, Houston, TX, 77030, USA
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
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Roshan A, Shah B, Anderson KD, Murphy S, Thomas B, McPhee AS, Lamb BW, Durrani AJ, Patel AJK. Robot-Assisted Pelvic Dissection for Enlarged Lymph Nodes in Melanoma Improves Recovery with Equivalent Oncological Outcomes to Open Pelvic Dissection. Ann Surg Oncol 2024; 31:2727-2736. [PMID: 38177461 PMCID: PMC10908615 DOI: 10.1245/s10434-023-14834-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/08/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Robot-assisted pelvic lymph node dissection (rPLND) has been reported in heterogenous groups of patients with melanoma, including macroscopic or at-high-risk-for microscopic metastasis. With changing indications for surgery in melanoma, and availability of effective systemic therapies, pelvic dissection is now performed for clinically detected bulky lymph node metastasis followed by adjuvant drug therapy. rPLND has not been compared with open pelvic lymph node dissection (oPLND) for modern practice. METHODS All patients undergoing pelvic node dissection for macroscopic melanoma at a single institution were reviewed as a cohort, observational study. RESULTS Twenty-two pelvic lymph node dissections were identified (8 oPLND; 14 rPLND). The number of pelvic lymph nodes removed was similar (median oPLND 6.5 (interquartile range [IQR] 6.0-12.5] versus rPLND 6.0 [3.75-9.0]), with frequent matted nodes (11/22, 50.0%). Operative time (median oPLND 130 min [IQR 95.5-182] versus rPLND 126 min [IQR 97.8-160]) and complications (Clavien-Dindo scale) were similar. Length of hospital stay (median 5.34 days (IQR 3.77-6.94) versus 1.98 days (IQR 1.39-3.50) and time to postoperative adjuvant therapy (median 11.6 weeks [IQR 10.6-18.5] versus 7.71 weeks [IQR 6.29-10.4]) were shorter in the rPLND group. No differences in pelvic lymph node recurrence (p = 0.984), distant metastatic recurrence (p = 0.678), or melanoma-specific survival (p = 0.655) were seen (median follow-up 21.1 months [rPLND] and 25.7 months [oPLND]). CONCLUSIONS rPLND is an effective way to remove bulky pelvic lymph nodes in melanoma, with a shorter recovery and reduced interval to initiating adjuvant therapy compared with oPLND. This group of patients may especially benefit from neoadjuvant systemic approaches to management.
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Affiliation(s)
- Amit Roshan
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK.
- Department of Plastic Surgery, Cambridge University Hospitals NHS Trust, Cambridge, UK.
| | - Bhumi Shah
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Keith D Anderson
- Department of Plastic Surgery, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Suzanne Murphy
- Department of Plastic Surgery, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Benjamin Thomas
- Department of Urology, Cambridge University Hospitals NHS Trust, Cambridge, UK
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne and International Medical Robotics Academy, Melbourne, VIC, Australia
| | - Arthur S McPhee
- Department of Urology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Benjamin W Lamb
- Department of Urology, Cambridge University Hospitals NHS Trust, Cambridge, UK
- Department of Urology, Barts Health NHS Trust, Barts Cancer Institute, Queen Mary University of London and University College London Hospitals, London, UK
| | - Amer J Durrani
- Department of Plastic Surgery, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Animesh J K Patel
- Department of Plastic Surgery, Cambridge University Hospitals NHS Trust, Cambridge, UK
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Albo G, Gallioli A, Ripa F, De Lorenzis E, Boeri L, Bebi C, Rocchini L, Longo F, Zanetti SP, Turetti M, Piccoli M, Montanari E. Extended pelvic lymph node dissection during robotic prostatectomy: antegrade versus retrograde technique. BMC Urol 2024; 24:64. [PMID: 38515053 PMCID: PMC10958886 DOI: 10.1186/s12894-024-01448-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Robot-assisted radical prostatectomy (RARP) with extended lymphadenectomy (ePLND) is the gold standard for surgical treatment of prostate cancer (PCa). Recently, the en-bloc ePLND has been proposed but no studies reported on the standardization of the technique. The aim of the study is to describe different standardized en-bloc ePLND, the antegrade and the retrograde ePLND, and to compare their surgical and oncological outcomes. MATERIALS & METHODS From January 2018 to September 2019, all patients subjected to RARP plus ePLND by one single surgeon were enrolled. ePLND was performed in a retrograde fashion by starting laterally to the medial umbilical ligament from the internal inguinal ring proceeding towards the ureter, or in an antegrade way by starting from the ureter at its crossing with the common iliac artery and proceeding towards the femoral canal. Patients' demographic data, clinical and surgical data were collected. Each en-bloc ePLND was categorized as "efficient" or "inefficient" by the operator, as surrogate of surgeon's satisfaction. RESULTS Antegrade and retrograde ePLND were performed in 41/105 (group A) and 64/105 (group R) patients, respectively. The two groups (A vs R) had similar median (IQR) number of lymph nodes retrieved [20 (16.25-31.5) vs 19 (15-26.25); p = 0.18], ePLND time [33.5 (29.5-38.5) min vs 33.5 (26.5-37.5) min; p = 0.4] and post-operative complications [8/41 (19.5%) vs 9/64 (14.1%); p = 0.61]. In group A, 3/41 (7.3%) clinically significant lymphoceles were reported, while 1/64 (1.6%) in group R (p = 0.3). 33/41 (80.5%) and 28/64 (44%) procedures were scored as efficient 59 in group A and R, respectively (p = 0.01). On multivariate regression, only BMI (B = 0.93; 95% CI 0.29-1.56; p = 0.005) was associated with a longer ePLND time. CONCLUSIONS The study indicates that antegrade and retrograde en-bloc extended pelvic lymph node dissection (ePLND) have comparable surgical and oncologic outcomes, supporting the importance of standardizing the procedure rather than focusing on the direction. Although both techniques aligned with current evidence regarding lymph node invasion and complications, the antegrade approach was subjectively perceived as safer due to early isolation of critical anatomical landmarks. Encouragement for the use of en-bloc ePLND, regardless of direction, is emphasized to improve prostate cancer staging accuracy and procedural standardization.
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Affiliation(s)
- Giancarlo Albo
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
- Department of Urology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Andrea Gallioli
- Department of Urology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Urology, Fundació Puigvert, Barcelona, Spain
| | - Francesco Ripa
- Department of Urology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Urology, Whittington Health NHS Trust, London, UK
| | - Elisa De Lorenzis
- Department of Urology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Boeri
- Department of Urology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Carolina Bebi
- Department of Urology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Paediatric Urology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Lorenzo Rocchini
- Department of Urology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Cantonal Hospital Entity Regional Hospital of Bellinzona and Valleys (ORBV) A., Gallino Street 12, CH-6500, Bellinzona, Switzerland
| | - Fabrizio Longo
- Department of Urology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Paolo Zanetti
- Department of Urology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Turetti
- Department of Urology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Michela Piccoli
- Department of Urology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Emanuele Montanari
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Urology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
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Dong B, Zhan H, Luan T, Wang J. The role and controversy of pelvic lymph node dissection in prostate cancer treatment: a focused review. World J Surg Oncol 2024; 22:68. [PMID: 38403658 PMCID: PMC10895790 DOI: 10.1186/s12957-024-03344-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/14/2024] [Indexed: 02/27/2024] Open
Abstract
Pelvic lymph node dissection (PLND) is commonly performed alongside radical prostatectomy. Its primary objective is to determine the lymphatic staging of prostate tumors by removing lymph nodes involved in lymphatic drainage. This aids in guiding subsequent treatment and removing metastatic foci, potentially offering significant therapeutic benefits. Despite varying recommendations from clinical practice guidelines across countries, the actual implementation of PLND is inconsistent, partly due to debates over its therapeutic value. While high-quality evidence supporting the superiority of PLND in oncological outcomes is lacking, its role in increasing surgical time and risk of complications is well-recognized. Despite these concerns, PLND remains the gold standard for lymph node staging in prostate cancer, providing invaluable staging information unattainable by other techniques. This article reviews PLND's scope, guideline perspectives, implementation status, oncologic and non-oncologic outcomes, alternatives, and future research needs.
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Affiliation(s)
- Baonan Dong
- Urology Surgery Department, The Second Affiliated Hospital of Kunming Medical University, 243 Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Hui Zhan
- Urology Surgery Department, The Second Affiliated Hospital of Kunming Medical University, 243 Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China.
| | - Ting Luan
- Urology Surgery Department, The Second Affiliated Hospital of Kunming Medical University, 243 Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Jiansong Wang
- Urology Surgery Department, The Second Affiliated Hospital of Kunming Medical University, 243 Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
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Farzat M, Wagenlehner FM. How Might the Number of Lymph Nodes Removed during RARP Impact the Postoperative Outcomes? Urol Int 2024; 108:175-182. [PMID: 38316122 DOI: 10.1159/000536317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/03/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Symptomatic lymphocele remains a relevant complication after pelvic tumor surgery. This study aims to investigate how the number of lymph nodes removed may influence postoperative outcomes and if it increases the probability of detecting lymph node metastasis. METHODS The study included 500 patients who underwent RARP including lymphadenectomy performed by a single surgeon. Patients were divided into two groups: group 1 consisted of 308 patients with 20 or fewer lymph nodes removed (mean 15), while group 2 had 192 patients with over 20 nodes removed (mean 27). Perioperative data were analyzed, and postoperative outcomes were compared between groups. RESULTS Overall, lymph node metastasis was detected in 17.8% of men. In detail, out of 19.6 lymph nodes removed, an average of 3.14 lymph nodes per patient showed metastasis, with a slightly higher incidence of 19.7% in group 2 compared to 16.5% in group 1, though not statistically significant (p = 0.175). The number of lymph node metastases was significantly higher in group 2 patients (3.47) versus group 1 (2.37) (p = 0.048). All complications except symptomatic lymphoceles (p = 0.004) were not significantly different between groups. Univariate linear regression analysis revealed no correlation between the number of removed lymph nodes and symptomatic lymphocele. However, it did correlate with catheter days and readmissions. CONCLUSION A correlation may exist between the number of lymph nodes removed during RARP and an increased incidence of complications, particularly symptomatic lymphocele. A more extensive PLND may result in prolonged catheter days and increased readmissions. With the increased extent of pelvic lymphadenectomy, the probability of detecting lymphogenic metastasis rises. The diagnostic value of PLND is well established. Further randomized trials are needed to weigh its necessity and extent.
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Affiliation(s)
- Mahmoud Farzat
- Department of Urology and Robotic Urology, Diakonie Klinikum Siegen, Siegen, Germany
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University of Giessen, Giessen, Germany
| | - Florian M Wagenlehner
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University of Giessen, Giessen, Germany
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Sigg S, Lehner F, Keller EX, Saba K, Moch H, Sulser T, Eberli D, Mortezavi A. Outcomes of robot-assisted laparoscopic extended pelvic lymph node dissection for prostate Cancer. BMC Urol 2024; 24:24. [PMID: 38287319 PMCID: PMC10823685 DOI: 10.1186/s12894-024-01409-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 01/16/2024] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Extended pelvic lymph node dissection (ePLND) in men undergoing robot-assisted laparoscopic radical prostatectomy (RARP) is a widely used procedure. However, little is known about anatomical site-specific yields and subsequent metastatic patterns in these patients. PATIENTS AND METHODS Data on a consecutive series of 1107 patients undergoing RARP at our centre between 2004 and 2018 were analysed. In men undergoing LN dissection, the internal, external and obturator nodes were removed and sent in separately. We performed an analysis of LN yields in total and for each anatomical zone, patterns of LN metastases and complications. Oncological outcome in pN+ disease was assessed including postoperative PSA persistence and survival. RESULTS A total of 823 ePLNDs were performed in the investigated cohort resulting in 98 men being diagnosed as pN+ (8.9%). The median (IQR) LN yield was 19 (14-25), 10 (7-13) on the right and 9 (6-12) on the left side (P < 0.001). A median of six (4-8) LNs were retrieved from the external, three (1-6) from the internal iliac artery, and eight (6-12) from the obturator fossa. More men had metastatic LNs on the right side compared to the left (41 vs. 19). Symptomatic lymphoceles occurred exclusively in the ePLND group (2.3% vs. 0%, p = 0.04). Postoperatively, 47 (47.9%) of men with pN+ reached a PSA of < 0.1μg/ml. There was no association between a certain pN+ region and postoperative PSA persistence or BCRFS. The estimated cancer specific survival rate at 5 years was 98.5% for pN+ disease. CONCLUSION Robot-assisted laparoscopic ePLND with a high LN yield and low complication rate is feasible. However, we observed an imbalance in more removed and positive LNs on the right side compared to the left. A high rate of postoperative PSA persistence and early recurrence in pN+ patients might indicate a possibly limited therapeutical value of the procedure in already spread disease. Yet, these men demonstrated an excellent survival.
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Affiliation(s)
- Silvan Sigg
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Fabienne Lehner
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Etienne Xavier Keller
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Karim Saba
- Urologiezentrum Hirslanden, Hirslanden Klinik Aarau, Aarau, Switzerland
| | - Holger Moch
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Tullio Sulser
- Department of Urology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel Eberli
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ashkan Mortezavi
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
- Department of Urology, University Hospital Basel, University of Basel, Basel, Switzerland.
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
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May M, Gilfrich C, Bründl J, Ubrig B, Wagner JR, Gloger S, Student V, Merseburger AS, Thomas C, Brookman-May SD, Wolff I. Impact of Peritoneal Interposition Flap on Patients Undergoing Robot-assisted Radical Prostatectomy and Pelvic Lymph Node Dissection: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Eur Urol Focus 2024; 10:80-89. [PMID: 37541915 DOI: 10.1016/j.euf.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/02/2023] [Accepted: 07/24/2023] [Indexed: 08/06/2023]
Abstract
CONTEXT Symptomatic lymphocele (sLC) occurs at a frequency of 2-10% after robot-assisted radical prostatectomy (RARP) with pelvic lymph node dissection (PLND). Construction of bilateral peritoneal interposition flaps (PIFs) subsequent to completion of RARP + PLND has been introduced to reduce the risk of lymphocele, and was initially evaluated on the basis of retrospective studies. OBJECTIVE To conduct a systematic review and meta-analysis of only randomized controlled trials (RCTs) evaluating the impact of PIF on the rate of sLC (primary endpoint) and of overall lymphocele (oLC) and Clavien-Dindo grade ≥3 complications (secondary endpoints) to provide the best available evidence. EVIDENCE ACQUISITION In accordance with the Preferred Reporting Items for Meta-Analyses statement for observational studies in epidemiology, a systematic literature search using the MEDLINE (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE databases up to February 3, 2023 was performed to identify RCTs. The risk of bias (RoB) was assessed using the revised Cochrane RoB tool for randomized trials. Meta-analysis used random-effect models to examine the impact of PIF on the primary and secondary endpoints. EVIDENCE SYNTHESIS Four RCTs comparing outcomes for patients undergoing RARP + PLND with or without PIF were identified: PIANOFORTE, PerFix, ProLy, and PLUS. PIF was associated with odds ratios of 0.46 (95% confidence interval [CI] 0.23-0.93) for sLC, 0.51 (95% CI 0.38-0.68) for oLC, and 0.41 (95% CI 0.21-0.83) for Clavien-Dindo grade ≥3 complications. Functional impairment resulting from PIF construction was not observed. Heterogeneity was low to moderate, and RoB was low. CONCLUSIONS PIF should be performed in patients undergoing RARP and simultaneous PLND to prevent or reduce postoperative sLC. PATIENT SUMMARY A significant proportion of patients undergoing prostate cancer surgery have regional lymph nodes removed. This part of the surgery is associated with a risk of postoperative lymph collections (lymphocele). The risk of lymphocele can be halved via a complication-free surgical modification called a peritoneal interposition flap.
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Affiliation(s)
- Matthias May
- Department of Urology, St. Elisabeth Hospital Straubing, Brothers of Mercy Hospital, Straubing, Germany.
| | - Christian Gilfrich
- Department of Urology, St. Elisabeth Hospital Straubing, Brothers of Mercy Hospital, Straubing, Germany
| | - Johannes Bründl
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Burkhard Ubrig
- Center for Minimally Invasive and Robotic Urology, Augusta Hospital Bochum, Witten/Herdecke University, Bochum, Germany
| | - Joseph R Wagner
- Urology Division, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT, USA
| | - Simon Gloger
- Center for Minimally Invasive and Robotic Urology, Augusta Hospital Bochum, Witten/Herdecke University, Bochum, Germany
| | - Vladimir Student
- Department of Urology, University Hospital Olomouc, Olomouc, Czechia
| | - Axel S Merseburger
- Department of Urology, University Hospital Schleswig-Holstein, Luebeck, Germany
| | - Christian Thomas
- Department of Urology, University Hospital Carl Gustav Carus, University Hospital of the Technical University of Dresden, Dresden, Germany
| | - Sabine D Brookman-May
- Department of Urology, Campus Grosshadern, Ludwig-Maximilians University, Munich, Germany; Janssen Pharma Research and Development, Spring House, PA, USA
| | - Ingmar Wolff
- Department of Urology, University Medicine Greifswald, Greifswald, Germany
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11
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Franco A, Ditonno F, Manfredi C, Johnson AD, Mamgain A, Feldman-Schultz O, Feng CL, Pellegrino AA, Mir MC, Porpiglia F, Crivellaro S, De Nunzio C, Chow AK, Autorino R. Robot-assisted Surgery in the Field of Urology: The Most Pioneering Approaches 2015-2023. Res Rep Urol 2023; 15:453-470. [PMID: 37842031 PMCID: PMC10575039 DOI: 10.2147/rru.s386025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/30/2023] [Indexed: 10/17/2023] Open
Abstract
Robot-assisted surgery has emerged as a transformative technology, revolutionizing surgical approaches and techniques that decades ago could barely be imagined. The field of urology has taken charge in pioneering a new era of minimally invasive surgery with the ascent of robotic systems which offer enhanced visualization, precision, dexterity, and enabling surgeons to perform intricate maneuvers with improved accuracy. This has led to improved surgical outcomes, including reduced blood loss, lower complication rates, and faster patient recovery. The aim of our review is to present an evidence-based critical analysis on the most pioneering robotic urologic approaches described over the last eight years (2015-2023).
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Affiliation(s)
- Antonio Franco
- Department of Urology, Rush University, Chicago, IL, USA
- Department of Urology, Sant’Andrea Hospital, Sapienza University, Rome, Italy
| | - Francesco Ditonno
- Department of Urology, Rush University, Chicago, IL, USA
- Department of Urology, University of Verona, Verona, Italy
| | - Celeste Manfredi
- Department of Urology, Rush University, Chicago, IL, USA
- Urology Unit, “Luigi Vanvitelli” University, Naples, Italy
| | | | | | | | - Carol L Feng
- Department of Urology, Rush University, Chicago, IL, USA
| | - Antony A Pellegrino
- Department of Urology, University of Illinois at Chicago, Chicago, Illinois, USA
- Unit of Urology/Division of Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Carmen Mir
- Department of Urology, Hospital Universitario La Ribera, Valencia, Spain
| | - Francesco Porpiglia
- Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Simone Crivellaro
- Department of Urology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Cosimo De Nunzio
- Department of Urology, Sant’Andrea Hospital, Sapienza University, Rome, Italy
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12
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Li Y, Ding J, Zheng H, Xu L, Li W, Zhu M, Zhang X, Ma C, Zhang F, Zhong P, Liang D, Han Y, Zhang S, He L, Li J. Speculation on optimal numbers of examined lymph node for early-stage epithelial ovarian cancer from the perspective of stage migration. Front Oncol 2023; 13:1265631. [PMID: 37810975 PMCID: PMC10556677 DOI: 10.3389/fonc.2023.1265631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 08/24/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction In early-stage epithelial ovarian cancer (EOC), how to perform lymphadenectomy to avoid stage migration and achieve reliable targeted excision has not been explored in depth. This study comprehensively considered the stage migration and survival to determine appropriate numbers of examined lymph node (ELN) for early-stage EOC and high-grade serous ovarian cancer (HGSOC). Methods From the Surveillance, Epidemiology, and End Results database, we obtained 10372 EOC cases with stage T1M0 and ELN ≥ 2, including 2849 HGSOC cases. Generalized linear models with multivariable adjustment were used to analyze associations between ELN numbers and lymph node stage migration, survival and positive lymph node (PLN). LOESS regression characterized dynamic trends of above associations followed by Chow test to determine structural breakpoints of ELN numbers. Survival curves were plotted using Kaplan-Meier method. Results More ELNs were associated with more node-positive diseases, more PLNs and better prognosis. ELN structural breakpoints were different in subgroups of early-stage EOC, which for node stage migration or PLN were more than those for improving outcomes. The meaning of ELN structural breakpoint varied with its location and the morphology of LOESS curve. To avoid stage migration, the optimal ELN for early-stage EOC was 29 and the minimal ELN for HGSOC was 24. For better survival, appropriate ELN number were 13 and 8 respectively. More ELNs explained better prognosis only at a certain range. Discussion Neither too many nor too few numbers of ELN were ideal for early-stage EOC and HGSOC. Excision with appropriate numbers of lymph node draining the affected ovary may be more reasonable than traditional sentinel lymph node resection and systematic lymphadenectomy.
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Affiliation(s)
- Yuan Li
- Department of Obstetrics and Gynecology, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Jiashan Ding
- Department of Gynecological Oncology, Xiangya Hospital Central South University, Central South University, Changsha, Hunan, China
| | - Huimin Zheng
- Department of Obstetrics and Gynecology, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Lijiang Xu
- Department of Obstetrics and Gynecology, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Weiru Li
- Department of Obstetrics and Gynecology, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Minshan Zhu
- Department of Obstetrics and Gynecology, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Xiaolu Zhang
- Department of Obstetrics and Gynecology, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Cong Ma
- Department of Obstetrics and Gynecology, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Fangying Zhang
- Department of Obstetrics and Gynecology, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Peiwen Zhong
- Department of Obstetrics and Gynecology, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Dong Liang
- Department of Obstetrics and Gynecology, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Yubin Han
- Department of Obstetrics and Gynecology, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Siyou Zhang
- Department of Obstetrics and Gynecology, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Linsheng He
- Department of Gynecologic Oncology, Jiangxi Maternal and Child Health Hospital, Nanchang Medical College, Nanchang, Jiangxi, China
| | - Jiaqi Li
- Department of Gynecologic Oncology, Jiangxi Maternal and Child Health Hospital, Nanchang Medical College, Nanchang, Jiangxi, China
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13
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Pellegrino F, Tin AL, Sjoberg DD, Benfante NE, Weber RC, Porwal SP, Briganti A, Montorsi F, Eastham JA, Laudone VP, Vickers AJ. The effect of the da Vinci ® Vessel Sealer on robot-assisted laparoscopic prostatectomy complications. J Robot Surg 2023; 17:1763-1768. [PMID: 37043122 PMCID: PMC10852274 DOI: 10.1007/s11701-023-01595-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/09/2023] [Indexed: 04/13/2023]
Abstract
The da Vinci® Vessel Sealer is a major contributor to the total cost of robot-assisted laparoscopic prostatectomy (RALP). We aimed to assess whether the use of the Vessel Sealer is associated with better surgical outcomes in a population of patients that underwent RALP with lymphadenectomy. We tested whether the use of the Vessel Sealer is associated with the development of lymphocele and/or other surgical outcomes. Most surgeons used the Vessel Sealer in almost all or almost no patients. Thus, to avoid the potential confounding variable of surgeon skill, we performed the initial analyses using data from a single surgeon who changed practice over time, and then using the entire population. Overall, the Vessel Sealer was used in 500 (36%) RALPs. Surgeon 1 performed 492 surgeries, and used the Vessel Sealer in 191 (39%). The Vessel Sealer was not associated with better surgical outcomes in patients operated on by Surgeon 1. The odds ratio for development of lymphocele was 1.95 (95% confidence interval [CI] 0.57-6.75). In the entire population, use of the sealer was significantly associated with a very small reduction of blood loss (22 cc, CI 13-30) but with a 32-min increase in the operating room time (CI 26-37). Use of the Vessel Sealer will have, at best, a very small effect on RALP outcomes that is of highly questionable relevance given its cost. In light of these results, the Vessel Sealer will only be used at our institution in the context of clinical trials.
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Affiliation(s)
- Francesco Pellegrino
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Division of Oncology/Unit of Urology, IRCCS San Raffaele Hospital, Urological Research Institute, Milan, Italy.
| | - Amy L Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole E Benfante
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ryan C Weber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shaun P Porwal
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alberto Briganti
- Division of Oncology/Unit of Urology, IRCCS San Raffaele Hospital, Urological Research Institute, Milan, Italy
| | - Francesco Montorsi
- Division of Oncology/Unit of Urology, IRCCS San Raffaele Hospital, Urological Research Institute, Milan, Italy
| | - James A Eastham
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent P Laudone
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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14
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Goto Y, Utsumi T, Maruo M, Kurozumi A, Noro T, Tanaka S, Sugawara S, Chiba K, Miyazaki K, Inoue A, Komaru A, Fukasawa S, Imamura Y, Sakamoto S, Nakatsu H, Suzuki H, Ichikawa T, Nagata M. Development and validation of novel nomogram to identify the candidates for extended pelvic lymph node dissection for prostate cancer patients in the robotic era. Int J Urol 2023; 30:659-665. [PMID: 37130793 DOI: 10.1111/iju.15195] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
OBJECTIVES To determine candidates for extended pelvic lymph node dissection using a novel nomogram to assess the risk of lymph node invasion in Japanese prostate cancer patients in the robotic era. METHODS A total of 538 patients who underwent robot-assisted radical prostatectomy with extended pelvic lymph node dissection in three hospitals were retrospectively analyzed. Medical records were reviewed uniformly and the following data collected: prostate-specific antigen, age, clinical T stage, primary and secondary Gleason score at prostate biopsy, and percentage of positive core numbers. Finally, data from 434 patients were used for developing the nomogram and data from 104 patients were used for external validation. RESULTS Lymph node invasion was detected in 47 (11%) and 16 (15%) patients in the development and validation set, respectively. Based on multivariate analysis, prostate-specific antigen, clinical T stage ≥3, primary Gleason score, grade group 5, and percentage of positive cores were selected as variables to incorporate into the nomogram. The area under the curve values were 0.781 for the internal and 0.908 for the external validation, respectively. CONCLUSIONS The present nomogram can help urologists identify candidates for extended pelvic lymph node dissection concomitant with robot-assisted radical prostatectomy among patients with prostate cancer.
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Affiliation(s)
- Yusuke Goto
- Department of Urology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takanobu Utsumi
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Masafumi Maruo
- Department of Urology, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Akira Kurozumi
- Department of Urology, Asahi General Hospital, Chiba, Japan
| | - Takahide Noro
- Prostate Center and Division of Urology, Chiba Cancer Center, Chiba, Japan
| | - Satoki Tanaka
- Department of Urology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sho Sugawara
- Department of Urology, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Kazuto Chiba
- Department of Urology, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Kanetaka Miyazaki
- Department of Urology, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Atsushi Inoue
- Department of Urology, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Atsushi Komaru
- Prostate Center and Division of Urology, Chiba Cancer Center, Chiba, Japan
| | - Satoshi Fukasawa
- Prostate Center and Division of Urology, Chiba Cancer Center, Chiba, Japan
| | - Yusuke Imamura
- Department of Urology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shinichi Sakamoto
- Department of Urology, Chiba University Graduate School of Medicine, Chiba, Japan
| | | | - Hiroyoshi Suzuki
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Tomohiko Ichikawa
- Department of Urology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Maki Nagata
- Department of Urology, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
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15
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Khalid A, Ashraf A, Salman MA, Newton RC. Internal Herniation of Small Bowel Underneath Iliac Vascular Axis After Pelvic Surgery: A Systematic Review. Cureus 2023; 15:e42960. [PMID: 37667721 PMCID: PMC10475313 DOI: 10.7759/cureus.42960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/06/2023] Open
Abstract
Internal abdominal hernias are rare entities that most commonly present with acute small bowel obstruction. These hernias can be congenital or acquired. While congenital hernias are considered the most common type, acquired hernias are becoming more common. Recently, a rare type of internal herniation has been reported underneath iliac vasculature in patients who have undergone pelvic lymph node dissection in the past. This study was carried out to assess the prevalence of this rare type of internal hernia. Two reviewers searched the literature in three online databases using the Cochrane methodology for systematic reviews. The search of databases yielded 70 articles. The studies which reported internal herniation underneath iliac vasculature were included. Studies that reported herniation underneath other pelvic organs or vasculature were excluded. After screening, 17 articles were deemed suitable and selected. All 17 cases reviewed underwent pelvic lymph node dissection in the past. The median latency period between index surgery and clinical presentation with the incarcerated hernia was 20 months. All 17 cases were managed surgically with small bowel resection carried out in 13 cases. Eleven authors reported closing the hernia defect with various techniques, while five decided not the close it. All 17 cases were alive at the time of discharge from the hospital, with a mean hospital stay of 12.7 days. Given our findings, there should be a high index of suspicion of internal hernia in patients presenting with small bowel obstruction with a history of pelvic lymph node dissection. In our review, internal herniation was always preceded by pelvic lymph node dissection, so the closure of the peritoneum should be considered while pelvic lymph node dissection is carried out.
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Affiliation(s)
- Aizaz Khalid
- General Surgery, University Hospitals Sussex National Health Service (NHS) Foundation Trust, Chichester, GBR
| | - Anza Ashraf
- General Surgery/Urology, Frimley Health National Health Service (NHS) Foundation Trust, Slough, GBR
| | - Mohamed A Salman
- General Surgery, University Hospitals Sussex National Health Service (NHS) Foundation Trust, Chichester, GBR
- General Surgery, KasrAlainy School of Medicine, Cairo University, Cairo, EGY
| | - Richard C Newton
- General Surgery, University Hospitals Sussex National Health Service (NHS) Foundation Trust, Chichester, GBR
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16
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Khalid A, Salman MA, Woodhams S, Newton RC. Strangulated Small Bowel Internal Hernia Under the External Iliac Artery After Robotic Cystoprostatectomy. Cureus 2023; 15:e39837. [PMID: 37397665 PMCID: PMC10314784 DOI: 10.7759/cureus.39837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/04/2023] Open
Abstract
Small bowel obstruction is a common surgical pathology encountered in the emergency department. The most common cause of small bowel obstruction is adhesions secondary to previous abdominal surgery. While strangulated external hernias are also a common cause of obstructions encountered, internal hernias leading to obstruction are rare. We present a 76-year-old male who presented with an acute abdomen and was later diagnosed with an internal hernia underneath his right external iliac artery. Internal herniation underneath the iliac vasculature is a recent phenomenon encountered very rarely after the natural anatomy has been disturbed in patients who have undergone pelvic lymph node dissection. Patients with a previous history of pelvic lymph node dissection should be suspected of having an internal hernia if they present with an acute abdomen. Closure of the peritoneum should also be considered in these patients as it may help prevent herniation.
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Affiliation(s)
- Aizaz Khalid
- General Surgery, University Hospitals Sussex NHS Foundation Trust, Chichester, GBR
| | - Mohamed A Salman
- General Surgery, University Hospitals Sussex NHS Foundation Trust, Chichester, GBR
| | - Simon Woodhams
- Urology, University Hospitals Sussex NHS Foundation Trust, Chichester, GBR
| | - Richard C Newton
- General Surgery, University Hospitals Sussex NHS Foundation Trust, Chichester, GBR
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17
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Li Z, Huang Y, Zhao D, Luo X, Wu Z, Zheng X, Xie Y, Liu Y, Wu J, Peng Y, Li Y, Zhou F. Development and internal validation of a novel nomogram for predicting lymph node invasion for prostate cancer patients undergoing extended pelvic lymph node dissection. Front Oncol 2023; 13:1186319. [PMID: 37223684 PMCID: PMC10202171 DOI: 10.3389/fonc.2023.1186319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/21/2023] [Indexed: 05/25/2023] Open
Abstract
Background Few studies have focused on the performance of Briganti 2012, Briganti 2017 and MSKCC nomograms in the Chinese population in assessing the risk of lymph node invasion(LNI) in prostate cancer(PCa) patients and identifying patients suitable for extended pelvic lymph node dissection(ePLND). We aimed to develop and validate a novel nomogram based on Chinese PCa patients treated with radical prostatectomy(RP) and ePLND for predicting LNI. Methods We retrospectively retrieved clinical data of 631 patients with localized PCa receiving RP and ePLND at a Chinese single tertiary referral center. All patients had detailed biopsy information from experienced uropathologist. Multivariate logistic-regression analyses were performed to identify independent factors associated with LNI. The discrimination accuracy and net-benefit of models were quantified using the area under curve(AUC) and Decision curve analysis(DCA).The nonparametric bootstrapping were used to internal validation. Results A total of 194(30.7%) patients had LNI. The median number of removed lymph nodes was 13(range, 11-18). In univariable analysis, preoperative prostate-specific antigen(PSA), clinical stage, biopsy Gleason grade group, maximum percentage of single core involvement with highest-grade PCa, percentage of positive cores, percentage of positive cores with highest-grade PCa and percentage of cores with clinically significant cancer on systematic biopsy differed significantly. The multivariable model that included preoperative PSA, clinical stage, biopsy Gleason grade group, maximum percentage of single core involvement with highest-grade PCa and percentage of cores with clinically significant cancer on systematic biopsy represented the basis for the novel nomogram. Based on a 12% cutoff, our results showed that 189(30%) patients could have avoided ePLND while only 9(4.8%) had LNI missing ePLND. Our proposed model achieved the highest AUC (proposed model vs Briganti 2012 vs Briganti 2017 vs MSKCC model: 0.83 vs 0.8 vs 0.8 vs 0.8, respectively) and highest net-benefit via DCA in the Chinese cohort compared with previous nomograms. In internal validation of proposed nomogram, all variables had a percent inclusion greater than 50%. Conclusion We developed and validated a nomogram predicting the risk of LNI based on Chinese PCa patients, which demonstrated superior performance compared with previous nomograms.
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Affiliation(s)
- Zhen Li
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yixin Huang
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Diwei Zhao
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xin Luo
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zeshen Wu
- Department of Urology, Huazhong University of Science and Technology Union Shenzhen Hospital (Nanshan Hospital), Shenzhen, China
| | - Xinyi Zheng
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Ye Xie
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Yixuan Liu
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Jianwei Wu
- School of Clinical Medicine, Tianjin Medical University, Tianjin, China
| | - Yulu Peng
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yonghong Li
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Fangjian Zhou
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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Paladini A, Cochetti G, Felici G, Russo M, Saqer E, Cari L, Bordini S, Mearini E. Complications of extraperitoneal robot-assisted radical prostatectomy in high-risk prostate cancer: A single high-volume center experience. Front Surg 2023; 10:1157528. [PMID: 37066016 PMCID: PMC10098012 DOI: 10.3389/fsurg.2023.1157528] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/28/2023] [Indexed: 03/31/2023] Open
Abstract
IntroductionThe role of robot-assisted radical prostatectomy (RARP) in high-risk prostate cancer (PCa) has been debated over the years, but it appears safe and effective in selected patients. While the outcomes of transperitoneal RARP for high-risk PCa have been already widely investigated, data on the extraperitoneal approach are scarcely available. The primary aim of this study is to evaluate intra- and postoperative complications in a series of patients with high-risk PCa treated by extraperitoneal RARP (eRARP) and pelvic lymph node dissection. The secondary aim is to report oncological and functional outcomes.MethodsData of patients who underwent eRARP for high-risk PCa were prospectively collected from January 2013 to September 2021. Intraoperative and postoperative complications were recorded, as also perioperative, functional, and oncological outcomes. Intraoperative and postoperative complications were classified by employing Intraoperative Adverse Incident Classification by the European Association of Urology and the Clavien–Dindo classification, respectively. Univariate and multivariate analyses were performed to evaluate a potential association between clinical and pathological features and the risk of complications.ResultsA total of 108 patients were included. The mean operative time and estimated blood loss were 183.5 ± 44 min and 115.2 ± 72.4 mL, respectively. Only two intraoperative complications were recorded, both grade 3. Early complications were recorded in 15 patients, of which 14 were of minor grade, and 1 was grade IIIa. Late complications were diagnosed in four patients, all of grade III. Body mass index (BMI) > 30 kg/m2, Prostate-Specific Antigen (PSA) > 20 ng/mL, PSA density >0.15 ng/mL2, and pN1 significantly correlated with a higher rate of overall postoperative complications. Moreover, BMI >30 kg/m2, PSA >20 ng/mL, and pN1 significantly correlated with a higher rate of early complications, while PSA >20 ng/mL, prostate volume <30 mL, and pT3 were significantly associated with a higher risk of late complications. In multivariate regression analysis, PSA >20 ng/mL significantly correlated with overall postoperative complications, while PSA > 20 and pN1 correlated with early complications. Urinary continence and sexual potency were restored in 49.1%, 66.7%, and 79.6% of patients and in 19.1%, 29.9%, and 36.2% of patients at 3, 6, and 12 months, respectively.ConclusionseRARP with pelvic lymph node dissection in patients with high-risk PCa is a feasible and safe technique, resulting in only a few intra- and postoperative complications, mostly of low grade.
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Affiliation(s)
- Alessio Paladini
- Urology Clinic, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Giovanni Cochetti
- Urology Clinic, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Graziano Felici
- Urology Clinic, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Correspondence: Graziano Felici
| | - Miriam Russo
- Urology Clinic, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Eleonora Saqer
- Urology Clinic, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Luigi Cari
- Section of Pharmacology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Stefano Bordini
- Urology Clinic, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Ettore Mearini
- Urology Clinic, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Wagner J, McLaughlin T, Pinto K, Tortora J, Gangakhedkar A, Staff I. The Effect of a Peritoneal Iliac Flap on Lymphocele Formation After Robotic Radical Prostatectomy: Results From the PLUS Trial. Urology 2023; 173:104-110. [PMID: 36549574 DOI: 10.1016/j.urology.2022.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/28/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To assess the effectiveness of a peritoneal flap on the formation of lymphoceles after robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection. METHODS We conducted a single surgeon, assessor blinded prospective randomized controlled trial (the Prospective Lymphocele Ultrasound Study) in men undergoing robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection. At the conclusion of the node dissection, patients were block randomized 1:1 to either standard of care (no bladder peritoneal flap) or to the creation of a bladder peritoneal flap. Lymphocele formation was assessed by pelvic ultrasound postoperatively. The primary outcome was lymphocele formation. Rates of lymphocele formation and complications were analyzed using chi-square. Other outcomes, including length of stay, number of lymph nodes removed, lymphocele volume, and quality of life measures, were analyzed by t-tests or Wilcoxon Ranked Sum Tests, as appropriate. An a priori power calculation was performed using O'Brien-Fleming alpha sharing for the interim analyses. Two preplanned interim analyses were performed when 45 and 90 patients per group had follow-up ultrasounds. RESULTS A statistically significant difference in lymphocele formation was seen on the second interim analysis for 183 patients (4.3% vs. 15.6%, p = .011) stopping enrollment; this remained significant in the final analysis of 216 patients (3.6% vs 14.2%, p = .006). No other significant differences were observed. CONCLUSION This prospective randomized trial supports the implementation of this simple modification for robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection.
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Affiliation(s)
- Joseph Wagner
- Urology Division, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT.
| | - Tara McLaughlin
- Urology Division, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT
| | - Kevin Pinto
- Urology Division, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT
| | - Joseph Tortora
- Hartford Hospital Research Program, Hartford Hospital, Hartford, CT
| | - Akshay Gangakhedkar
- Urology Division, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT
| | - Ilene Staff
- Hartford Hospital Research Program, Hartford Hospital, Hartford, CT
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20
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Risk factors for lymphorrhea and lymphocele after radical prostatectomy: a retrospective case-control study. World J Urol 2023; 41:1033-1039. [PMID: 36792813 DOI: 10.1007/s00345-023-04321-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 01/27/2023] [Indexed: 02/17/2023] Open
Abstract
PURPOSE To investigate the risk factors for postoperative lymphorrhea or/and lymphocele (PLL) in patients undergoing radical prostatectomy (RP). MATERIALS AND METHODS The clinical data of 606 patients were retrospectively collected. The receiver operating characteristic (ROC) curve was utilized to identify the optimal cutoff value. Multivariable logistic regression analysis was used to screen the independent predictors of PLL. RESULTS Univariate analysis showed that nine factors differed between the PLL and non-PLL group. Multivariable logistic regression analysis showed that low preoperative fibrinogen level, extraperitoneal surgery, robot-assisted laparoscopic radical prostatectomy (RALRP), and hypoalbuminemia were risk factors and the use of fibrin glue was a protective factor. Correlation analysis showed that the scope of LN dissection (LND) and number of lymph nodes (LNs) dissected were positively correlated with PLL in the extraperitoneal approach, but were not significantly correlated with PLL in the transperitoneal approach. The use of fibrin glue was negatively associated with PLL in the overall procedure and the extraperitoneal approach, but not significantly so in the transperitoneal approach. Comparison of LNs clearance between the two surgical approaches revealed that the extent of LND and number of LNs dissected in the extraperitoneal approach were less than in the transperitoneal approach. CONCLUSION During RALRP, more attention should be paid to fully clotting the broken end of lymphatic vessels. The use of fibrin glue could reduce the probability of PLL. The extent of LND or number of LNs dissected were positively correlated with PLL in the extraperitoneal approach.
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21
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Student V, Tudos Z, Studentova Z, Cesak O, Studentova H, Repa V, Purova D, Student V. Effect of Peritoneal Fixation (PerFix) on Lymphocele Formation in Robot-assisted Radical Prostatectomy with Pelvic Lymphadenectomy: Results of a Randomized Prospective Trial. Eur Urol 2023; 83:154-162. [PMID: 36041934 DOI: 10.1016/j.eururo.2022.07.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/27/2022] [Accepted: 07/26/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Symptomatic lymphoceles present the most common complication of robot-assisted radical prostatectomy (RARP) with extended pelvic lymph node dissection (ePLND). No surgical technique has so far shown success in reducing the incidence rate, but several retrospective studies have shown the beneficial effect of the fixation of the peritoneum. OBJECTIVE To introduce a modification in the technique of fixing the peritoneum to the pubic bone and to confirm whether this intervention reduces the incidence of lymphoceles. DESIGN, SETTING, AND PARTICIPANTS A prospective randomized (1:1) single-center one-sided blind study was conducted in patients with localized prostate cancer (cT1-2cN0M0) indicated for RARP with ePLND operated between December 2019 and June 2021. In the intervention group, the free flap of the peritoneum was fixed to the pubic bone. In the control group, the peritoneal flap was left free without fixation. SURGICAL PROCEDURE In the intervention group, the free flap of the peritoneum was fixed to the pubic bone (PerFix) so that lateral holes were left, allowing drainage of lymph from the pelvis into the abdominal cavity, where it would be resorbed. The iliac vessels and obturator fossa remained uncovered by the peritoneum and the bladder. MEASUREMENTS The primary objective was to evaluate the frequency of symptomatic lymphoceles during follow-up. The secondary endpoints were the radiological presence of lymphoceles on computed tomography of the pelvis carried out 6 wk after surgery, the volume of the lymphoceles, and the degree of severe (Clavien-Dindo ≥3) complications. RESULTS AND LIMITATIONS Of the 260 randomized patients, 245 were evaluated in the final analysis-123 in the intervention and 122 in the control group. The median follow-up was 595 d. There were no differences between the groups regarding clinical and pathological variables. The median of 17 nodes removed was the same in both groups (p = 0.961). Symptomatic lymphoceles occurred in 17 patients (6.9%), while in the intervention group these were found in three (2.4%) versus 14 (11.5%) in the control group (p = 0.011). The number of radiologically detected asymptomatic lymphoceles did not differ (p = 0.095). There was no significant difference in lymphocele volume between the two groups (p = 0.118). The rate of serious complications (Clavien 3a and 3b) was 4.8% in the intervention group and 9.1% in the control group (p = 0.587). A multivariate logistic regression model of symptomatic lymphocele occurrence was created with significant factors: body mass index (odds ratio [OR] = 1.1, 95% confidence interval [CI] = [1.03, 1.26], p = 0.012) and intervention (OR = 4.6, 95% CI = [1.28, 16.82], p = 0.02). CONCLUSIONS Fixation of the peritoneum (PerFix) reduced the incidence of symptomatic lymphoceles in RARP with ePLND. We found no difference in the frequency of asymptomatic lymphocele development. The volume of the detected lymphoceles was similar. PATIENT SUMMARY In this study, we compared the rate of development of postoperative complications using the peritoneal fixation technique with that of a nonfixation control group for robot-assisted radical prostatectomy with extended pelvic lymphadenectomy. Fixation of the peritoneum should obviate the development of severe complications in the postoperative period.
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Affiliation(s)
- Vladimir Student
- Department of Urology, University Hospital Olomouc, Olomouc, Czech Republic.
| | - Zbynek Tudos
- Department of Radiology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Zuzana Studentova
- Department of Urology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Ondrej Cesak
- Department of Urology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Hana Studentova
- Department of Oncology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Vaclav Repa
- Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Dana Purova
- Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Vladimir Student
- Department of Urology, University Hospital Olomouc, Olomouc, Czech Republic
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Rocco B, Eissa A, Gaia G, Assumma S, Sarchi L, Bozzini G, Micali S, Calcagnile T, Sighinolfi MC. Pelvic lymph node dissection in prostate and bladder cancers. Minerva Urol Nephrol 2022; 74:680-694. [PMID: 36197698 DOI: 10.23736/s2724-6051.22.04904-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Prostate cancer and bladder cancer accounts for approximately 13.5% and 3% of all male cancers and all newly diagnosed cancers (regardless sex), respectively. Thus, these cancers represent a major health and economic burden globally. The knowledge of lymph node status is an integral part of the management of any solid tumor. In the urological field, pelvic lymph node dissection (PLND) is of paramount importance in the diagnosis, management, and prognosis of prostate and bladder cancers. However, PLND may be associated with several comorbidities. In this narrative review, the most recent updates concerning the patterns and incidence of lymph node metastasis, the role of different imaging studies and nomograms in determining patients' eligibility for PLND, and the anatomical templates of PLND in urologic patients with bladder or prostate cancer will be discussed.
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Affiliation(s)
- Bernardo Rocco
- Department of Urology, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Ahmed Eissa
- Department of Urology, Faculty of Medicine, Tanta University, Tanta, Egypt -
| | - Giorgia Gaia
- Department of Obstetrics and Gynecology, ASST Santi Paolo e Carlo, Milan, Italy
| | - Simone Assumma
- Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
| | - Luca Sarchi
- Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Salvatore Micali
- Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
| | - Tommaso Calcagnile
- Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria C Sighinolfi
- Department of Urology, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
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Differences in rates of pelvic lymph node dissection in National Comprehensive Cancer Network favorable, unfavorable intermediate- and high-risk prostate cancer across United States SEER registries. Curr Urol 2022; 16:191-196. [PMID: 36714227 PMCID: PMC9875209 DOI: 10.1097/cu9.0000000000000132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/17/2022] [Indexed: 02/01/2023] Open
Abstract
Background The National Comprehensive Cancer Network (NCCN) guidelines recommend pelvic lymph node dissection (PLND) in NCCN high- and intermediate-risk prostate cancer patients. We tested for PLND nonadherence (no-PLND) rates within the Surveillance Epidemiology and End Results (2010-2015). Materials and methods We identified all radical prostatectomy patients who fulfilled the NCCN PLND guideline criteria (n = 23,495). Nonadherence rates to PLND were tabulated and further stratified according to NCCN risk subgroups, race/ethnicity, geographic distribution, and year of diagnosis. Results Overall, the no-PLND rate was 26%; it was 41%, 25%, and 11% in the NCCN intermediate favorable, intermediate unfavorable, and high-risk prostate cancer patients, respectively (p < 0.001). Over time, the no-PLND rates declined in the overall cohort and within each NCCN risk subgroup. Georgia exhibited the highest no-PLND rate (49%), whereas New Jersey exhibited the lowest (15%). Finally, no-PLND race/ethnicity differences were recorded only in the NCCN intermediate unfavorable subgroup, where Asians exhibited the lowest no-PLND rate (20%) versus African Americans (27%) versus Whites (26%) versus Hispanic-Latinos (25%). Conclusions The lowest no-PLND rates were recorded in the NCCN high-risk patients followed by NCCN intermediate unfavorable and favorable risk in that order. Our findings suggest that unexpectedly elevated differences in no-PLND rates warrant further examination. In all the NCCN risk subgroups, the no-PLND rates decreased over time.
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Complications of Extended Pelvic Lymph Node Dissection in Patients Undergoing Minimally Invasive Radical Prostatectomy: Analysis and Risk Factors. Prostate Cancer 2022; 2022:7631903. [PMID: 36317165 PMCID: PMC9617711 DOI: 10.1155/2022/7631903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/15/2022] [Indexed: 11/20/2022] Open
Abstract
Background The knowledge of risk factors and complications related to extended pelvic lymph node dissection (ePLND) during radical prostatectomy can help selecting patients who will benefit the most with lymph node dissection concomitant to radical prostatectomy. Materials and Methods Retrospective cohort evaluating 135 patients with PC, with a high risk for lymph node metastasis, submitted to ePLND by a single surgeon between 2013 and 2019, performed either by the laparoscopic or laparoscopic robot-assisted approach. Data related to complications were properly recorded using the Martin's criteria and were classified by the Satava and Clavien–Dindo–Strasberg methods. Logistic regression was used to determine predictors of complications related to ePLND. Results The mean number of lymph nodes removed was 10.2 ± 4.9, and in 28.2%, they were positive for metastasis. There were five intraoperative complications (4%), all in patients operated by laparoscopic approach. There were nine severe postoperative complications (7.3%), four of which occurred after postoperative day 30. Three patients (2.4%) had thromboembolic complications and five patients (4.0%) had lymphocele that required treatment. There was a correlation between the American Society of Anesthesiologists (ASA) physical status classification and postoperative complications (p=0.06), but it was not possible to identify statistically significant predictors. Conclusion ePLND during radical prostatectomy has a low rate of intraoperative complications and may change prostate cancer staging. Postoperative complications, especially venous thromboembolism and lymphocele, need to be monitored even in the late postoperative period.
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Korten M, Pose RM, Graefen M, Tilki D, Michl U, Knipper S, Beyer B. Preprostatic lymph nodes in prostate cancer hot or not? Impact on oncological outcome after radical prostatectomy. World J Urol 2022; 40:2231-2237. [DOI: 10.1007/s00345-022-04103-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 07/09/2022] [Indexed: 10/16/2022] Open
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Fujiwara M, Numao N, Yamamoto S, Ishikawa Y, Fujiwara R, Oguchi T, Komai Y, Matsuoka Y, Yuasa T, Yonese J. Predictive ability of prebiopsy magnetic resonance imaging and biopsy for side-specific negative lymph node metastasis at radical prostatectomy. Prostate 2022; 82:904-910. [PMID: 35297503 DOI: 10.1002/pros.24334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/14/2022] [Accepted: 03/02/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Prostate cancer localization is reportedly associated with the laterality of lymph node metastasis. Thus, it may be feasible to predict side-specific lymph node metastasis (LNM) at radical prostatectomy (RP). To investigate whether multiparametric magnetic resonance imaging and biopsy findings can predict side-specific negative LNM and to explore the feasibility of unilateral lymph node dissection (LND) at RP. METHODS A total of 500 patients who were diagnosed with prostate cancer with prebiopsy multiparametric magnetic resonance imaging of the prostate and subsequent prostate biopsy and who underwent RP and extended LND without neoadjuvant treatment were enrolled. Multiparametric magnetic resonance imaging, biopsy findings, and LNM were assessed for each side. The negative predictive value (NPV) of multiparametric magnetic resonance imaging or biopsy or both for ipsilateral LNM was examined. RESULTS LNM was found in 9.2% (46/500) and 15.6% (28/180) of patients in the overall and high-risk cohorts, respectively. Magnetic resonance imaging and biopsy findings were negative in 408 and 262 sides, respectively, in the overall cohort and 144 and 100 sides, respectively, in the high-risk cohort. The NPVs of magnetic resonance imaging, biopsy, and both for ipsilateral LNM were 98.3%, 98.5%, and 99.1%, respectively, in the overall cohort, and 95.8%, 97.1%, and 97.6%, respectively, in the high-risk cohort. CONCLUSIONS Unilateral LND may be indicated based on side-specific LNM risk as assessed by prebiopsy multiparametric magnetic resonance imaging and biopsy.
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Affiliation(s)
- Motohiro Fujiwara
- Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Noboru Numao
- Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shinya Yamamoto
- Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yudai Ishikawa
- Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryo Fujiwara
- Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomohiko Oguchi
- Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshinobu Komai
- Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoh Matsuoka
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Takeshi Yuasa
- Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Junji Yonese
- Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Barbosa ÁRG, Amaral BS, Lourenço DB, Bianco B, Gushiken FA, Apezzato M, Silva JF, Cunha MLD, Filippi RZ, Baroni RH, Lemos GC, Carneiro A. Accuracy of 68Ga-PSMA PET-CT and PET-MRI in lymph node staging for localized prostate cancer. EINSTEIN-SAO PAULO 2022; 20:eAO6599. [PMID: 35584444 PMCID: PMC9094607 DOI: 10.31744/einstein_journal/2022ao6599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 08/20/2021] [Indexed: 11/30/2022] Open
Abstract
Objective To evaluate the predictive value of positron emission computed tomography or magnetic resonance (PET-CT and PET-MRI) using gallium-68-labeled prostate-specific membrane antigen (68Ga-PSMA) in lymph node involvement in prostate cancer. Methods A retrospective study comprising 91 patients diagnosed with prostate cancer between 2016 to 2020, who underwent 68Ga-PSMA PET-CT or PET-MRI for staging before prostatectomy. The patients were divided into Group 1, with 65 patients with satisfactory pathological lymph node analysis, and Group 2, with 91 patients representing the sum of patients with pathological lymph node analysis and those with postoperative prostate-specific antigen within 60 days after surgery. Receiver Operating Characteristic curves were used to assess accuracy of predictive capacity of imaging exams for lymph node involvement. Results Regarding local clinical staging, the groups showed similar results, and 50% were classified as staging T2a. The accuracy of 68Ga-PSMA PET-CT for prostate cancer lymph node staging was 86.5% (95%CI 0.74-0.94; p=0.06), with a sensitivity of 58.3% and specificity of 95%. The accuracy of 68Ga-PSMA PET-MRI was 84.6% (95%CI 0.69-0.94; p=0.09), with a sensitivity of 40% and specificity of 100%. Considering both 68Ga-PSMA PET-CT and PET-MRI, the accuracy was 85.7% (95%CI 0.76-0.92; p=0.015), with sensitivity of 50% and specificity of 97%. Conclusion The imaging tests 68Ga-PSMA PET-CT and PET-MRI were highly accurate to detect preoperative lymph node involvement, and could be useful tools to indicate the need for extended lymph node dissection during radical prostatectomy.
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Li K, Yang X, Zhuang J, Cai L, Han J, Yu H, Zhou Z, Lv J, Feng D, Yuan B, Wu Q, Li P, Cao Q, Lu Q. External validation of Pentafecta in patients undergoing laparoscopic radical cystectomy: results from a high-volume center. BMC Urol 2022; 22:41. [PMID: 35313884 PMCID: PMC8939065 DOI: 10.1186/s12894-022-00987-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 03/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate whether Pentafecta is suitable for bladder cancer patients receiving laparoscopic radical cystectomy (LRC). METHODS From November 2013 to December 2020, muscle invasive Bladder Cancer (MIBC) and non-muscle invasive Bladder Cancer (NMIBC) patients who received LRC and urinary diversion were retrospectively analyzed. Pentafecta was defined as meeting five criteria: negative soft margin, ≥ 16 lymph nodes (LNs) removed, major complications free, urinary diversion related sequelae free and clinical recurrence free within 1 year. Analyze the achievement of five criteria and compare the overall survival (OS) of Pentafecta group with non-attainment group. Multivariable Cox's regression was performed to evaluate the impact of Pentafecta on OS. Multivariable logistic regression was performed to explore the effect of surgical experience on Pentafecta attainment. RESULTS A total of 340 patients were included, negative soft margin, ≥ 16 lymph nodes (LNs) removed, major complications free, urinary diversion related sequelae free and clinical recurrence free within 1 year were observed in 95.3%, 30.3%, 83.8%, 75.0% and 85.6% of patients, respectively. Pentafecta group had a significantly longer OS than the non-attainment group (P = 0.027). The group with 10-15 LNs removed and meeting the other four criteria had a similar OS to group with ≥ 16 LNs removed (Pentafecta group) (5-year OS: 67.3% vs 72.7%, P = 0.861). Pentafecta (HR = 0.33, P = 0.011), positive lymph nodes (HR = 2.08, P = 0.028) and MIBC (HR = 3.70, P < 0.001) were all significant predictors of OS in multivariable Cox's regression. Surgical experience (OR = 1.05, P < 0.001), conduit (OR = 2.09, P = 0.047) and neobladder (OR = 2.47, P = 0.048) were all independent predictors of Pentafecta attainment in multivariable logistic regression. CONCLUSIONS Pentafecta is suitable for bladder cancer patients receiving LRC and has the potential to be a valuable tool for evaluating the quality of LRC. Based on Pentafecta analysis, removing 10 LNs instead of 16 LNs as the one of the five criteria may be more appropriate for bladder cancer patients.
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Affiliation(s)
- Kai Li
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Xiao Yang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Juntao Zhuang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Lingkai Cai
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Jie Han
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Hao Yu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Zijian Zhou
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Jianchen Lv
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Dexiang Feng
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Baorui Yuan
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Qikai Wu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Pengchao Li
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Qiang Cao
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China.
| | - Qiang Lu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China.
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Frego N, Paciotti M, Buffi NM, Maffei D, Contieri R, Avolio PP, Fasulo V, Uleri A, Lazzeri M, Hurle R, Saita A, Guazzoni GF, Casale P, Lughezzani G. External Validation and Comparison of Two Nomograms Predicting the Probability of Lymph Node Involvement in Patients subjected to Robot-Assisted Radical Prostatectomy and Concomitant Lymph Node Dissection: A Single Tertiary Center Experience in the MRI-Era. Front Surg 2022; 9:829515. [PMID: 35284478 PMCID: PMC8913721 DOI: 10.3389/fsurg.2022.829515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 01/18/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionTo externally validate and directly compare the performance of the Briganti 2012 and Briganti 2019 nomograms as predictors of lymph node invasion (LNI) in a cohort of patients treated with robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND).Materials and MethodsAfter the exclusion of patients with incomplete biopsy, imaging, or clinical data, 752 patients who underwent RARP and ePLND between December 2014 to August 2021 at our center, were included. Among these patients, 327 (43.5%) had undergone multi-parametric MRI (mpMRI) and mpMRI-targeted biopsy. The preoperative risk of LNI was calculated for all patients using the Briganti 2012 nomogram, while the Briganti 2019 nomogram was used only in patients who had performed mpMRI with the combination of targeted and systematic biopsy. The performances of Briganti 2012 and 2019 models were evaluated using the area under the receiver-operating characteristics curve analysis, calibrations plot, and decision curve analysis.ResultsA median of 13 (IQR 9–18) nodes per patient was removed, and 78 (10.4%) patients had LNI at final pathology. The area under the curves (AUCs) for Briganti 2012 and 2019 were 0.84 and 0.82, respectively. The calibration plots showed a good correlation between the predicted probabilities and the observed proportion of LNI for both models, with a slight tendency to underestimation. The decision curve analysis (DCA) of the two models was similar, with a slightly higher net benefit for Briganti 2012 nomogram. In patients receiving both systematic- and targeted-biopsy, the Briganti 2012 accuracy was 0.85, and no significant difference was found between the AUCs of 2012 and 2019 nomograms (p = 0.296). In the sub-cohort of 518 (68.9%) intermediate-risk PCa patients, the Briganti 2012 nomogram outperforms the 2019 model in terms of accuracy (0.82 vs. 0.77), calibration curve, and net benefit at DCA.ConclusionThe direct comparison of the two nomograms showed that the most updated nomogram, which included MRI and MRI-targeted biopsy data, was not significantly more accurate than the 2012 model in the prediction of LNI, suggesting a negligible role of mpMRI in the current population.
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Affiliation(s)
- Nicola Frego
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Marco Paciotti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Nicolò Maria Buffi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Davide Maffei
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Roberto Contieri
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Pier Paolo Avolio
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Vittorio Fasulo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Alessandro Uleri
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Massimo Lazzeri
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Rodolfo Hurle
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Alberto Saita
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Giorgio Ferruccio Guazzoni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Paolo Casale
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Giovanni Lughezzani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
- *Correspondence: Giovanni Lughezzani
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Blas L, Shiota M, Nagakawa S, Tsukahara S, Matsumoto T, Monji K, Kashiwagi E, Takeuchi A, Inokuchi J, Eto M. Validation of models predicting lymph node involvement probability in patients with prostate cancer. Int J Urol 2022; 29:428-434. [PMID: 35102610 DOI: 10.1111/iju.14802] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES There are many models to predict lymph node involvement in patients with prostate cancer. We aimed to externally validate several models in a Japanese cohort. METHODS We considered patients who were treated with robotic-assisted radical prostatectomy with extended pelvic lymph node dissection for prostate cancer. The risk of lymph node involvement was calculated for each patient in several models. Model performance was assessed by calculating the receiver operating characteristic curve and the area under the curve, calibration plots, and decision curve analyses. RESULTS We identified lymph node involvement in 61 (18.4%) of the 331 considered patients. Patients with lymph node involvement had a higher prostate-specific antigen level, percentage of positive biopsy cores, primary Gleason grade, Gleason group grade, and clinical T-stage category. The Memorial Sloan Kettering Cancer Center web calculator presented the highest area under the curve (0.78) followed by the Yale formula area under the curve (0.77), the updated version of Briganti nomogram of 2017 area under the curve (0.76), and the updated version of the Partin table by Tosoian et al. had an area under the curve of 0.75. However, the 95% confidence interval for these models overlapped. The calibration plot showed that the Memorial Sloan Kettering Cancer Center web calculator and the updated version of the Briganti nomogram calibrated better. In the decision curve analyses, all models showed net benefit; however, it overlapped among them. However, the Memorial Sloan Kettering Cancer Center web calculator and the updated Briganti nomogram presented the highest net benefit for lymph node involvement risks <35%. CONCLUSION Models predicting lymph node involvement were externally validated in Japanese men. The Memorial Sloan Kettering Cancer Center web calculator and the updated Briganti nomogram of 2017 were the most accurate performing models.
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Affiliation(s)
- Leandro Blas
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masaki Shiota
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shohei Nagakawa
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shigehiro Tsukahara
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takashi Matsumoto
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keisuke Monji
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Eiji Kashiwagi
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ario Takeuchi
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Junichi Inokuchi
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masatoshi Eto
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Extent of pelvic lymph node dissection improves early oncological outcomes for patients with high-risk prostate cancer without lymph node involvement after robot-assisted radical prostatectomy. Int J Clin Oncol 2022; 27:781-789. [DOI: 10.1007/s10147-022-02121-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/13/2022] [Indexed: 01/18/2023]
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Shida Y, Hakariya T, Mitsunari K, Matsuo T, Ohba K, Miyata Y, Sakai H. Preoperative Predictors of Lymph Node Invasion and Biochemical Recurrence in High-risk Prostate Cancer. CANCER DIAGNOSIS & PROGNOSIS 2022; 2:49-54. [PMID: 35400005 PMCID: PMC8962846 DOI: 10.21873/cdp.10075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/19/2021] [Indexed: 06/07/2023]
Abstract
AIM To evaluate the preoperative predictors of pathological lymph node (LN) metastasis and prognostic factors for postoperative biochemical recurrence (BCR) in robot-assisted radical prostatectomy with extended pelvic LN dissection in patients with D'Amico high-risk prostate cancer (PCa). PATIENTS AND METHODS Overall, 107 patients with D'Amico high-risk PCa underwent robot-assisted radical prostatectomy with extended pelvic LN dissection without neoadjuvant or adjuvant therapy. BCR was defined as a prostate-specific antigen (PSA) level ≥0.2 ng/ml. Moreover, BCR-free survival rates were determined using Kaplan-Meier analysis. Logistic regression analysis was used to evaluate preoperative predictors of pathological LN metastasis. Cox regression analysis was used to evaluate the effects of preoperative and pathologic variables on BCR. RESULTS The median follow-up was 21 months, and the 5-year BCR-free survival rate was 59.8%. The positive LN rate was 21.5%. In multivariate analysis, the percentage of positive cores was a significant preoperative predictor of positive LNs. Patients with >50% positive cores (p=0.004) and PSA density (PSAD) >0.5 ng/ml/cc (p=0.005) had a high risk of having ≥3 positive LNs. In multivariate analysis, PSAD >0.5% was a significant preoperative predictor of BCR. Among the postoperative predictors, the number of positive LNs was significantly associated with BCR. Patients with ≥3 positive LNs (n=7) had significantly lower BCR-free survival rates than patients with one or two positive LNs (n=16) (p<0.001). Patients with >50% positive cores and PSAD >0.5 ng/ml/cc had a risk for a high number of positive LNs (≥3) that was strongly associated with shorter BCR-free survival (p<0.001). CONCLUSION The percentage of positive cores may be useful as a preoperative predictor of pathological LN metastasis in patients with high-risk PCa. Patients with >50% positive cores and PSAD >0.5 ng/ml/cc were found to have a high risk for ≥3 positive LNs and shorter BCR-free survival.
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Affiliation(s)
- Yohei Shida
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomoaki Hakariya
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kensuke Mitsunari
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomohiro Matsuo
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kojiro Ohba
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yasuyoshi Miyata
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hideki Sakai
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Haiquel L, Cathelineau X, Sanchez-Salas R, Macek P, Secin F. Pelvic lymph node dissection in high-risk prostate cancer. Int Braz J Urol 2022; 48:54-66. [PMID: 33861538 PMCID: PMC8691250 DOI: 10.1590/s1677-5538.ibju.2020.1063] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/22/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The therapeutic role of pelvic lymph node dissection (PLND) in prostate cancer (PCa) is unknown due to absence of randomized trials. OBJECTIVE to present a critical review on the therapeutic benefits of PLND in high risk localized PCa patients. MATERIALS AND METHODS A search of the literature on PLND was performed using PubMed, Cochrane, and Medline database. Articles obtained regarding diagnostic imaging and sentinel lymph node dissection, PLND extension, impact of PLND on survival, PLND in node positive "only" disease and PLND surgical risks were critically reviewed. RESULTS High-risk PCa commonly develops metastases. In these patients, the possibility of presenting lymph node disease is high. Thus, extended PLND during radical prostatectomy may be recommended in selected patients with localized high-risk PCa for both accurate staging and therapeutic intent. Although recent advances in detecting patients with lymph node involvement (LNI) with novel imaging and sentinel node dissection, extended PLND continues to be the most accurate method to stage lymph node disease, which may be related to the number of nodes removed. However, extended PLND increases surgical time, with potential impact on perioperative complications, hospital length of stay, rehospitalization and healthcare costs. Controversy persists on its therapeutic benefit, particularly in patients with high node burden. CONCLUSION The impact of PLND on biochemical recurrence and PCa survival is unclear yet. Selection of patients may benefit from extended PLND but the challenge remains to identify them accurately. Only prospective randomized study would answer the precise role of PLND in high-risk pelvis confined PCa patients.
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Affiliation(s)
- Luciano Haiquel
- Sanatorio Las Lomas de San IsidroDepartment of UrologyBuenos AiresArgentinaDepartment of Urology, Sanatorio Las Lomas de San Isidro, Buenos Aires, Argentina
| | - Xavier Cathelineau
- Université Paris DescartesL’Institut Mutualiste MontsourisDepartment of UrologyParisFranceDepartment of Urology, L’Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - Rafael Sanchez-Salas
- Université Paris DescartesL’Institut Mutualiste MontsourisDepartment of UrologyParisFranceDepartment of Urology, L’Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - Petr Macek
- Université Paris DescartesL’Institut Mutualiste MontsourisDepartment of UrologyParisFranceDepartment of Urology, L’Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - Fernando Secin
- Universidad de Buenos AiresDiscipline of UrologyArgentinaDiscipline of Urology, Universidad de Buenos Aires, Argentina
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Tanhaeivash R, Grimm MO. Factors Affecting Transperitoneal Robot-Assisted Laparoscopic Radical Prostatectomy. J Laparoendosc Adv Surg Tech A 2021; 32:781-786. [PMID: 34962160 DOI: 10.1089/lap.2021.0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives: To evaluate the impact of body mass index (BMI), preoperative risk classification, previous inguinal herniotomy, and abdominal operations on several steps of robot-assisted radical prostatectomy (RARP) and lymph node (LN) involvement. Methods: A total number of 225 consecutive patients were included in the study who underwent transperitoneal RARP by 1 surgeon. We defined the following parameters as dependent variables: duration of prostatectomy, duration of pelvic lymphadenectomy, incision to suture time, console time, number of dissected LNs and number of positive LNs for metastasis. We assessed the impact of the following covariates using univariate nonparametric and multivariate analysis: BMI, preoperative D'Amico risk classification, history of inguinal herniotomy, and previous abdominal operations. Results: We observed a statistically significant difference among our three BMI groups (<25, ≥25 and <30, and ≥30 kg/m2) regarding pelvic lymphadenectomy and LN metastasis. Moreover, among the three risk groups (low, intermediate, and high) duration of prostatectomy, pelvic lymphadenectomy, and LN metastasis were statistically different. Previous abdominal operations have been also demonstrated to significantly influence the pelvic lymphadenectomy. In addition, our multivariate model proved the impact of our covariates on pelvic lymphadenectomy. Conclusions: Our findings highlight the impact of BMI and preoperative risk on various steps of RARP. We revealed longer duration of pelvic lymphadenectomy and more nodal yield in patients with higher BMI and high-risk disease. Therefore, we suggest that BMI and risk classification according to D'Amico should be taken into account while a RARP is being planned.
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Affiliation(s)
- Roozbeh Tanhaeivash
- Department of Urology, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Marc-Oliver Grimm
- Department of Urology, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
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Wenzel M, Preisser F, Hoeh B, Welte MN, Humke C, Wittler C, Würnschimmel C, Becker A, Karakiewicz PI, Chun FKH, Mandel P, Kluth LA. Influence of Biopsy Gleason Score on the Risk of Lymph Node Invasion in Patients With Intermediate-Risk Prostate Cancer Undergoing Radical Prostatectomy. Front Surg 2021; 8:759070. [PMID: 34957202 PMCID: PMC8695544 DOI: 10.3389/fsurg.2021.759070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 10/25/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To analyze the influence of biopsy Gleason score on the risk for lymph node invasion (LNI) during pelvic lymph node dissection (PLND) in patients undergoing radical prostatectomy (RP) for intermediate-risk prostate cancer (PCa). Materials and Methods: We retrospectively analyzed 684 patients, who underwent RP between 2014 and June 2020 due to PCa. Univariable and multivariable logistic regression, as well as binary regression tree models were used to assess the risk of positive LNI and evaluate the need of PLND in men with intermediate-risk PCa. Results: Of the 672 eligible patients with RP, 80 (11.9%) men harbored low-risk, 32 (4.8%) intermediate-risk with international society of urologic pathologists grade (ISUP) 1 (IR-ISUP1), 215 (32.0%) intermediate-risk with ISUP 2 (IR-ISUP2), 99 (14.7%) intermediate-risk with ISUP 3 (IR-ISUP3), and 246 (36.6%) high-risk PCa. Proportions of LNI were 0, 3.1, 3.7, 5.1, and 24.0% for low-risk, IR-ISUP1, IR-ISUP 2, IR-ISUP-3, and high-risk PCa, respectively (p < 0.001). In multivariable analyses, after adjustment for patient and surgical characteristics, IR-ISUP1 [hazard ratio (HR) 0.10, p = 0.03], IR-ISUP2 (HR 0.09, p < 0.001), and IR-ISUP3 (HR 0.18, p < 0.001) were independent predictors for lower risk of LNI, compared with men with high-risk PCa disease. Conclusions: The international society of urologic pathologists grade significantly influence the risk of LNI in patients with intermediate- risk PCa. The risk of LNI only exceeds 5% in men with IR-ISUP3 PCa. In consequence, the need for PLND in selected patients with IR-ISUP 1 or IR-ISUP2 PCa should be critically discussed.
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Affiliation(s)
- Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany.,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Felix Preisser
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Maria N Welte
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Clara Humke
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Clarissa Wittler
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Christoph Würnschimmel
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada.,Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Becker
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Philipp Mandel
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
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Vorobev V, Beloborodov V, Luchkevich V, Shmakov D, Baklanova O, Sidorov S, Sharakshinov B. Analysis of Complications Development Predictors after Radical Prostatectomy. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.7158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction: The standard treatment for prostate cancer is radical prostatectomy (RP). This surgical technique results in typical complications such as intraoperative blood loss, urethral strictures (vesicourethral anastomosis), urinary incontinence, erectile dysfunction, lymphocele, and the ureter or rectum injury. The study aims to analyze the development of complications after radical prostatectomy.
Materials and methods: The article presents a retrospective analysis of clinical cases with an established diagnosis of prostate cancer from 2012 to 2018 in Irkutsk, Russian Federation. During this period, 52 patients met the study criteria. A multivariate analysis established Non-Nerve-sparing RRP (OR-0.9; 95% CI-1.9; -0.07; p=0.035) as a significant incontinence predictor after 2 years.
Results: Multivariate analysis also established previous transurethral operations as a significant predictor of the vesicourethral anastomosis stricture (OR 6.09; 95% CI 0.71; 11.4; p=0.026), which indicates a six times risk of developing a vesicourethral anastomosis stricture if the patient already had one or more transurethral surgery. Obesity (OR 0.12; 95% CI 0.03; 0.21; p = 0.008), diabetes (OR 2.3; 95% CI 0.45; 4.2; p = 0.015) and coagulopathy (OR 3.1; 95% CI 0.5; 5.7; p = 0.019) became independent predictors of lymphocele development.
Conclusions: The study revealed some new information on the possible predictors of such complications as urinary incontinence in the late period, the lymphocele, and stricture of the vesicourethral anastomosis. Some of the results require further study and confirmation.
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Wei L, Huang Y, Chen Z, Lei H, Qin X, Cui L, Zhuo Y. Artificial Intelligence Combined With Big Data to Predict Lymph Node Involvement in Prostate Cancer: A Population-Based Study. Front Oncol 2021; 11:763381. [PMID: 34722318 PMCID: PMC8551611 DOI: 10.3389/fonc.2021.763381] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/22/2021] [Indexed: 01/12/2023] Open
Abstract
Background A more accurate preoperative prediction of lymph node involvement (LNI) in prostate cancer (PCa) would improve clinical treatment and follow-up strategies of this disease. We developed a predictive model based on machine learning (ML) combined with big data to achieve this. Methods Clinicopathological characteristics of 2,884 PCa patients who underwent extended pelvic lymph node dissection (ePLND) were collected from the U.S. National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015. Eight variables were included to establish an ML model. Model performance was evaluated by the receiver operating characteristic (ROC) curves and calibration plots for predictive accuracy. Decision curve analysis (DCA) and cutoff values were obtained to estimate its clinical utility. Results Three hundred and forty-four (11.9%) patients were identified with LNI. The five most important factors were the Gleason score, T stage of disease, percentage of positive cores, tumor size, and prostate-specific antigen levels with 158, 137, 128, 113, and 88 points, respectively. The XGBoost (XGB) model showed the best predictive performance and had the highest net benefit when compared with the other algorithms, achieving an area under the curve of 0.883. With a 5%~20% cutoff value, the XGB model performed best in reducing omissions and avoiding overtreatment of patients when dealing with LNI. This model also had a lower false-negative rate and a higher percentage of ePLND was avoided. In addition, DCA showed it has the highest net benefit across the whole range of threshold probabilities. Conclusions We established an ML model based on big data for predicting LNI in PCa, and it could lead to a reduction of approximately 50% of ePLND cases. In addition, only ≤3% of patients were misdiagnosed with a cutoff value ranging from 5% to 20%. This promising study warrants further validation by using a larger prospective dataset.
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Affiliation(s)
- Liwei Wei
- Department of Urology, the First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yongdi Huang
- College of Mathematics and Physics, Beijing University of Chemical Technology, Beijing, China
| | - Zheng Chen
- Department of Urology, the First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hongyu Lei
- College of Mathematics and Physics, Beijing University of Chemical Technology, Beijing, China
| | - Xiaoping Qin
- Department of Urology, the First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Lihong Cui
- College of Mathematics and Physics, Beijing University of Chemical Technology, Beijing, China
| | - Yumin Zhuo
- Department of Urology, the First Affiliated Hospital of Jinan University, Guangzhou, China
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Stabile A, Pellegrino A, Mazzone E, Cannoletta D, de Angelis M, Barletta F, Scuderi S, Cucchiara V, Gandaglia G, Raggi D, Necchi A, Karakiewicz P, Montorsi F, Briganti A. Can Negative Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography Avoid the Need for Pelvic Lymph Node Dissection in Newly Diagnosed Prostate Cancer Patients? A Systematic Review and Meta-analysis with Backup Histology as Reference Standard. Eur Urol Oncol 2021; 5:1-17. [PMID: 34538770 DOI: 10.1016/j.euo.2021.08.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/05/2021] [Accepted: 08/31/2021] [Indexed: 01/06/2023]
Abstract
CONTEXT The role of positron emission tomography/computed tomography (PET/CT) with prostate-specific membrane antigen (PSMA) in the primary staging for patients with prostate cancer (PCa) is still debated. OBJECTIVE To analyze published studies reporting the accuracy of PSMA PET/CT for detecting lymph node invasion (LNI) at pelvic lymph node dissection (PLND). EVIDENCE ACQUISITION A search of PubMed/MEDLINE, Cochrane library's Central, EMBASE and Scopus databases, from inception to May 2021, was conducted. The primary outcome was to evaluate the sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of PSMA PET/CT in detecting LNI on a per-patient level. As a secondary outcome, NPV of PET PSMA was tested on a per-node-level analysis. Detection rates were pooled using random-effect models. Preplanned subgroup analyses tested the diagnostic accuracy after stratification for the preoperative risk group. PPV and NPV variation over LNI prevalence was evaluated. Only studies including extended PLND (ePLND) as the reference standard test were included. EVIDENCE SYNTHESIS Twenty-seven studies, with a total of 2832 participants, were included in quantitative synthesis. The sensitivity, specificity, PPV, and NPV of PSMA PET/CT for LNI were, respectively, 58% (95% confidence interval [CI] 50-66%), 95% (95% CI 93-97%), 79% (95% CI 72-85%), and 87% (95% CI 84-89%), with overall moderate heterogeneity between studies. At bivariate analysis, the diagnostic accuracy of PSMA PET/CT estimated through summary receiver operating characteristic-derived area under the curve was 84% (95% CI 81-87%). On a per-node level, NPV of PET PSMA was 97% (95% CI 96-99%). At subgroup analyses, according to preoperative risk groups, sensitivity, specificity, PPV, and NPV were 51%, 93%, 73%, and 81%, respectively, in high-risk patients. Over the LNI prevalence range of 5-40%, PPV increased from 59% to 91%, while NPV decreased from 99% to 84%. CONCLUSIONS PSMA PET/CT scan provides promising accuracy in the field of primary nodal staging for PCa. The high NPV in men with a lower risk of LNI might be clinically useful to reduce the number of unnecessary PLND procedures performed. Conversely, in high-risk patients, negative PSMA PET/CT cannot replace staging ePLND. PATIENT SUMMARY In this systematic review and meta-analysis, we demonstrated that prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) scan may optimize the primary nodal staging and surgical management of prostate cancer patients candidate to radical prostatectomy. The high negative predictive value in men with a lower risk of lymph node invasion might be clinically useful for reducing the number of useless pelvic lymph node dissection (PLND) procedures performed. Conversely, in high-risk patients, negative PSMA PET/CT cannot allow avoiding of PLND.
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Affiliation(s)
- Armando Stabile
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Antony Pellegrino
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Elio Mazzone
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Donato Cannoletta
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Mario de Angelis
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Barletta
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Simone Scuderi
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Vito Cucchiara
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giorgio Gandaglia
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Daniele Raggi
- Department of Oncology, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Necchi
- Department of Oncology, Vita-Salute San Raffaele University, Milan, Italy
| | - Pierre Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Francesco Montorsi
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Briganti
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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Okubo Y, Sato S, Osaka K, Yamamoto Y, Suzuki T, Ida A, Yoshioka E, Suzuki M, Washimi K, Yokose T, Kishida T, Miyagi Y. Clinicopathological Analysis of the ISUP Grade Group And Other Parameters in Prostate Cancer: Elucidation of Mutual Impact of the Various Parameters. Front Oncol 2021; 11:695251. [PMID: 34395260 PMCID: PMC8356042 DOI: 10.3389/fonc.2021.695251] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/13/2021] [Indexed: 01/29/2023] Open
Abstract
Background Prostate cancer has become increasingly common worldwide. Although Grade group (GG) is widely accepted as an indicator of prostate cancer grade, there are malignancies that cannot be defined by GG alone. Moreover, the relationship between GG and other parameters remains unclear. Herein, we aimed to explore the biological characteristics of prostate cancer. Methods This study included 299 radical prostatectomy cases. The Chi-square test and analysis of variance were used to analyze the association of GG with binary and continuous variables. We then conducted morphological analyses. Multivariate analyses were performed to extract the data on risk factors for biochemical recurrence (BCR) and lymph node metastasis. Results The lymphatic, venous, perineural, and seminal vesicle invasion rates were 37/299 (12.4%), 25/299 (8.4%), 280/299 (93.6%), and 23/299 (7.7%), respectively. The extraprostatic extension (EPE), positive surgical margin, tertiary Gleason pattern 5, intraductal carcinoma of the prostate gland, and lymph node metastasis rates were 89/299 (29.8%), 106/299 (35.5%), 33/260 (12.7%), 56/299 (18.7%), and 23/299 (7.7%), respectively. As GG increased, various parameters became easier to visualize; however, there were differences between the parameters. Postoperative BCR was observed in 31/242 (12.8%) cases without preoperative hormone therapy; GG2, GG3, GG4, and GG5 accounted for 4, 7, 7, and 13 cases, respectively. Multivariate analyses revealed that GG and tumor diameter were significant risk factors for early BCR, whereas lymphatic invasion, EPE, and seminal vesicle invasion were significant risk factors for lymph node metastasis. For BCR, the odds ratios (ORs) for GG and tumor diameter were 2.253 (95% confidence interval (CI]): 1.297–3.912; P=0.004) and 1.074 (95% CI: 1.011–1.142; P=0.022), respectively. For lymph node metastasis, ORs for the presence of lymphatic invasion, EPE, and seminal vesicle invasion were 7.425 (95% CI: 1.688–22.583; P=0.004), 4.391 (95% CI: 1.037–18.589; P=0.044), and 5.755 (95% CI: 1.308–25.316; P=0.021), respectively. Conclusions We summarized various parameters correlating with each GG. Through multivariate analyses, we established the independent risk factors for early BCR and lymph node metastasis. In addition to GG, other important indices of malignancy were determined and weighted to provide a basis for future investigations.
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Affiliation(s)
- Yoichiro Okubo
- Department of Pathology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Shinya Sato
- Molecular Pathology and Genetics Division, Kanagawa Cancer Center Research Institute, Kanagawa, Japan
| | - Kimito Osaka
- Department of Urology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Yayoi Yamamoto
- Department of Radiology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Takahisa Suzuki
- Department of Urology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Arika Ida
- Department of Pathology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Emi Yoshioka
- Department of Pathology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Masaki Suzuki
- Department of Pathology, Kanagawa Cancer Center, Kanagawa, Japan.,Department of Pathology, University of Tokyo Hospital, Tokyo, Japan
| | - Kota Washimi
- Department of Pathology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Tomoyuki Yokose
- Department of Pathology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Takeshi Kishida
- Department of Urology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Yohei Miyagi
- Molecular Pathology and Genetics Division, Kanagawa Cancer Center Research Institute, Kanagawa, Japan
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Impact of positive surgical margin status in predicting early biochemical recurrence after robot-assisted radical prostatectomy. Int J Clin Oncol 2021; 26:1961-1967. [PMID: 34313905 DOI: 10.1007/s10147-021-01977-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/25/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND We investigated the association between positive surgical margin (PSM) status and biochemical recurrence (BCR) after robot-assisted radical prostatectomy (RARP) to develop a prognostic factor-based risk stratification model for BCR. METHODS We analyzed the data of 483 patients who underwent RARP at our hospital between October 2010 and April 2019; 435 patients without neoadjuvant therapy were finally included. The BCR-free survival rate was determined using Kaplan-Meier analysis. Effects of the PSM status, including the number of PSMs, Gleason score (GS) at a PSM, and the maximum PSM length for BCR, were investigated using Cox regression analysis. RESULTS BCR was confirmed after RARP in 61 patients (14.0%), and PSM was confirmed in 74 patients (17.0%); PSM was a significant predictor of BCR (p < 0.001). The median number of PSMs was 2 (1-6), and the median maximum length of PSM was 6.0 (2.0-17.0) mm. Multivariable analysis showed lymph node invasion (p < 0.001), GS of ≥ 7 at a PSM (p = 0.022) and a maximum PSM length of > 6.0 mm (p = 0.003) were significant predictors of BCR. We classified the patients without lymph node invasion into good-, intermediate-, and poor-risk groups according to the other two risk factors (presence of 0, 1, and 2 factors, respectively) and rates of 1-year BCR-free survival (100.0, 72.7, and 48.1%, respectively). CONCLUSION Higher GS at PSM and greater length of PSM were significant predictors of BCR after RARP, and console surgeons should be careful to prevent PSM during RARP.
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Akiyoshi T, Yamaguchi T, Hiratsuka M, Mukai T, Hiyoshi Y, Nagasaki T, Ueno M, Fukunaga Y, Konishi T. Oncologic impact of lateral lymph node metastasis at the distal lateral compartment in locally advanced low rectal cancer after neoadjuvant (chemo)radiotherapy. Eur J Surg Oncol 2021; 47:3157-3165. [PMID: 34284904 DOI: 10.1016/j.ejso.2021.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/07/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION The frequency and oncologic outcomes of lateral lymph node (LLN) metastasis at the most distal lateral compartment (DLC) among clinical stage II-III low rectal cancer patients treated with neoadjuvant (chemo)radiotherapy (nCRT) are poorly understood. The aim was to investigate the oncologic impact of LLN metastasis in the DLC versus the proximal lateral compartment (PLC). MATERIALS AND METHODS Consecutive patients with low rectal cancer treated with nCRT followed by total mesorectal excision and selective LLN dissection including the DLC were analyzed retrospectively. DLC was defined as the area distal to the infra-piriformis foramen on axial MRI images. Size and location of LLN metastasis on MRI, and survival were retrospectively assessed. RESULTS Of the 718 patients, 72 (10.0%) had pathological LLN metastasis. Thirty-two (44.4%) had metastasis in the DLC (DLC group), while 40 (55.6%) had metastasis in the PLC without metastasis in the DLC (PLC group). The proportion of ypN2 category tended to be lower in the DLC group (15.6% vs 35.0%, P = 0.105). The median number of metastatic LLN was similar (1 vs. 1, P = 0.691). The median short-axis size of metastatic LLN was smaller in the DLC group than in the PLC group on pre-treatment (P < 0.001) and re-staging (P = 0.004) MRI. By multivariable analysis, LLN metastasis in the DLC was predictive of better disease-free survival (HR, 0.412; 95% CI, 0.159-0.958, P = 0.039). CONCLUSION LLN metastasis in the DLC is frequent and has favorable oncologic outcomes after surgical dissection with nCRT.
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Affiliation(s)
- Takashi Akiyoshi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Tomohiro Yamaguchi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Makiko Hiratsuka
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiki Mukai
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yukiharu Hiyoshi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiya Nagasaki
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masashi Ueno
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Yosuke Fukunaga
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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Pose RM, Knipper S, Würnschimmel C, Tennstedt P, Michl U, Maurer T, Graefen M, Steuber T. Significant reduction of lymphoceles after radical prostatectomy and pelvic lymph node dissection. BJU Int 2021; 128:728-733. [PMID: 34036733 DOI: 10.1111/bju.15497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/23/2021] [Accepted: 05/23/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To reduce the risk of symptomatic lymphocele (SLC), we present a technique using peritoneal fenestration that allows lymphatic fluid to drain into the abdomen, as SLC formation after open retropubic radical prostatectomy (ORP) with pelvic lymph node dissection (PLND) is a common adverse event. PATIENTS AND METHODS We identified 1513 patients who underwent ORP with PLND between July 2018 and November 2019. Of those, 307 patients (20.3%) received peritoneal fenestration and 1206 (79.7%) no fenestration. The rate of LCs and the necessity for intervention were analysed by uni- and multivariable logistic regression (MLR) models. A propensity score matching was performed, as well. RESULTS The median (interquartile range [IQR]) age was 65 (60-70) years. A median (IQR) of 16 (10-22) lymph nodes were dissected, 22 vs 14 lymph nodes in the fenestration vs non-fenestration group (P < 0.001). Overall, 189 patients (12.5%) were diagnosed with a LC after ORP, while 21 patients (6.8%) in the fenestration and 168 (13.9%) in the non-fenestration group had LCs (P = 0.001). In 70 patients (4.7%), LCs required further intervention, categorised as Clavien-Dindo Grade IIIa/b, with a smaller proportion in the fenestration group (2.9% vs 5.0% in the non-fenestration group, P < 0.001). There were no Clavien-Dindo Grade IV or V complications, in particular no abdominal complications in association with peritoneal fenestration observed. In MLR, peritoneal fenestration was associated with a reduced risk of LCs (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.2-0.5; P < 0.001). The risk reduction was also shown after propensity score matching (OR 0.38, 95% CI 0.21-0.68; P = 0.001). The number needed to treat was 14. CONCLUSIONS Peritoneal fenestration may decrease the rate of SLC after ORP with (extended) PLND. Therefore, it should be part of the operative strategy.
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Affiliation(s)
- Randi M Pose
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Sophie Knipper
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Würnschimmel
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre Tennstedt
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Uwe Michl
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Maurer
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Steuber
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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A Genomic-Clinicopathologic Nomogram for the Prediction of Lymph Node Invasion in Prostate Cancer. JOURNAL OF ONCOLOGY 2021; 2021:5554708. [PMID: 34122545 PMCID: PMC8172299 DOI: 10.1155/2021/5554708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/28/2021] [Accepted: 04/01/2021] [Indexed: 12/24/2022]
Abstract
Background Lymph node status is important for treatment decision making in prostate cancer (PCa). We aimed to develop a genomic-clinicopathologic nomogram for the prediction of lymph node invasion (LNI) in PCa. Methods Differentially expressed genes between LNI and non-LNI PCa samples were identified in the Cancer Genome Atlas database. Univariate Cox regression analysis and minimum redundancy maximum relevance were performed for gene selection. The synthetic minority oversampling technique (SMOTE) was conducted to balance the minority group (LNI group). Machine learning models were constructed in the training set and assessed in the validation set. Univariable logistic regression and multivariable logistic regression were applied to build a nomogram. Furthermore, the RNA-sequence data from our center were used to validate the expression levels of hub genes between five matched primary PCa and the corresponding LNI samples. Results The 37-gene-based support vector machine (SVM) model had the optimal synthesized performance in the SMOTE-balanced training (area under the curve (AUC): 0.947) and validation (AUC: 0.901) sets. Incorporating the SVM-based risk score and the Gleason grade, the genomic-clinicopathologic nomogram demonstrated good prediction and calibration both in the SMOTE-balanced training (AUC: 0.946) and validation (AUC: 0.910) sets. The dysregulated expression of hub genes between PCa and LNI samples was also validated. Conclusion The proposed nomogram combining the 37-gene-based SVM model with the Gleason grade had the potential to preoperatively predict LNI in PCa. Some of the hub genes should be prioritized for functional studies and mechanistic analyses.
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Hoekstra RJ, Goossens WJH, Beulens A, van Herk H, Hoevenaars BM, de Baaij J, Somford DM, Sedelaar JPM, van Basten JPA, Vrijhof HJEJ. Reassessment of Prostate Biopsy Specimens for Patients Referred for Robot-assisted Radical Prostatectomy Rarely Influences Surgical Planning. EUR UROL SUPPL 2021; 28:36-42. [PMID: 34337523 PMCID: PMC8317876 DOI: 10.1016/j.euros.2021.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 11/23/2022] Open
Abstract
Background The minimum volume standard is 100 robot-assisted radical prostatectomy (RARP) procedures per hospital in the Netherlands, so patients have to be referred to high-volume surgical centers for RARP. During preoperative work-up, prostate biopsies taken elsewhere are reassessed, with upgrading or downgrading of the initial Gleason grade group a possible consequence. Objective To determine if prostate biopsy reassessment leads to adjustment of the surgical plan regarding a nerve-sparing approach and extended pelvic lymph node dissection (ePLND) during RARP. Design, setting, and participants For 125 men who were referred to the Prosper prostate center at Canisius Wilhelmina Hospital (CWH) in the Netherlands between 2013 and 2016, results for the initial assessment of prostate biopsy by a local uropathologist were compared to results for biopsy reassessment by dedicated uropathologists at CWH. Results and limitations The pathologists reached agreement in 80% of the cases. In cases for which there was disagreement (n = 25), biopsy revision involved upgrading of the initial grade group in 68% and downgrading in 32%. Biopsy reassessment led to a change in surgical plan in ten cases (8%). As a result of upgrading, ePLND was performed in three patients (2%). ePLND was omitted in one patient (1%) because of downgrading. For three patients (2%) a non–nerve-sparing procedure was planned after upgrading of the initial grade group. For four patients (3%), a unilateral nerve-sparing procedure was performed after downgrading. Conclusions This study shows that there is large interobserver agreement between uropathologists in the assessment of Gleason grade group in prostate biopsy specimens. Reassessment rarely leads to a change in surgical plan regarding the indication for a nerve-sparing approach and ePLND. Therefore, reassessment of prostate biopsy before radical prostatectomy can be omitted when the initial pathological assessment was performed by a dedicated uropathologist. Patient summary Reassessment of the initial prostate biopsy specimen for patients referred to a specialist center for robot-assisted removal of the prostate rarely influences surgical planning and can be omitted.
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Affiliation(s)
- Robert J Hoekstra
- Department of Urology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.,Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Prosper Prostate Clinic, Nijmegen, The Netherlands
| | - Ward J H Goossens
- Department of Urology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Alexander Beulens
- Department of Urology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Hilde van Herk
- Department of Pathology, PAMM Foundation Laboratory for Pathology and Medical Microbiology, Veldhoven, The Netherlands
| | - Brigiet M Hoevenaars
- Department of Pathology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Joost de Baaij
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Prosper Prostate Clinic, Nijmegen, The Netherlands
| | - Diederik M Somford
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Prosper Prostate Clinic, Nijmegen, The Netherlands
| | - J P Michiel Sedelaar
- Prosper Prostate Clinic, Nijmegen, The Netherlands.,Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jean-Paul A van Basten
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Prosper Prostate Clinic, Nijmegen, The Netherlands
| | - H J Eric J Vrijhof
- Department of Urology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.,Prosper Prostate Clinic, Nijmegen, The Netherlands
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Goßler C, May M, Breyer J, Stojanoski G, Weikert S, Lenart S, Ponholzer A, Dreissig C, Burger M, Gilfrich C, Bründl J, Rosenhammer B. High BMI, Aggressive Tumours and Long Console Time Are Independent Predictive Factors for Symptomatic Lymphocele Formation after Robot-Assisted Radical Prostatectomy and Pelvic Lymph Node Dissection. Urol Int 2021; 105:453-459. [PMID: 33794533 DOI: 10.1159/000514439] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/22/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Lymphocele (LC) formation is a common complication which may cause severe symptoms after robot-assisted radical prostatovesiculectomy (RARP) with concomitant pelvic lymph node dissection (PLND). Compared to open radical prostatectomy, the amount of data on potential risk factors for LC formation is still limited. The aim of the present study was to identify risk factors for symptomatic LC formation (sLC) after RARP with PLND. METHODS We used the data of a prospective multicentre series of 232 RARP patients which were treated between March 2017 and December 2017. The primary endpoint was the presence of sLC within 90 days. Asymptomatic LC (aLC) formation was also recorded. We evaluated clinical, perioperative, and histopathological criteria and compared their distribution in patients with and without post-operative sLC. Uni- and multivariable logistic regression analyses (MVAs) were performed to identify potential predictors for LC formation. Regarding the influence of patients' BMI, 2 models were calculated: BMI continuously (model 1) and BMI dichotomized with cut-off 30 kg/m2 (WHO definition, model 2). RESULTS Post-operative sLC was present in 21 patients (9.1%), while aLC was detected in 49 patients (21.1%) 90 days after RARP with PLND. Patients with sLC showed higher median baseline PSA levels (9.8 vs. 8.1 ng/mL), higher prevalence of obesity (BMI >30; 42.9 vs. 19.9%), and longer median console time (180 vs. 165 min) compared to patients without sLC. On MVA higher BMI {model 1: OR 1.145 (confidence interval [CI] 1.025-1.278); model 2: OR 2.761 (1.045-7.296)}, longer console time (model 1: OR 1.013 [1.005-1.021]; model 2: OR 1.013 [1.005-1.020]) and an ISUP grade ≥3 (model 1: OR 3.247 [1.182-8.917]; model 2: OR 2.791 [1.050-7.423]) were identified as independent predictors for sLC development. CONCLUSION Patients with aggressive tumours and higher BMI should be informed about a potentially increased risk for sLC formation. In case of a long console time, a close and regular follow-up should be considered to check for LC development.
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Affiliation(s)
- Christopher Goßler
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Matthias May
- Department of Urology, St. Elisabeth Hospital Straubing, Brothers of Mercy Hospital, Straubing, Germany
| | - Johannes Breyer
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Gjoko Stojanoski
- Department of Urology, St. Elisabeth Hospital Straubing, Brothers of Mercy Hospital, Straubing, Germany
| | - Steffen Weikert
- Department of Urology, Vivantes Humboldt Hospital, Berlin, Germany
| | - Sebastian Lenart
- Department of Urology and Andrology, St. John of God Hospital Vienna, Brothers of Mercy Hospital, Vienna, Austria
| | - Anton Ponholzer
- Department of Urology and Andrology, St. John of God Hospital Vienna, Brothers of Mercy Hospital, Vienna, Austria
| | | | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Christian Gilfrich
- Department of Urology, St. Elisabeth Hospital Straubing, Brothers of Mercy Hospital, Straubing, Germany
| | - Johannes Bründl
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Bernd Rosenhammer
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
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46
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Goldman CC, Dall CP, Sholklapper T, Brems J, Kowalczyk K. Complex space of Retzius lymphocele resulting in iliac compression and submassive pulmonary embolism after robotic Retzius sparing prostatectomy. Urol Case Rep 2021; 36:101598. [PMID: 33659187 PMCID: PMC7890136 DOI: 10.1016/j.eucr.2021.101598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 11/25/2022] Open
Abstract
Lymphoceles are common following prostatectomy with lymph node dissection, but the vast majority are asymptomatic. We present a unique case of a large complex lymphocele tracking into the anterior space of Retzius following Retzius sparing prostatectomy and bilateral pelvic lymphadenectomy. The patient initially presented with shortness of breath and subsequent diagnosis of a submassive pulmonary embolism. Further evaluation revealed compression of the iliac vessels by the fluid collection. Following multiple failed attempts of drainage percutaneously, the patient required return to the operating room for peritoneal marsupialization, drainage of fluid collection, and evacuation of large amounts of clot within the collection.
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Affiliation(s)
- Charlotte C Goldman
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Urology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Christopher P Dall
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Urology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Tamir Sholklapper
- Georgetown University School of Medicine, Georgetown University, Washington, DC, USA
| | - Jacob Brems
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Urology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Keith Kowalczyk
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, USA.,Georgetown University School of Medicine, Georgetown University, Washington, DC, USA
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47
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Rajakumar T, Yassin M, Musbahi O, Harris E, Lopez JF, Bryant RJ, Tullis ID, Vojnovic B, Hamdy FC, Lamb AD. Use of intraoperative fluorescence to enhance robot-assisted radical prostatectomy. Future Oncol 2021; 17:1083-1095. [PMID: 33590768 DOI: 10.2217/fon-2020-0370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Robot-assisted radical prostatectomy has become the standard of care for the removal of localized prostate cancer. Positive outcomes depend upon the precise removal of the prostate and associated tissue without damage to nearby structures. This process can be aided by fluorescence-guided surgery to enhance the visual contrast between different structures. Here the authors have conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify ten investigations into the use of fluorescence-guided surgery in robot-assisted radical prostatectomy. These studies used fluorescent tracers to identify structures, including the prostate, neurovascular bundle and lymph nodes. These studies demonstrate the safe and effective use of fluorescence-guided surgery in robot-assisted radical prostatectomy and pave the way for further developments in this field.
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Affiliation(s)
- Timothy Rajakumar
- Department of Urology, Churchill Hospital Cancer Centre, Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK
| | - Musaab Yassin
- Department of Urology, Churchill Hospital Cancer Centre, Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK
| | - Omar Musbahi
- Department of Urology, Churchill Hospital Cancer Centre, Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK
| | - Eli Harris
- Bodleian Healthcare Libraries, University of Oxford, OX3 9DU, UK
| | - J Francisco Lopez
- Department of Urology, Churchill Hospital Cancer Centre, Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK
| | - Richard J Bryant
- Department of Urology, Churchill Hospital Cancer Centre, Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK
- Nuffield Department of Surgical Sciences, University of Oxford, OX3 9DU, UK
| | - Iain Dc Tullis
- Department of Oncology, Cancer Research UK & Medical Research Council Oxford Institute for Radiation Oncology, University of Oxford, OX3 7DQ, UK
| | - Borivoj Vojnovic
- Department of Oncology, Cancer Research UK & Medical Research Council Oxford Institute for Radiation Oncology, University of Oxford, OX3 7DQ, UK
| | - Freddie C Hamdy
- Department of Urology, Churchill Hospital Cancer Centre, Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK
- Nuffield Department of Surgical Sciences, University of Oxford, OX3 9DU, UK
| | - Alastair D Lamb
- Department of Urology, Churchill Hospital Cancer Centre, Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK
- Nuffield Department of Surgical Sciences, University of Oxford, OX3 9DU, UK
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48
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Ogawa K, Shimizu Y, Uketa S, Utsunomiya N, Asai S, Ishihara M, Hashimoto K, Kanamaru S. Rapid recurrence of squamous cell carcinoma at a lymphocele after nephroureterectomy: A rare case report. IJU Case Rep 2021; 4:118-121. [PMID: 33718823 PMCID: PMC7924088 DOI: 10.1002/iju5.12259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/15/2021] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Lymphoceles are sometimes formed after pelvic lymph node dissection. However, recurrence at lymphoceles has not been reported previously. Here, we report a case of rapid prognosis of the recurrence at a lymphocele after nephroureterectomy. CASE PRESENTATION A 78-year-old man underwent retroperitoneoscopic radical nephroureterectomy with pelvic lymphadenectomy for left ureteral urothelial carcinoma. The histopathological diagnosis was high-grade invasive urothelial carcinoma with squamous differentiation. Follow-up computed tomography at 3 months postoperatively showed a lymphocele with a small solid component, in the left pelvic region. At 7 months postoperatively, he presented with severe fatigue, and computed tomography showed a solid tumor had replaced the lymphocele. Computed tomography-guided biopsy was performed and histopathological diagnosis was squamous cell carcinoma. CONCLUSION This report provides support for possible recurrence at the lymphocele after nephroureterectomy. If lymphocele occurs after surgery for malignant disease, it is recommended to follow up with the possibility of recurrence in the lymphatic cysts in mind.
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Affiliation(s)
- Kosuke Ogawa
- Department ofUrologyKobe City Nishi‐Kobe Medical CenterKobeHyogoJapan
| | - Yousuke Shimizu
- Department ofUrologyKobe City Nishi‐Kobe Medical CenterKobeHyogoJapan
| | - Shoko Uketa
- Department ofUrologyKobe City Nishi‐Kobe Medical CenterKobeHyogoJapan
| | | | - Satsuki Asai
- Department ofPathologyKobe City Nishi‐Kobe Medical CenterKobeHyogoJapan
| | - Misa Ishihara
- Department ofPathologyKobe City Nishi‐Kobe Medical CenterKobeHyogoJapan
| | - Kimio Hashimoto
- Department ofPathologyKobe City Nishi‐Kobe Medical CenterKobeHyogoJapan
| | - Sojun Kanamaru
- Department ofUrologyKobe City Nishi‐Kobe Medical CenterKobeHyogoJapan
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49
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Deutsch S, Hadaschik B, Lebentrau S, Ubrig B, Burger M, May M. Clinical Importance of a Peritoneal Interposition Flap to Prevent Symptomatic Lymphoceles after Robot-Assisted Radical Prostatectomy and Pelvic Lymph Node Dissection: A Systematic Review and Meta-Analysis. Urol Int 2021; 106:28-34. [PMID: 33567440 DOI: 10.1159/000512960] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 11/04/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Robot-assisted radical prostatectomy (RARP) including pelvic lymph node dissection (PLND) is the current state of the art in surgical therapy of localized prostate cancer with intermediate or high risk. PLND in particular is associated with morbidity inherent to this method; the rate of symptomatic lymphoceles (sLCs), for example, ranges up to 10%. OBJECTIVE Various intraoperative modifications have been developed with the aim of reducing the sLC rate. Based on current studies, a peritoneal interposition flap (PIF) appears to be one of the most effective methods for this purpose. Under the criteria of a systematic review, 5 retrospective studies have been identified until now, 4 of which showed a positive effect of PIF on the sLC rate. RESULTS AND LIMITATIONS A total of 1,308 patients were included in the aggregated analysis of these 5 studies. The amount of sLCs was 1.3% (8/604) and 5.7% (40/704) in the PIF and standard groups, respectively (p < 0.001). The resulting odds ratio (OR) was 0.23 (95% confidence interval [CI]: 0.05-0.99), taking in-to account a noteworthy heterogeneity of the 5 studies (Q = 9.47, p = 0.05; I2 = 58%). In addition, a prospective randomized and blinded study (Pianoforte trial) with corresponding sLC rates of 8.3% (9/108) versus 9.7% (12/124) (p = 0.820) exists. In this study, the OR was 0.85 (95% CI: 0.34-2.10, p = 0.722). CONCLUSION Despite positive results from retrospective studies with indirect evidence, the role of the PIF in the reduction of sLC in RARP could not be conclusively assessed yet. The results of the first prospective randomized study do not show a positive effect of PIF, declaring a research gap for further studies with direct evidence.
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Affiliation(s)
| | - Boris Hadaschik
- Department of Urology, University Hospital Essen, Essen, Germany.,German Cancer Consortium (DKTK), University Hospital Essen, Essen, Germany
| | - Steffen Lebentrau
- Department of Urology, Brandenburg Medical School Theodor Fontane, Ruppiner Kliniken, Neuruppin, Germany
| | - Burkhard Ubrig
- Department of Urology, Augusta Kliniken Bochum Hattingen, Bochum, Germany
| | - Max Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Matthias May
- Department of Urology, St. Elisabeth-Hospital Straubing, Brothers of Mercy Hospital, Straubing, Germany
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50
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Schneider G, Ourfali S, Rouviere O, Pagnoux G, Colombel M. Lymphatic embolization for the management of symptomatic pelvic lymphocele after radical prostatectomy with lymph node dissection: Report of two cases. IJU Case Rep 2021; 4:5-9. [PMID: 33426486 PMCID: PMC7784736 DOI: 10.1002/iju5.12212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Pelvic lymphocele is the most common complication of pelvic lymph node dissection after radical prostatectomy. Management of symptomatic pelvic lymphocele begins with percutaneous drainage, followed by sclerotherapy or surgical marsupialization and more recently, lymphatic embolization. In this article, we show the feasibility and results of two lymphatic embolization after prostatectomy with lymph node dissection. CASE PRESENTATION We decided to perform lymphatic embolization in two patients with persistent symptomatic pelvic lymphocele, after percutaneous drainage. This was done through inguinal lymph node puncture using Lipiodol and N-butyl cyanoacrylate glue injection. Drainage removal was done on the day after the procedure and clinical recovery was maintained at follow-up visits, 3 and 4 months later, in both patients. Computed tomography at 6 and 10 weeks after embolization showed the disappearance of the lymphocele. CONCLUSION Our two case reports support the promising results of lymphatic embolization in this pathology.
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Affiliation(s)
- Gregoire Schneider
- Urologic Surgery and Transplantation DepartmentHôpital Edouard HerriotHospices Civils de LyonLyonFrance
| | - Said Ourfali
- Urologic Surgery and Transplantation DepartmentHôpital Edouard HerriotHospices Civils de LyonLyonFrance
- Université Lyon 1 Faculté de Médecine Lyon EstUniversité de LyonLyonFrance
| | - Olivier Rouviere
- Department of UroradiologyHôpital Edouard HerriotHospices Civils de LyonLyonFrance
- Université Lyon 1 Faculté de Médecine Lyon EstUniversité de LyonLyonFrance
| | - Gaele Pagnoux
- Department of UroradiologyHôpital Edouard HerriotHospices Civils de LyonLyonFrance
| | - Marc Colombel
- Urologic Surgery and Transplantation DepartmentHôpital Edouard HerriotHospices Civils de LyonLyonFrance
- Université Lyon 1 Faculté de Médecine Lyon EstUniversité de LyonLyonFrance
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