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Sivalingam S, Oxley J, Probert JL, Stolzenburg JU, Schwaibold H. Role of Pelvic Lymphadenectomy in Prostate Cancer Management. Urology 2007; 69:203-9. [PMID: 17320652 DOI: 10.1016/j.urology.2006.10.031] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2006] [Revised: 08/24/2006] [Accepted: 10/23/2006] [Indexed: 11/19/2022]
Affiliation(s)
- S Sivalingam
- Bristol Urological Institute, Southmead Hospital, Bristol, United Kingdom.
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Knap MM, Lundbeck F, Overgaard J. The role of pelvic lymph node dissection as a predictive and prognostic factor in bladder cancer. Eur J Cancer 2003; 39:604-13. [PMID: 12628839 DOI: 10.1016/s0959-8049(02)00768-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to evaluate the value of pelvic lymph node dissection (PLND) performed as a separate procedure in a consecutive Danish bladder cancer cohort and also to analyse if the number of lymph nodes excised had an impact on outcome. From 1992 to 1998, 339 cystectomy candidates were retrospectively reviewed. Based on a preoperative PLND, 248 patients (10% N+) underwent radical cystectomy and 91 (87% N+) underwent radio- or chemotherapy. The median follow-up was 6.3 years. PLND was able to separate N+ from N0 patients with a false-negative rate of 3% compared with the following cystectomy. Lymph node-positive patients treated with cystectomy (n=24) all died from their bladder cancer. Therefore, accurate pathological N classification before the treatment decision seems worthwhile. The median number of lymph nodes excised was six and the number of lymph nodes had an independent prognostic impact on survival. This underlines the need for guidelines for surgical lymphadenectomy and the pathological assessment of lymph nodes in bladder cancer.
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Affiliation(s)
- M M Knap
- Department of Urology, Aarhus University Hospital, Denmark.
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Bolla M. Treatment of Localized or Locally Advanced Prostate Cancer: The Clinical Use of Radiotherapy. ACTA ACUST UNITED AC 2003. [DOI: 10.1016/s1570-9124(03)00006-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Indications for Pelvic Lymphadenectomy. Prostate Cancer 2003. [DOI: 10.1016/b978-012286981-5/50029-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Clearly, pelvic lymphadenectomy can provide important staging information in the management of prostate cancer, but this benefit is counterbalanced by a modest increase in morbidity and the significant cost of the procedure. It is difficult to provide universal recommendations concerning the indications for pelvic lymphadenectomy. Part of the problem lies in the fact that urologists perform pelvic lymphadenectomy for several different reasons. Some surgeons perform pelvic lymphadenectomy to better counsel patients after radical prostatectomy about their risk for disease progression and for planning adjuvant radiotherapy or hormonal therapy. For these surgeons, preoperative clinical staging parameters do not exclude patients from pelvic lymphadenectomy, and frozen section analysis intraoperatively provides no useful information. Alternatively, the staging information from pelvic lymphadenectomy can be used to justify cancellation of the subsequent prostatectomy should regional spread of prostate cancer be identified, sparing the patient the morbidity of an unnecessary radical prostatectomy. With this approach, despite the false-negative rate of up to 30%, the expense of frozen section analysis seems justified. For this second group of surgeons, the problem becomes balancing the modest morbidity and cost of pelvic lymphadenectomy against the probability that nodal spread of prostate cancer will be missed if the procedure is omitted. The authors consider a greater than 4% risk for missing regional disease to be unacceptable in this setting. Following this assumption, Table 3 outlines parameters for clinical stage, Gleason score, and preoperative PSA within which pelvic lymphadenectomy is indicated. These recommendations are based on [table: see text] predictions from the Partin nomogram, which has been validated using a series of over 4000 patients. For the large number of patients with clinical T1c disease and a preoperative PSA less than 10 ng/mL, bilateral pelvic lymphadenectomy is indicated only if prostate biopsy identifies tumor of Gleason grade 4 or higher. For lower-grade tumors in this patient population, the risk for nodal metastasis was less than 5% in the Johns Hopkins and Mayo Clinic series of over 5800 patients with prostate cancer. For a large pool of patients, the several thousand dollar cost of pelvic lymphadenectomy and the risk for injury to the obturator nerves and vessels, the formation of lymphoceles, and chronic genital edema can be eliminated with low risk. A nomogram-based approach provides only a starting point for a decision analysis framework to determine whether the surgeon should perform lymphadenectomy at the time of radical prostatectomy because current nomograms predict only lymph node positivity. In a decision analysis framework, some patient and physician value is derived from a negative lymphadenectomy. Moreover, the morbidity associated with pelvic lymphadenectomy and the potential inconvenience associated with treating such morbidity also would be factored into the decision. Consequently, a decision analysis framework that takes into account prognostic value, costs, morbidity, and health state uses ultimately will provide the most informative method for determining when pelvic lymphadenectomy is indicated in patients with prostate cancer.
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Affiliation(s)
- R E Link
- Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
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Wolf JS. Indications, technique, and results of laparoscopic pelvic lymphadenectomy. J Endourol 2001; 15:427-35; discussion 447-8. [PMID: 11394457 DOI: 10.1089/089277901300189493] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite considerable clinical research, there is still controversy about the optimal management of the pelvic lymph nodes in men with prostate cancer. This article reviews the creation and application of selection criteria for laparoscopic pelvic lymphadenectomy and describes the various techniques.
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Affiliation(s)
- J S Wolf
- Department of Surgery, University of Michigan, Ann Arbor 48109-0330, USA.
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Kim JC, Gerber GS. Should laparoscopy be the standard approach used for pelvic lymph node dissection? Curr Urol Rep 2001; 2:171-9. [PMID: 12084287 DOI: 10.1007/s11934-001-0015-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Involvement of the pelvic lymph nodes in patients with prostate cancer worsens the overall prognosis of this common disease entity. Prior radiographic staging techniques, including fine-needle aspiration, are limited by a poor sensitivity and are not reliable. The gold standard for the evaluation of pelvic lymph nodes in men with prostate cancer involves performing a lymphadenectomy. Historically, this procedure was performed using an open surgical technique. Unfortunately, this invasive procedure is associated with significant morbidity. In response, modern surgical technology has provided newer, less invasive techniques, including laparoscopic pelvic lymphadenectomy (LPLND). Improved detection of localized prostate cancer through the institution of screening protocols and early detection programs has decreased the number of patients presenting with lymph node involvement. Various clinical indicators, including prostate-specific antigen, grade, and stage, have been used to improve the selection of "high-risk" patients that are appropriate candidates for pelvic lymph node dissection. The technique of LPLND is a valid option in the armamentarium for staging of prostate cancer. The laparoscopic approach provides the same staging accuracy as the open surgical technique and is superior with respect to morbidity. LPLND is limited to patients who present with a high risk of advanced prostate cancer. In addition, the urologist must accept the additional training, financial expense, and "learning curve" associated with this technique.
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Affiliation(s)
- J C Kim
- Department of Surgery, Section of Urology, The University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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Akakura K, Furuya Y, Suzuki H, Komiya A, Ichikawa T, Igarashi T, Tanaka M, Murakami S, Ito H. External beam radiation monotherapy for prostate cancer. Int J Urol 1999; 6:408-13. [PMID: 10466453 DOI: 10.1046/j.1442-2042.1999.00082.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND To clarify the implications and limitations of external beam radiation monotherapy for localized prostate cancer, the long-term outcomes and prognostic factors were investigated. METHODS Between 1976 and 1994, 91 patients with untreated prostate cancer were treated with external beam radiation therapy alone. Thirty-two were classified as T1b, eight were T2a, four were T2b and 47 were T3. Pelvic lymphadenectomy was carried out in 69 cases; 57 were staged as pN0, eight were pN1, four were pN2 and 22 were pNX. Linac X-rays were used in 55 cases, fast neutron in 15 and a combination of the two in 21. No other therapy was given until relapse and when relapse was evident endocrine therapy was started. RESULTS The observation period ranged from 3 to 206 months with a median of 78 months. Local control rate and disease-free, cause-specific and overall survivals at 10 years were 74.0, 49.6, 74.2 and 39.2%, respectively. By univariate analysis, T category, pN category and histologic grade were significant prognostic indicators for disease-free survival. Multivariate analysis revealed that T category was an independent prognostic factor. In T2b and T3 diseases, pN0/1 patients demonstrated significantly better disease-free survival than pNX. CONCLUSIONS A favorable long-term outcome was achieved by external beam radiation monotherapy in patients with minimally extended prostate cancer (T1b and T2a). For locally advanced disease (T2b and T3), staging pelvic lymphadenectomy would be useful for the selection of patients.
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Affiliation(s)
- K Akakura
- Department of Urology, Chiba University School of Medicine, Japan.
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Ramshaw BJ, Esartia P, Mason EM, Wilson R, Duncan T, White J, Lucas G. Laparoscopy for diagnosis and staging of malignancy. SEMINARS IN SURGICAL ONCOLOGY 1999; 16:279-83. [PMID: 10332773 DOI: 10.1002/(sici)1098-2388(199906)16:4<279::aid-ssu2>3.0.co;2-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of minimally invasive surgery for abdominal pathology, including malignancy, has increased significantly within the past decade. Despite the advances in radiographic imaging, the use of laparoscopy for diagnosing and staging abdominal malignancy has become an important tool in the overall care of these patients. A review of published series for a variety of abdominal malignancies is presented. With the growing experience in this technique, some preliminary conclusions and ongoing issues are discussed.
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Affiliation(s)
- B J Ramshaw
- Department of General Surgery, Atlanta Medical Center, Georgia.
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Fornara P, Doehn C, Jocham D. Role of laparoscopy in the lymph-node staging of urological malignancies. MINIM INVASIV THER 1999. [DOI: 10.3109/13645709909153173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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STONE NELSONN, STOCK RICHARDG, PARIKH DHAVAL, YEGHIAYAN PAULA, UNGER PAMELA. PERINEURAL INVASION AND SEMINAL VESICLE INVOLVEMENT PREDICT PELVIC LYMPH NODE METASTASIS IN MEN WITH LOCALIZED CARCINOMA OF THE PROSTATE. J Urol 1998. [DOI: 10.1016/s0022-5347(01)62393-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- NELSON N. STONE
- From the Departments of Urology, Radiation Oncology and Pathology, Mount Sinai School of Medicine and Medical Center New York, New York
| | - RICHARD G. STOCK
- From the Departments of Urology, Radiation Oncology and Pathology, Mount Sinai School of Medicine and Medical Center New York, New York
| | - DHAVAL PARIKH
- From the Departments of Urology, Radiation Oncology and Pathology, Mount Sinai School of Medicine and Medical Center New York, New York
| | - PAULA YEGHIAYAN
- From the Departments of Urology, Radiation Oncology and Pathology, Mount Sinai School of Medicine and Medical Center New York, New York
| | - PAMELA UNGER
- From the Departments of Urology, Radiation Oncology and Pathology, Mount Sinai School of Medicine and Medical Center New York, New York
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Kava BR, Dalbagni G, Conlon KC, Russo P. Results of laparoscopic pelvic lymphadenectomy in patients at high risk for nodal metastases from prostate cancer. Ann Surg Oncol 1998; 5:173-80. [PMID: 9527271 DOI: 10.1007/bf02303851] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic pelvic lymphadenectomy (LPLND) can be performed safely and with minimal morbidity in the staging of prostate cancer. Its utility in evaluating patients at high risk for metastatic disease before primarily nonsurgical treatment modalities was evaluated. METHODS Twenty-four consecutive patients who underwent LPLND between June 1993 and July 1996 were studied. These patients were considered poor surgical candidates based on several risk factors, as follows: elevation of serum PSA >20 in 19 patients (79%); elevation of serum acid phosphatase in 4 patients (17%); digital rectal examination findings indicative of extraprostatic extension or seminal vesical involvement in 14 patients (58%); and poorly differentiated tumors on prostate biopsy in 19 patients (79%). Nineteen patients (79%) had two or more of these risk factors. Median PSA for the entire series of patients was 35.2 ng/mL (range 7.9 to 133 ng/mL), and median Gleason score was 7 (range 5 to 9). Preoperative CT or MRI was negative for pelvic lymph node metastases in 17 of 23 patients (79%), and bone scan was negative in all 24 patients. RESULTS Unilateral (n = 2) or bilateral (n = 22) LPLND was performed in all patients. Six patients (25%) had lymph node metastases detected laparoscopically. Five of the six patients had palpable extraprostatic extension (T3a/b) or invasion of a seminal vesical (T3c), and in four of these patients the site of the metastatic lymph nodes was ipsilateral to the palpable prostate abnormality. None of the risk factors was independently predictive of lymph node metastases within this series of patients. An average of 10.8 +/- 6.5 lymph nodes was removed at a mean operative time of 174 +/- 10 minutes for patients undergoing bilateral LPLND. Estimated blood loss was minimal for 20 of 22 patients (92%) undergoing LPLND alone, and there were no complications requiring open exploration. Mean postoperative hospital stay was 1.2 +/- 0.5 days for patients undergoing LPLND alone. CONCLUSIONS LPLND can be used efficiently to identify patients with nodal metastases from select high-risk patients. This, in turn, can exclude such patients from noncurative local and regional therapy.
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Affiliation(s)
- B R Kava
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Elbahnasy AM, Hoenig DM, Shalhav A, McDougall EM, Clayman RV. Laparoscopic staging of bladder tumor: concerns about port site metastases. J Endourol 1998; 12:55-9. [PMID: 9531153 DOI: 10.1089/end.1998.12.55] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Since the first laparoscopic pelvic lymph node dissection (LPLND) was performed for prostate cancer, only one case of port site metastasis has been reported, an incidence of 0.1%. On the other hand, three cases of port site metastasis have been reported after laparoscopic staging of transitional-cell carcinoma (TCC) of the bladder, a reported incidence of almost 4%. Herein, we review the circumstances of these three cases and address the potential risk factors and possible preventive measures regarding LPLND and port site metastasis in patients with TCC of the bladder.
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Affiliation(s)
- A M Elbahnasy
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Raboy A, Adler H, Albert P. Extraperitoneal endoscopic pelvic lymph node dissection: a review of 125 patients. J Urol 1997; 158:2202-4; discussion 2204-5. [PMID: 9366344 DOI: 10.1016/s0022-5347(01)68195-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE We evaluated the efficacy of a totally extraperitoneal approach to endoscopic pelvic lymph node dissection. MATERIALS AND METHODS Extraperitoneal endoscopic pelvic lymphadenectomy was performed in 125 patients with clinically localized prostate cancer. All patients were candidates for brachytherapy, cryotherapy or radical perineal prostatectomy. The first 65 patients underwent lymphadenectomy regardless of local clinical stage, prostate specific antigen (PSA) or tumor grade. The last 60 patients met 2 of 3 selection criteria, consisting of clinical local stage T2b or greater, prostate specific antigen greater than 20 and Gleason score 7 or higher. Patients were evaluated for morbidity and mortality, nodal yield, operative time, conversion rate to transperitoneal laparoscopic or open lymphadenectomy and hospital stay. RESULTS Mean operative time was 104 minutes, mean length of stay was 2.1 days and mean nodal yield was 10.2. Of the patients 19.2% had positive nodes, and positive nodal yield increased to 32.9% when selection criteria were used. Of the cases 4% were converted to a transabdominal laparoscopic approach and 2.4% to open lymphadenectomy. Symptomatic lymphoceles required percutaneous drainage in 2.4% of the patients. One patient died of massive pulmonary embolism. CONCLUSIONS This study demonstrates that the extraperitoneal endoscopic pelvic lymph node dissection is an effective and relatively safe method of surgically staging prostate cancer. It compares favorably to other methods of surgical staging.
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Affiliation(s)
- A Raboy
- Staten Island University Hospital and State University of New York, Health Science Center, Brooklyn, USA
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Raboy A, Ferzli G, Albert P. Initial experience with extraperitoneal endoscopic radical retropubic prostatectomy. Urology 1997; 50:849-53. [PMID: 9426712 DOI: 10.1016/s0090-4295(97)00485-8] [Citation(s) in RCA: 159] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES We report our initial experience using laparoscopic instruments and techniques in the performance of radical retropubic prostatectomy (RRP) through an entirely extraperitoneal endoscopic (EE) approach. METHODS A 62-year-old man with a Gleason score of 7 and clinical stage T1c adenocarcinoma of the prostate underwent EERRP. The procedure was evaluated for achievement of removal of the prostate and seminal vesicles and for complete vesicourethral anastomosis. Operative time, blood loss, hospital stay, and pathologic findings were also evaluated. RESULTS Complete endoscopic removal of the prostate and seminal vesicles was achieved. Endoscopic reconstruction of the bladder neck with a watertight anastomosis was successful. Operative time was 5 hours and 45 minutes, with an estimated blood loss of 600 cc. Hospital stay was 2.5 days. Final pathologic evaluation was a Gleason score of 7 and Stage T2 disease with negative margins. CONCLUSIONS The initial experience for EERRP is encouraging. Further evaluation to refine the technique and determine its efficacy and role in treating prostate cancer is in order.
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Affiliation(s)
- A Raboy
- Department of Urology, Staten Island University Hospital, NY, USA
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Stone NN, Stock RG, Unger P. Laparoscopic pelvic lymph node dissection for prostate cancer: comparison of the extended and modified techniques. J Urol 1997; 158:1891-4. [PMID: 9334624 DOI: 10.1016/s0022-5347(01)64161-2] [Citation(s) in RCA: 163] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE We compared the results of extended (obturator, hypogastric, common and external iliac nodes) to modified (obturator and hypogastric nodes only) laparoscopic pelvic lymph node dissection in patients with clinically localized prostate cancer. MATERIALS AND METHODS A total of 189 patients with stage T1 to T3 prostate cancer underwent modified (150) or extended (39) laparoscopic pelvic lymph node dissection for pelvic nodal assessment before definitive treatment. RESULTS Twice as many lymph nodes were removed via extended than modified laparoscopic pelvic lymph node dissection (mean 17:8 versus 9.3). The overall positivity rate was 23 of 189 lymph nodes (12.2%), including 14 of 150 (7.3%) for modified and 9 of 39 (23.1%) for extended dissection (p = 0.02). Two patients (22%) who underwent extended dissection had positive lymph nodes in the external iliac area. Patients who presented with the high risk features of prostate specific antigen (PSA) greater than 20 ng./ml., Gleason score 7 or greater, or stage T2b disease or greater had a 26.5% (p = 0.0002), 22% (p = 0.0006) or 16.4% (p = 0.003) likelihood of positive lymph nodes, respectively. For extended versus modified laparoscopic pelvic lymph node dissection node positivity in high risk patients was 27% versus 18.8% (p = 0.4), 30 versus 26.4% (p = 0.8) and 25.4 versus 14.6% (p = 0.17) for Gleason score 7 or greater, PSA greater than 20 ng./ml. and disease stage T2b to T3a, respectively. Patients who underwent the extended procedure had a higher complication rate (35.9 versus 2%, p < 0.0001). No laparotomy was required. CONCLUSIONS Despite yielding a 2-fold higher node count and higher node positivity rate, extended laparoscopic pelvic lymph node dissection offers no advantage over modified laparoscopic pelvic lymph node dissection for diagnosing positive lymph nodes when results are analyzed by prognostic factors. The extended procedure is associated with a much higher complication rate. In patients with the high risk features of PSA greater than 20 ng./ml., Gleason score 7 or greater and stage T2b to T3a disease modified laparoscopic pelvic lymph node dissection can be performed safely and effectively to help identify those who may benefit most from curative therapy.
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Affiliation(s)
- N N Stone
- Department of Urology, Mount Sinai School of Medicine, New York, New York, USA
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Cadeddu JA, Elashry OM, Snyder O, Schulam P, Moore RG, Loughlin KR, Winfield HN, Clayman RV, Kavoussi LR. Effect of laparoscopic pelvic lymph node dissection on the natural history of D1 (T1-3, N1-3, M0) prostate cancer. Urology 1997; 50:391-4. [PMID: 9301703 DOI: 10.1016/s0090-4295(97)00243-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Reports of abdominal wall tumor implantation after laparoscopic procedures have raised questions regarding the safety of laparoscopic surgery when applied to patients with malignancies. Our objective was to determine if laparoscopic pelvic lymph node dissection (LPLND) had a negative effect on tumor behavior and clinical outcome in men with Stage T1-3, N1-3, M0 (D1) prostate cancer. METHODS Fifty-two men were retrospectively identified at four institutions who had pelvic nodes positive for metastatic prostate adenocarcinoma at LPLND and at least 1 year of follow-up. Operative and clinical records were reviewed to determine morbidity, adjuvant treatment, onset of hormone-resistant disease, and survival. RESULTS During a mean follow-up of 3.1 years, there were no cases of trocar site tumor implantation. There were four perioperative complications, including enterotomy, epigastric vessel injury, abscess, and symptomatic lymphocele formation. There were three deaths from prostate cancer (5.8%) occurring 3 to 4 years after LPLND. For the 45 men treated with early androgen ablation, the 5-year biochemical prostate-specific antigen and clinical progression free rates were 45% and 55%, respectively. CONCLUSIONS Abdominal wall tumor implantation after LPLND for prostate cancer was not demonstrated, even in patients who developed hormone-resistant disease. LPLND in men with Stage D1 disease did not alter short-term disease progression. Longer follow-up in a larger cohort is necessary to determine if LPLND will have an impact on the 5 and 10-year disease progression and survival rates for patients with Stage D1 prostate cancer.
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Affiliation(s)
- J A Cadeddu
- Department of Urology, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA
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Staging Pelvic Lymphadenectomy for Localized Carcinoma of the Prostate: A Comparison of 3 Surgical Techniques. J Urol 1997. [DOI: 10.1016/s0022-5347(01)64965-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lécuru F, Robin F, Neji K, Darles C, De Bievres P, Vildé F, Taurelle R. Laparoscopic pelvic lymphadenectomy in an anatomical model: results of an experimental comparative trial. Eur J Obstet Gynecol Reprod Biol 1997; 72:51-5. [PMID: 9076422 DOI: 10.1016/s0301-2115(96)02652-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The aim of this paper was to compare the accuracy of laparoscopic versus open pelvic lymphadenectomy in an experimental trial. STUDY DESIGN We performed unilateral laparoscopy pelvic lymphadenectomy (LPL) in 33 non-embalmed cadavers between the external iliac vein, the obliterated umbilical artery and the obturator nerve. Then a laparotomy was performed to inspect the LPL limits, look for laparoscopic complications and finally realize a controlateral lymphadenectomy. The LPL side was randomly decided. A pathologist counted the number of lymph nodes collected with both techniques. We compared the number of retrieved lymph nodes, the completeness of the dissection and the complication rate with those two procedures. Student's t-test, chi 2-test and non-parametric tests were used when appropriate. RESULTS No dissection had to be aborted. One hundred and twelve nodes were removed laparoscopically (mean, 3.73; S.E., 2.9) and 84 at laparotomy (mean, 2.77; S.E., 2.06). There was no significant difference in the number of nodes retrieved with both procedures. Effectiveness of laparoscopy was not significantly different in the first ten procedures, in the second ten or in the last ten LPL. Residual tissue was observed after LPL in 13.3% of the procedures whereas all open lymphadenectomies were complete. LPL sensitivity reached at least 86% in this paper. Failures were more frequent at the beginning of the study (50% among the first ten dissections), in obese subjects or in subjects with prior history of laparotomy (but the difference was not significant). Two venous injuries occurred during LPL (6.7%). Complication rates for the two techniques were not significantly different. However, the LPL complication rate was higher at the beginning of the study and increased significantly in subjects with prior history of laparotomy (P < 0.05). CONCLUSIONS This randomized study shows that LPL and laparotomy have similar effectiveness. Incomplete dissections and complications are more frequent in obese subjects or in case of prior history of laparotomy. Fifteen procedures seems necessary to learn the technique and provide constant and safe results in routine practice.
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Affiliation(s)
- F Lécuru
- Service de Gynécologie-Obstérique, Hôpital Boucicaut, Paris, France
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Lezin MS, Cherrie R, Cattolica EV. Comparison of laparoscopic and minilaparotomy pelvic lymphadenectomy for prostate cancer staging in a community practice. Urology 1997; 49:60-3; discussion 63-4. [PMID: 9000187 DOI: 10.1016/s0090-4295(96)00378-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To compare the cost-effectiveness and morbidity of minilaparotomy (MINILAP) and laparoscopic pelvic lymphadenectomy (LAP) in a community practice setting. METHODS We reviewed our experience with 44 consecutive patients with prostate cancer who had staging pelvic lymphadenectomy from January 1992 through April 1995 in a general health maintenance organization urology practice. Of this group, 22 men had LAP and 22 men had MINILAP. RESULTS MINILAP and LAP groups were similar in age (mean 67 years). Gleason score (mean 7.2 and 6.8), prostate-specific antigen level (mean 46 and 49 ng/mL), and clinical stage (T1 to T3). Operative time was statistically significantly shorter for MINILAP (mean 1.2 hours) than for LAP (mean 2.9 hours). Complication rate was 9.1% for MINILAP and 31.8% for LAP. Lymph node metastasis was found in 45% of MINILAP patients and in 27% of LAP patients. Mean initial hospital stay was 1.0 day for MINILAP and 1.6 days for LAP. Total hospital stay including hospital readmission for complications was 1.5 days for MINILAP and 2.6 days for LAP. Cost of MINILAP was at least $1900 less than that of LAP because of shorter total hospital stay, shorter operation time, and lower equipment cost. CONCLUSIONS Compared with LAP, MINILAP was more cost-effective and produced less morbidity. Patient satisfaction with the procedures was similar. MINILAP is an excellent alternative to LAP for prostate cancer staging in general urology practice.
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Affiliation(s)
- M S Lezin
- Department of Urology, Kaiser Permanente Medical Center, Oakland, California 94611-5693, USA
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24
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Bianchi G, Beltrami P. Laparoscopic surgical lymphadenectomies in urological tumours. Urologia 1996. [DOI: 10.1177/039156039606300320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In the last few years laparoscopie surgery has also been used in urological pathologies. Various types of operations have been performed with this technique, but only recently has there been an attempt to give precise indications. Laparoscopy is being used to carry out pelvic lymphadenectomy for cancer of the prostate, the penis and the female urethra, and retroperitoneal lymphadenectomy for non-seminomatous germinal cancer of the testis. The aim of this work, which reports the authors’ experience with this technique, is to define its advantages and limitations in order to identify correct indications.
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Affiliation(s)
- G. Bianchi
- Divisione Urologica - Ospedale di Cattinara - Trieste
| | - P. Beltrami
- Cattedra e Divisione Clinicizzata di Urologia - Università degli Studi - Verona
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25
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Brant LA, Brant WO, Brown MH, Seid DL, Allen RE. A new minimally invasive open pelvic lymphadenectomy surgical technique for the staging of prostate cancer. Urology 1996; 47:416-21. [PMID: 8633413 DOI: 10.1016/s0090-4295(99)80464-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We report a new method for lymphadenectomy, the minilaparotomy (inguinal) pelvic lymph node dissection (MLPLND), and compare it with laparoscopic pelvic lymph node dissection (LPLND) in terms of cost, effectiveness, operation time and morbidity. We reviewed a series of 111 consecutive patients: 51 had MLPLND and 60 had LPLND. All patients had proved adenocarcinoma of the prostate by biopsy. Of the MLPLND patients, only 1 had to stay overnight in the hospital, and all left within 24 hours. Pelvic lymphadenectomy consisted of nodal removal along the internal iliac vessels and the external iliac vein, and nodes of the obturator foramen. A total of 14% of the patients had disease involving the lymph nodes. The cost of MLPLND was 50% of the cost of LPLND, with no interoperative or postoperative morbidity. This new operation can be performed thoroughly an inexpensively in approximately 35 minutes, with little or no morbidity. Since the drawbacks of laparoscopic techniques associated with instrument costs and the learning curve for this technically difficult operation are eliminated, staging pelvic lymphadenectomy can be performed routinely on a wider variety of patients with potential metastatic disease. Currently, we recommend MLPLND to any patient with a tumor of Gleason score 7 or higher or a serum prostate-specific antigen value of 15 ng/mL or higher.
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Affiliation(s)
- L A Brant
- School of Medicine, University of California, San Diego, USA
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26
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Abstract
Laparoscopic pelvic lymph node dissection (PLND) is the most commonly performed laparoscopic procedure in urology today. Indications for laparoscopic PLND are being refined to selectively identify patients who are at high risk for lymphatic metastases. From a technical standpoint, the anatomic detail and number of lymph nodes retrieved by the laparoscopic approach are comparable to open PLND. Laparoscopic PLND is associated with a steep learning curve and increased operative time; however, the decreased postoperative discomfort, shortened hospital stay, rapid resumption of normal activities, and enhanced cosmesis are clear advantages over open PLND.
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Affiliation(s)
- I S Gill
- Department of Surgery, University of Nebraska Medical Center, Omaha 68198-2360, USA
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27
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Jarrard DF, Chodak GW. Prostate cancer staging after radiation utilizing laparoscopic pelvic lymphadenectomy. Urology 1995; 46:538-41. [PMID: 7571224 DOI: 10.1016/s0090-4295(99)80268-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES This report assesses the feasibility of laparoscopic pelvic lymphadenectomy in irradiated patients with prostate cancer being considered for salvage therapy. METHODS Six men, each with a prior history of external beam radiation therapy, and prostate-specific antigen or clinical failure, were selected as potential candidates for salvage therapy. Utilizing a standard diamond pattern trocar conformation, laparoscopy was performed to evaluate pelvic lymph node status. RESULTS The procedure was successfully completed in all patients with a mean operating room time of 154 minutes. Blood loss averaged 55 cc. Serious intraoperative or postoperative complications were not encountered in the follow-up of 6 months. Metastatic disease was demonstrated in 1 patient. CONCLUSIONS Laparoscopic pelvic lymph node dissection is technically feasible in patients who have received irradiation, and appears to confer no additional morbidity over standard laparoscopic lymphadenectomy.
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Affiliation(s)
- D F Jarrard
- University of Chicago, Department of Surgery, Illinois, USA
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29
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Affiliation(s)
- Inderbir S. Gill
- Division of Urology, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, and Division of Urology, Department of Surgery and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Ralph V. Clayman
- Division of Urology, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, and Division of Urology, Department of Surgery and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Elspeth M. McDougall
- Division of Urology, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, and Division of Urology, Department of Surgery and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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30
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Indications for Seminal Vesicle Biopsy and Laparoscopic Pelvic Lymph Node Dissection in Men With Localized Carcinoma of Prostate. J Urol 1995. [DOI: 10.1016/s0022-5347(01)66874-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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31
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Indications for Seminal Vesicle Biopsy and Laparoscopic Pelvic Lymph Node Dissection in Men With Localized Carcinoma of Prostate. J Urol 1995. [DOI: 10.1097/00005392-199510000-00038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Barry MJ, Fleming C, Coley CM, Wasson JH, Fahs MC, Oesterling JE. Should Medicare provide reimbursement for prostate-specific antigen testing for early detection of prostate cancer? Part III: Management strategies and outcomes. Urology 1995; 46:277-89. [PMID: 7544931 DOI: 10.1016/s0090-4295(99)80208-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- M J Barry
- Medical Practices Evaluation Center, Massachusetts General Hospital, Boston 02114, USA
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Campbell SC, Klein EA, Levin HS, Piedmonte MR. Open pelvic lymph node dissection for prostate cancer: a reassessment. Urology 1995; 46:352-5. [PMID: 7544933 DOI: 10.1016/s0090-4295(99)80219-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To provide a risk-to-benefit analysis of open staging pelvic lymph node dissection (PLND) for prostate cancer. METHODS The medical records of all patients presenting with prostate cancer from July 1989 to April 1994 were reviewed. A total of 245 patients with clinically localized disease were selected to undergo radical retropubic prostatectomy (RRP) preceded by open PLND. Univariate and multivariate analyses were performed to evaluate the predictive value of the preoperative serum prostate-specific antigen (PSA) concentration, clinical stage, and Gleason score with regard to final nodal status. The cost and morbidity associated with PLND in the setting of RRP was also defined. RESULTS Overall, only 16 patients (6.5%) had lymph node metastases. Lymph node involvement correlated significantly with elevated serum PSA values (P = 0.0001), high Gleason score (P = 0.0022), and advanced clinical stage (P = 0.0001). Lymph node metastases were particularly uncommon in patients with nonpalpable tumors (1 of 67 [1.5%]), PSA values less than 10 (2 of 154 [1.3%]), and Gleason score less than 6 (1 of 26 [3.8%]). Overall, 179 patients (73.1%) presented with at least one or more of these favorable characteristics, and only 4 (2.2%) had lymph node involvement. Complications related to the lymphadenectomy occurred in 10 patients (4.1%). The cost per metastasis diagnosed in patients with low-risk characteristics was approximatley $43,600. CONCLUSIONS An open staging PLND may no longer be justified on a routine basis in patients undergoing radical retropubic prostatectomy.
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Affiliation(s)
- S C Campbell
- Department of Urology, Cleveland Clinic Foundation, Ohio 44195, USA
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Garzotto MG, Newman RC, Cohen MS, Rout R, Grice OD. Closure of laparoscopic trocar sites using a spring-loaded needle. Urology 1995; 45:310-2. [PMID: 7855980 DOI: 10.1016/0090-4295(95)80023-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Closure of laparoscopic trocar sites can be difficult, particularly in the obese patient. We have begun using a spring-loaded needle to facilitate closure of these sites. We have found that the device allows for accurate suture placement, the potential of decreased closure time, reduced risk for trocar site dehiscence, and can be used in obtaining hemostasis of abdominal wall vessels.
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Affiliation(s)
- M G Garzotto
- Department of Surgery, University of Florida, Gainesville
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36
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Bianchi G, Tallarigo C, Beltrami P, Schiavone D, Cavalleri S, Giusti G. Laparoscopic pelvic lymphadenectomy in the staging of prostatic cancer: Our experience in 37 cases. Urologia 1995. [DOI: 10.1177/039156039506201s02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
— This paper reports the result of our experience on 37 patients with prostatic carcinoma who underwent laparoscopic pelvic lymphadenectomy. The technique we practised is very similar to the one described by Schuessler in 1991. The average total number of lymph nodes removed and operative time were comparable to standard open techniques. Nine patients had distant metastasis (24.3%). We had no important complications in our series of patients. The minimally invasive approach and the rapid resumption of everyday activity widely balance the cost of this procedure if we consider its diagnostic use.
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Affiliation(s)
- G. Bianchi
- Cattedra e Divisione Clinicizzata di Urologia - Università degli Studi - Verona
| | - C. Tallarigo
- Cattedra e Divisione Clinicizzata di Urologia - Università degli Studi - Verona
| | - P. Beltrami
- Cattedra e Divisione Clinicizzata di Urologia - Università degli Studi - Verona
| | - D. Schiavone
- Cattedra e Divisione Clinicizzata di Urologia - Università degli Studi - Verona
| | - S. Cavalleri
- Cattedra e Divisione Clinicizzata di Urologia - Università degli Studi - Verona
| | - G. Giusti
- Cattedra e Divisione Clinicizzata di Urologia - Università degli Studi - Verona
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Lang GS, Ruckle HC, Hadley HR, Lui PD, Stewart SC. One hundred consecutive laparoscopic pelvic lymph node dissections: comparing complications of the first 50 cases to the second 50 cases. Urology 1994; 44:221-5. [PMID: 8048197 DOI: 10.1016/s0090-4295(94)80135-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To report the outcome of our first 100 consecutive laparoscopic pelvic lymph node dissections (LPLND) and compare the early complication rate of the first 50 cases (14%) to the second 50 cases (4%). METHODS We reviewed 100 patients who underwent LPLND: Ninety-six patients had carcinoma of the prostate and underwent LPLND prior to radical prostatectomy or definitive radiation therapy. Four patients had histologically proved penile (2) or bladder carcinoma (2) and underwent LPLND to assess their pelvic lymph nodes. RESULTS We encountered 7 major and minor complications in our first 50 cases, and 2 minor complications in our second 50 cases. The overall complication rate was 9% (9 of 100). CONCLUSIONS We believe that modification of our operative technique and changes in patient management resulted in a lower complication rate in the second 50 patients. We conclude that although LPLND has a significant learning curve, it is a viable surgical staging option for patients with urologic pelvic malignancies.
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Affiliation(s)
- G S Lang
- Division of Urology, Loma Linda University School of Medicine, California
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