Laparoscopic standard pelvic node dissection for carcinoma of the prostate: is it accurate?

Prostate cancer: detection of lymph node metastases outside the routine surgical area with ferumoxtran-10-enhanced MR imaging

PURPOSE

To prospectively evaluate the feasibility of magnetic resonance (MR) imaging with ferumoxtran-10 in patients with prostate cancer to depict lymph node metastases outside the routine pelvic lymph node dissection (PLND) area.

MATERIALS AND METHODS

The study was approved by the institutional review boards at all four hospitals; patients provided written informed consent. Two hundred ninety-six consecutive men (mean age, 67 years; range, 47-83 years) with prostate cancer and an intermediate-to-high risk for nodal metastases (prostate-specific antigen level >10 ng/mL, Gleason score >6, or stage T3 disease) were enrolled. MR lymphography of the pelvis was performed 24 hours after intravenous drip infusion of ferumoxtran-10. Positive nodes at MR lymphography were indicated to be inside or outside the routine dissection area (RDA). On the basis of MR lymphography computed tomographic (CT)-guided biopsy, routine PLND, or MR imaging-guided minimal extended PLND was performed.

RESULTS

MR lymphography findings were positive in 58 patients. Of these, 44 had histopathologic confirmation of lymph node metastases. In 18 of 44 patients (41%), MR lymphography findings showed nodes exclusively outside the RDA, which were confirmed with MR lymphography-guided extended PLND (n = 13) and CT-guided biopsy (n = 5). In another 18 patients (41%), positive nodes were located both inside and outside the RDA at MR lymphography. In these 18 patients, routine PLND was used to confirm the nodes inside the RDA (n = 11); CT-guided biopsy was used to confirm nodes outside the RDA (n = 7). In the remaining eight patients, MR lymphography findings showed only nodes inside the RDA, which was confirmed with PLND (n = 5) and CT-guided biopsy (n = 3). In 14 of the 58 patients (24%), there was no histologic confirmation.

CONCLUSION

In 41% of patients with prostate cancer, nodal metastases outside the area of routine PLND were detected by using MR imaging with ferumoxtran-10.

Laparoscopic pelvic lymph-node dissection in prostate cancer before external beam radiotherapy: Risk factors of nodal involvement and relapse following intended curative treatment

OBJECTIVE

To report experience with laparoscopic pelvic lymph-node dissection (LPLND) in patients with prostate cancer before radiotherapy. Selection of risk factors for nodal involvement (N1) and recurrence following radiotherapy was made.

MATERIAL AND METHODS

From November 1999 to June 2007, 177 patients with prostate cancer underwent LPLND at this department. The lymphadenectomy was limited to the obturator fossa bilaterally. Patients without nodal involvement were offered external beam radiotherapy with adjuvant hormone treatment.

RESULTS

Complications occurred in 17 patients (9%). The majority of these were minor and were managed by conservative methods. Twenty-six patients (15%) were diagnosed with N1. High Gleason score and a high percentage of positive needle core biopsies were both risk factors of N1 as well as recurrent disease following radiotherapy (p<0.01 and 0.01, respectively). Clinically, T3 disease was associated with a risk of recurrence but not N1. High prostate-specific antigen (PSA) nadir was also a significant predictor of recurrence. Neither pretreatment PSA nor prostate volume was associated with N1 or recurrence.

CONCLUSIONS

LPLND is a safe, well-established staging modality in clinically localized prostate cancer before radiotherapy. Risk factors upon diagnosis may be useful in the estimation of N1 and risk of recurrence.

DETECTION OF EARLY LYMPH NODE METASTASES IN PROSTATE CANCER BY LAPAROSCOPIC RADIOISOTOPE GUIDED SENTINEL LYMPH NODE DISSECTION

PURPOSE

Radioisotope guided sentinel lymph node (SLN) dissection (SLND) for prostate cancer has been shown to increase the sensitivity of detecting early metastases in open pelvic lymph node dissection. We developed a technique that allows SLND to be performed by laparoscopy in conjunction with laparoscopic radical prostatectomy.

MATERIALS AND METHODS

In 71 consecutive patients SLND was performed by 1 surgeon preceding laparoscopic radical prostatectomy. Mean preoperative prostate specific antigen was 8.88 ng/ml (range 2.1 to 25.4). At 24 hours prior to surgery 3 ml (200 MBq) Tc labeled human albumin colloid were injected into the prostate gland under transrectal ultrasound guidance. An especially designed laparoscopic gamma probe was used to measure radioactivity during surgery. SLNs were identified and removed. If frozen section analysis showed metastases, extended pelvic lymph node dissection was performed.

RESULTS

Radioactivity was detected on 2, 1 and no sides in 50 (70.4%), 19 (26.7%) and 2 patients (2.8%), respectively. In 81 of the 142 pelvic side walls (54.7%) SLNs were exclusively outside of the obturator fossa. Histopathological examination showed metastases to SLNs in 9 patients (12.9%). Eight of the 11 detected metastases (72.7%) were outside of the obturator fossa. Lymph node metastases were exclusively found in Tc marked lymph nodes. Mean tumor size was 1.7 mm (range 0.2 to 3.9).

CONCLUSIONS

SLND is feasible by laparoscopy. It detects micrometastases outside of the obturator fossa in a significant number of patients. We noted that the transperitoneal approach allowing wide exposure and a gamma probe with a 90-degree lateral energy window is the most important factor to enable successful laparoscopic SLND.

Controversies in the radiotherapeutic management of poor prognosis locally advanced prostate cancer

The Grand Round was held at the Christie Hospital, Manchester, U.K., on 30 November 2002. It followed a presentation by Dr David Dearnaley from the Royal Marsden Hospital in Sutton on 'Novel approaches and trials in prostate cancer'. Controversies in the management of locally advanced prostate cancer were illustrated by a case presentation and followed by a discussion on the evaluation of disease extent, and the roles of radiotherapy and hormone ablation.

Is a limited lymph node dissection an adequate staging procedure for prostate cancer?

PURPOSE

Generally lymph node dissection is only considered a staging procedure for prostate cancer. Therefore, the need for meticulous lymph node dissection is often questioned and only sampling is suggested. We performed a prospective study to identify the pattern of lymph node metastasis in prostate cancer and determine how extensive lymph node dissection must be not to under stage cases.

MATERIALS AND METHODS

All patients with clinically organ confined prostate cancer, no prior hormonal treatment, negative preoperative staging computerized tomography and bone scan, who underwent radical prostatectomy between 1989 and 1999, were evaluated prospectively as to the number and location of lymph node metastasis. A meticulous lymph node dissection was performed along the external iliac vein, obturator nerve and internal iliac (hypogastric) vessels. Nodes from each location and side were submitted separately for histological evaluation.

RESULTS

In 365 patients with a median serum prostate specific antigen of 11.9 ng./ml. (range 0.4 to 172) the median number of nodes removed was 21 (range 6 to 50). Lymph nodes were positive in 88 (24%) patients and the median number of positive nodes was 2 (range 1 to 19). Internal iliac lymph nodes were positive in 51 (58%) of the 88 patients, including 34 with additional positive lymph nodes along the external iliac vein and/or obturator nerve. Internal iliac lymph nodes alone were positive in 17 (19%) of 88 patients.

CONCLUSIONS

There were significant numbers of lymph node metastases at all 3 different areas of lymphadenectomy. Positive lymph nodes were found along the internal iliac artery in more than half (58%) of the patients and exclusively in 19%. Therefore, we consider lymph node dissection along the internal iliac (hypogastric) vessels essential for representative staging. Without this dissection a fifth of node positive cases would have been under staged and diseased nodes would have remained in more than half of the cases.

Indications for pelvic lymphadenectomy in prostate cancer

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.

Clinical staging of prostate cancer: reproducibility and clarification of issues

The American Joint Committee on Cancer (AJCC) staging system for prostate cancer adopted in 1992 is based on tumor-node-metastasis (TNM) designations. It has been widely accepted for use in local and advanced disease. The purpose of this study was to assess reproducibility of staging among observers and to help clarify staging issues. Twelve prostate cancer cases were sent to 20 physicians with special expertise in prostate cancer including eight urologists, eight radiation oncologists, and four medical oncologists. Physicians were asked to assign a stage based on the 1992 AJCC clinical staging. The most frequently reported stage assigned to each case was taken to be the consensus. Agreement was the percentage of physicians who reported that particular stage. Seventy-five percent of the physicians responded. The overall agreement for assignment of T stage was 63.9%. Differences were found by specialty for inclusion of available information in designating a T stage. The overall agreement for N stage was 73.8%. The most common designation was Nx regardless of availability of a computed tomography scan. The overall agreement for M stage was 76.6%. Without a bone scan the most common designation was Mx regardless of Gleason grade or prostate-specific antigen (PSA). A frequent comment was that PSA was more indicative of disease extent than current clinical staging. The reproducibility of the 1992 clinical AJCC staging is poor even among experts in the field. This problem arises primarily from disagreement regarding which studies are included in assigning a stage. Some of these difficulties are addressed in the 1997 revision. However, the clinical staging does not address the true biological significance of disease in many instances.

Indications, technique, and results of laparoscopic pelvic lymphadenectomy

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.

Should laparoscopy be the standard approach used for pelvic lymph node dissection?

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.

A comparison of the relative merits of radical perineal and radical retropubic prostatectomy

OBJECTIVE

To compare the outcome, advantages and disadvantages of retropubic and perineal approach to radical prostatectomy, as performed by one surgeon.

PATIENTS AND METHODS

This unrandomized study included 138 patients who underwent either radical retropubic (RRP) or radical perineal prostatectomy (RPP), based on the specific conditions or the patient's choice; 79 patients (mean age 64.6 years) underwent RPP and 59 (mean age 61.7 years) RRP. Outcome measures included estimated blood loss, the incidence of blood transfusions, positive margins and complications, operative duration, analgesic use, days in hospital and quality of life.

RESULTS

There was no difference in operative duration, and the incidence of positive margins or complications between the groups. The mean estimated blood loss in the RPP and RRP groups was 415 and 1,138 mL, respectively. The RPP group stayed a mean of 2.2 days less in hospital and took 2.8 days less to regain a full diet than the RRP group; the RPP group needed 1.7 days before using oral analgesics and the RRP group 3.8 days. Of patients in both groups, 85% were pad-free at one year and their overall quality of life was similar.

CONCLUSIONS

The results of RRP and RPP are comparable; the advantages of the perineal approach include minimal blood loss, low-intensity postoperative nursing care, low analgesic use and earlier discharge from hospital.

Geometry of laparoscopic suturing and knotting techniques

BACKGROUND

Spatial limitation, together with a fixed trocar position, restricted handling, and movement of the instruments, is inevitably associated with reconstructive laparoscopy and retroperitoneoscopy. This problem includes not only suturing technique and instruments but also geometric factors of endoscopic reconstruction, such as optimal distances between the working trocars, length of instruments, and angles between the instruments and the object. We present an experimental access to determine the specific impact of these factors on reconstructive laparoscopy.

MATERIALS AND METHODS

In an in vitro model, end-to-end anastomoses of porcine intestine were performed using a standardized intracorporeal suturing technique. Suturing was performed without and after training in reconstructive surgery with variation of the following geometric factors: (1) the distance between the working trocars (between 6 and 12 cm); (2) the position of the object (lateral right, medially, lateral left); (3) the camera position (medially, lateral right, lateral left); (4) the angle between the instruments and a horizontal line (15 degrees , 55 degrees, 90 degrees); (5) the intracorporeal length of instruments (between 10 and 25 cm); and (6) narrowed space available for the instruments (between 4 and 25 cm).

RESULTS

Continual training decreased the time required for suturing between 30% to 50%. Training decreased the time required for nonsuturing activities between 50% and 70% but the time required for suturing activities only between 20% and 45%. If the space between instruments and camera was limited, shifting the camera into a lateral position simplified the procedure of intracorporeal suturing. Angles of <55 degrees between instruments and the horizontal line simplified laparoscopic suturing, as did angles of <45 degrees between the instruments. In cases of maximally narrowed space (diameter of 4 cm), a suture filament length of <10 cm decreased the time required by 30%.

CONCLUSION

We suggest an isosceles triangle between the instruments with an angle between 25 degrees and 45 degrees and an angle of <55 degrees between the instruments and the horizontal line as the optimal geometry for intracorporeal suturing. These data should be considered when planning a reconstructive laparoscopic procedure (i.e., alignment of trocars, table position). However, further studies are required to confirm these preliminary results.

Staging laparoscopic pelvic lymphadenectomy in prostate cancer

OBJECTIVE

To assess the results of transperitoneal laparoscopic pelvic lymphadenectomy as a separate staging procedure in patients with early prostate cancer.

PATIENTS AND METHODS

The results were reviewed from the first 27 patients with prostate cancer admitted for laparoscopic lymphadenectomy between January 1994 and March 1998. Initially, all patients with a negative bone scan and either a negative computed tomography or negative magnetic resonance scan were admitted for laparoscopic staging. After several reports detailing ways of reducing the number of negative lymphadenectomy operations, from July 1996 only those patients with a preoperative prostate specific antigen (PSA) serum level of >10 ng/mL were admitted to the study. All procedures were performed by one experienced laparoscopic surgeon. A radical retropubic prostatectomy was performed as a separate procedure by a consultant urologist within 2 weeks. The effectiveness of the staging operation was analysed by assessing the nodal yield, and the results, including operative duration, complications and length of stay, were compared with other published series. Further analysis was provided by reviewing the PSA levels, Gleason grade sum and clinical digital staging.

RESULTS

The nodal yield was similar to that published in series from other institutions, with a median (range) of 6.5 (0-12). However, the operation was significantly quicker, at a median (range) of 55 (40-110) min for a bilateral dissection. There were only minor complications, with no detectable reduction in complications with experience; the median (range) postoperative stay was 1 (1-4) days. Two of the 27 patients had metastatic disease within the lymph nodes. If a PSA level of >10 ng/mL had been instituted as an entry criteria at the start of the study, six patients would have been excluded and thus the positive lymphadenectomy rate would have been two of 21 patients (10%). Of 54 patients eligible to enter the study, half did not require a lymphadenectomy.

CONCLUSIONS

Laparoscopic transperitoneal lymphadenectomy can be performed expeditiously and safely. A two-stage procedure in some patients with prostate cancer is the management of choice. Attention to carefully closing the peritoneum with sutures minimizes any retropubic adhesions and no problems associated with the staging procedure were encountered during subsequent radical retropubic prostatectomy. In efforts to reduce negative staging lymphadenectomies, the exclusion values for staging should not be set too high (PSA and Gleason grading sum). Such practice, despite a relatively safe staging procedure, would lead to unnecessary radical prostatectomy.

Systematic sextant biopsies improve preoperative prediction of pelvic lymph node metastases in patients with clinically localized prostatic carcinoma

PURPOSE

An algorithm including the results of systematic sextant biopsies was statistically developed and evaluated to predict the probability of pelvic lymph node metastases in patients with clinically localized carcinoma of the prostate.

MATERIALS AND METHODS

Clinical stage, serum prostate specific antigen concentration, Gleason score, number of positive biopsies, number of biopsies containing any Gleason grade 4 or 5 cancer and number of biopsies predominated by Gleason grade 4 or 5 cancer were recorded in 345 patients undergoing pelvic lymph node dissection and correlated with the incidence of lymph node metastases. Multivariate logistic regression, and classification and regression trees analyses were performed.

RESULTS

In univariate analysis all variables had a statistically significant influence on lymph node status. Logistic regression showed that the amount and distribution of undifferentiated Gleason grade 4 and 5 cancer in the biopsies were the best predictors of lymphatic spread followed by serum prostate specific antigen. Classification and regression trees analysis classified 79.9% of patients who had 3 or fewer biopsies with Gleason grade 4 or 5 cancer and no biopsies predominated by undifferentiated cancer as a low risk group. In this group positive lymph nodes occurred in only 2.2% (95% confidence interval 0.8 to 4.7%).

CONCLUSIONS

Including the results of systematic sextant biopsies substantially enhances the predictive accuracy of algorithms that define the probability of lymph node metastases in prostatic cancer. Patients thus defined as having no lymphatic spread could potentially be spared pelvic lymph node dissection before definitive local treatment.

Laparoscopic pelvic lymph node dissection for prostate cancer: comparison of the extended and modified techniques

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.

Anatomical basis for pelvic lymphadenectomy in prostate cancer: results of an autopsy study and implications for the clinic

PURPOSE

Pelvic lymphadenectomy remains the most reliable method to prove lymph node metastases in prostate cancer. However, evaluation of lymphadenectomy to be complete and sufficient as judged by the number of removed lymph nodes in hampered by the fact that, in contrast to other malignancies (for example breast or gastric cancer), anatomical studies investigating the regular and average number of pelvic lymph nodes are missing. We established an anatomically based standard for pelvic lymphadenectomy.

MATERIALS AND METHODS

Standard pelvic lymphadenectomy was performed on 30 human cadavers and 59 consecutive patients with clinically organ confined prostate cancer during radical retropubic prostatectomy. Number, size and topography of the lymph nodes were noted separately for each anatomical region of both iliac fossas.

RESULTS

The mean number of lymph nodes removed in the autopsy series plus or minus standard deviation (22.7 +/- 10.2, range 8 to 56) was nearly identical to that from patients with prostate cancer (20.5 +/- 6.6, range 10 to 37) but striking interindividual differences were observed. Patients with prostate cancer demonstrated enlarged nodes regardless of whether they did or did not contain tumor. Interestingly, pelvic lymph node metastases were more common on the left side regardless of the primary tumor site.

CONCLUSIONS

Approximately 20 pelvic lymph nodes may serve as a guideline for a sufficient standard pelvic lymph node dissection. Lymphadenopathy in prostate cancer patients is not always a result of metastases but, rather, hyperplastic or regressive alterations. A preferential distribution of lymph node metastases along the left iliac vessels regardless of the primary tumor site in the prostate warrants further investigation.

Laparoscopic unilateral ovarian transposition prior to irradiation: prospective study of 20 cases

BACKGROUND

The objective of this study was to evaluate the feasibility, morbidity, and efficacy of unilateral laparoscopic ovarian transposition on the preservation of hormonal function in premenopausal patients requiring pelvic irradiation (external and/or intracavity by brachytherapy).

METHODS

This prospective study was based on 20 patients: 17 presenting with cervical cancer, 2 with Hodgkin's disease, and 1 with ependymoma of the cauda equina. The operative technique consisted of releasing the right ovary from its pelvic attachments, and placing it as high and as laterally as possible in the right paracolic gutter, after creating a pedicle on the infundibulopelvic ligament. The follow-up of ovarian function was more than 1 year for 14 patients.

RESULTS

The therapeutic protocol was not modified as a result of ovarian transposition. No intraoperative or postoperative complications were observed. The mean dose of irradiation received by the transposed ovary was 1.75 gray (Gy) (range 0.4-3.7). Mean follow-up was 2 years. Two cases of menopause (14.7%), in the only 2 patients older than 40 years, were observed among the 14 patients followed for more than 1 year. The success rate was 100% for patients younger than age 40 years.

CONCLUSIONS

Laparoscopic ovarian transposition is a simple and reliable method, which does not complicate subsequent therapeutic protocol. Its short term efficiency is comparable to results obtained by laparotomy, with a lesser morbidity. Although long term evaluation is necessary, laparoscopic surgery should be considered as an alternative to laparotomy for ovarian transposition.

Laparoscopic surgical lymphadenectomies in urological tumours

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.

A new minimally invasive open pelvic lymphadenectomy surgical technique for the staging of prostate cancer

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.

Laparoscopic pelvic lymphadenectomy: transperitoneal approach

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.

Prostate cancer staging after radiation utilizing laparoscopic pelvic lymphadenectomy

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.

Linfadenectomia laparoscopica e Mini-lap: Attualità, limiti ed indicazioni

The authors, according to their preliminary experience with laparoscopic lymphadenectomy and Mini-lap performed for the staging of 15 patients with prostatic carcinoma, have compared the morbidity, the diagnostic accuracy rate and costs of these two techniques, referring critically to international literature and evaluating the real efficacy of a delayed laparoscopic pelvic lymphadenectomy prior to radical prostatectomy. Moreover they have tested the general applicability of the equation by Roach et al., which was empirically derived from a nomogram reported by Partin et al., to predict the risk of lymph node metastasis, applying it to a selected group of patients who underwent radical prostatectomy from 1992 to 1994 in order to maximize the utility of lymphadenectomy for prostatic cancer staging.

Combined hormonal and radiation therapy for lymph node-positive prostate cancer

OBJECTIVES

To evaluate the efficacy of combined radiation and hormonal therapy in patients with prostate cancer metastatic to the pelvic lymph nodes.

METHODS

Fifty consecutive patients with node-positive prostate cancer were evaluated by the Departments of Urology and Radiation Oncology at the University of Pennsylvania and offered combined hormonal and radiation therapy. All patients received pelvic radiation to 45 Gy, with a boost dose to the prostate to 65 to 71 gy. Forty-five of the patients were treated with concurrent hormonal therapy consisting of diethylstilbestrol (2 patients), orchiectomy (18 patients), leuprolide (5 patients), or combined androgen blockade (20 patients); the other 5 patients declined hormonal therapy. Patients represented a group with locally advanced disease with a high incidence of T3 tumors (66%), high grade (74%; Gleason score more than 7), high prostate-specific antigen (PSA) (40%; more than 30.0 ng/mL), and a high incidence of gross (36%) or bilateral (30%) adenopathy and a high incidence of multiply involved lymph nodes (62%).

RESULTS

Median follow-up of patients is 42 months (range, 10 to 102). All 5 patients declining hormonal therapy relapsed within 18 months and only 1 patient survived longer than 3 years. Among patients treated with combined hormonal and radiation therapy, the 6-year survival rate is 82%, the clinical disease-free survival at 6 years is 71%, and the probability of survival free of recurrence, with a PSA less than 0.2 ng/mL, is 62%. Only two PSA recurrences occurred, both in patients who elected to discontinue hormone therapy. There was no synergistic toxicity observed as a result of combined therapy.

CONCLUSIONS

Combined hormonal and radiation therapy offers the potential for extended disease-free survival and may represent an effective treatment option for patients with locally advanced prostate cancer.

Are pelvic computed tomography, bone scan and pelvic lymphadenectomy necessary in the staging of prostatic cancer?

OBJECTIVE

To investigate the effectiveness and economy of pelvic computed tomography (CT), bone scan and pelvic lymphadenectomy as staging modalities in patients undergoing radical prostatectomy. The use of prostate specific antigen (PSA) and Gleason's score as adjuncts to predict extracapsular disease were also evaluated and their economic implications examined.

PATIENTS AND METHODS

Between January 1990 and June 1993, 861 men were newly diagnosed with prostate cancer, of whom 409 underwent surgery. All patients underwent pelvic CT scans and PSA analysis. Patients undergoing surgery had pre-operative bone scans and Gleason's scoring of their pathological tissue.

RESULTS

Only 13 (1.5%) of 861 men had positive pelvic CT scans. Of the 409 patients who underwent surgery, all had negative pelvic CT and bone scans, and all underwent a modified pelvic lymphadenectomy; 192 (47%) had extracapsular disease. Only 15 (3.7%) patients who underwent surgery were found to have positive nodes.

CONCLUSIONS

The use of pelvic CT and bone scans for clinical staging in patients with a PSA level of < or = 20 ng/mL should not be advocated because they have a very low yield and are not cost effective. We question the role of a modified pelvic lymphadenectomy for staging purposes, either by an open or laparoscopic procedure, because the yield of positive diagnoses is very low.

PSA and clinical problems relating to prostate cancer

The PSA is the most important tumoral marker for prostate cancer. Not all Authors agree that it plays an important role in screening and diagnosis, classification and prognosis; they agree, instead, about its monitoring the response to therapy. Two personal experiences are presented: in one the PSA values are compared with the prostatic biopsies in 100 patients with suspect rectal exploration; in the other the PSA value, taken at the moment of diagnosis, is compared with the result of the radionuclide bone scan in 43 patients with prostate cancer.

Mini-laparotomy staging pelvic lymph node dissection for localized prostate cancer

We report our early experience with mini-laparotomy staging pelvic lymph node dissection (PLND) for clinically localized prostate cancer. We have used virtually the same original technique described by Steiner and Marshall. A 5 cm lower midline abdominal incision provides excellent exposure, allowing complete PLND under direct visualization. If radical retropubic prostatectomy is indicated by the state of the pelvic lymph nodes, this can be performed only by extending the same incision. Nine patients with histologically proven prostate cancer underwent mini-laparotomy staging PLND. The average intraoperative time for mini-laparotomy PLND was 33 minutes (range, 25-50 minutes). The intraoperative blood loss was 44 ml (range, 20-90 ml). The mean number of pelvic lymph nodes removed was 6.9 (range, 5-10 nodes) on the right and 10.8 (range, 8-21 nodes) on the left. Eight patients underwent immediate radical retropubic prostatectomy and one had radiation therapy. There were no complications directly related to the mini-laparotomy staging PLND. Mini-laparotomy staging PLND is an attractive alternative to laparoscopic PLND, especially for patients at low risk of lymph node metastasis.

Laparoscopic pelvic lymphadenectomy in the staging of prostatic cancer: Our experience in 37 cases

— 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.

Laparoscopic treatment of small-bowel obstruction following laparoscopic lymphadenectomy

Laparoscopic pelvic lymph node dissection followed by radical perineal prostatectomy has become the treatment of choice for selected patients at our institution with clinically localized adenocarcinoma of the prostate. We describe 2 cases in which bowel obstruction caused by incarceration of a loop of small bowel into a trocar site was managed with laparoscopic techniques.

One hundred consecutive laparoscopic pelvic lymph node dissections: comparing complications of the first 50 cases to the second 50 cases

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.