Extraperitoneal pelvioscopy in lymph node staging of bladder and prostatic cancer

Minimally invasive extraperitoneal lymphadenectomy: clinical validation of an original technique

PURPOSE

To validate an original technique described for pelvic node dissection.

PATIENTS AND METHODS

A series of 192 patients were included in this study. The surgical technique we reported in 1987 is based on the use of a special retractor called the pelvioscope. The incision is the classical MacBurney incision on the right and its equivalent on the left. After the division of the muscles, the peritoneum is mobilized medially, and the pelvioscope is introduced. The node resection is then performed with classical surgical instruments.

RESULTS

In total; 151 bilateral, 20 unilateral right, and 21 unilateral left node dissections have been performed. In one case, dissection was not possible on both sides, and in two cases, the dissection was not complete on one side (patients previously operated on). The average intraoperative time was 69 minutes for a unilateral procedure and 103 minutes for a bilateral procedure. The mean number of pelvic lymph nodes removed was 5.6 on each side. The overall rate of complications was 7.3%.

CONCLUSION

The effectiveness of this minimally invasive surgery is clear, and the morbidity is low.

Laparoscopic staging of bladder tumor: concerns about port site metastases

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.

Critical Evaluation of Prostate Carcinoma Imaging

Since accurate clinical staging is the ideal presupposition for any therapeutic decision in prostate cancer (PC), the aim of this paper is to review sensitivity, specificity and accuracy of the imaging techniques routinely used to diagnose and stage PC. They are highly important parameters for selecting patients in whom the disease is confined to the prostate and who may benefit from radical surgery. This is particularly important when considering the high incidence of progression in patients with extracapsular disease or positive surgical margins and that 40–60% of patients with a clinically confined disease have extracapsular involvement shown at the histological examination.

Accuracy of combined computerized tomography and fine needle aspiration cytology in lymph node staging of localized prostatic carcinoma

The sensitivity and accuracy rate of computerized tomography (CT) in lymph node staging of localized prostatic carcinoma is commonly considered to be low. Fine needle aspiration cytology of pathological lymph nodes seen on radiological staging can enhance this low accuracy rate. We prospectively investigated the accuracy of CT and fine needle aspiration cytology in lymph node evaluation of 285 patients with clinically locally confined prostatic carcinoma. The sensitivity, specificity and accuracy rates of this combined method were 77.8%, 100% and 96.5%, respectively. False-negative staging results were found in only 10 patients with minimal nodal disease. Although in contrast with previous reports, combined CT and fine needle aspiration cytology in our hands seems to be a highly efficient staging method for lymph node involvement. This method could be considered as an alternative to surgical lymphadenectomy in the preoperative evaluation of the nodal status of patients with localized prostatic carcinoma who are scheduled for radical prostatectomy or curative radiotherapy.

Laparoscopic Pelvic Lymph Node Dissection: Considerations and Technique

44 men scheduled for radical prostatectomy were alternately designated to undergo either open (24) or laparoscopic (20) pelvic lymphadenectomy. The technique is described. Tumour stage, grade and PSA serum level are reported for each group as well as the number and site of lymph node metastases found in both groups. External iliac lymph nodes must be included in the lymphadenectomy because of their frequent neoplastic involvment. The number of lymph node metastases is much higher in patients with stage B2-C, Mostofi grade 3 or Gleason score 6 or more and PSA serum level of 20 ng/ml or more; in this group of patients, laparoscopic surgery may become the method of choice for assessing lymph node status.

Histological Assessment of Lymph Node Metastases in Staging Lymphadenectomy for Prostate Cancer

Pelvic lymph node involvement in 44 patients with histologically confirmed prostatic carcinoma was assessed by open lymphadenectomy (24 patients) or laparoscopic lymph node dissection (20 patients). With open lymphadenectomy, node metastases were diagnosed on frozen section prior to radical surgery, in only 2 out of 7 patients. With laparoscopic dissection, metastases were correctly diagnosed in 6 out of 7 patients; one, however, was missed. Reasons for missing node metastases lie in the difficulty of recognizing nodes harboring carcinoma on gross examination. Indeed, metastases are often small and do not significantly alter the macroscopic appearence of the involved lymph node.

Current and future roles of laparoscopic surgery in urology

There is little doubt that laparoscopy will gain an increasing role in urologic surgery. Pelvic node dissection, varicocelectomy, and evaluation of nonpalpable undescended testes are already widely performed. As improved instrumentation is developed expressly designed for urologic applications, there will be even greater interest and wider applicability of laparoscopic techniques. However, as this occurs, it is essential that each new procedure be critically evaluated to be certain that it offers significant benefit without added morbidity as compared with standard techniques.