Epidemiology and therapy of symptomatic lymphoceles after robot-assisted radical prostatectomy (RARP)

Lymphoceles after pelvic lymph node dissection during robot-assisted radical prostatectomy

Background

Lymphoceles, lymph fluid-filled collections within the body lacking epithelial lining, are a common complication after pelvic lymph node dissection (PLND) during robot-assisted radical prostatectomy (RARP). In this study, we investigate the incidence of imaging confirmed symptomatic lymphoceles (SLC) in a centralized high-volume operating centre and assess predictive factors and treatment.

Methods

We retrospectively analysed the incidence, risk factors and treatment of a consecutive series of patients who underwent PLND during RARP between September 2018 and January 2021 in a specialised operation clinic. We compared baseline patients' characteristics and pathological data between men who developed an SLC and those who did not. A multivariable model for the occurrence of an SLC was created using predetermined, clinically relevant variables to investigate predictive factors.

Results

We analysed the records of 404 patients. The median follow-up length was 29 months. A total of 30 (7.4%) patients with an SLC were identified. The median time until SLC presentation was 12 weeks [interquartile range (IQR), 4-31 weeks], one-third of SLCs presented after 180 days. Percutaneous drainage was performed in 17 patients (57%). On multivariable analysis, only body mass index (BMI) significantly increased the odds of an SLC [per 5 odds ratio (OR) =1.7; 95% confidence interval (CI): 1.0-3.0, P=0.04].

Conclusions

SLCs present significant consequences, as more than half of patients with an SLC were treated with percutaneous drainage. Many patients presented later than the centralized surgeons' postoperative follow-up, a drawback of centralized care. An increased BMI was a significant predictor for SLC.

The Effect of a Peritoneal Iliac Flap on Lymphocele Formation After Robotic Radical Prostatectomy: Results From the PLUS Trial

OBJECTIVE

To assess the effectiveness of a peritoneal flap on the formation of lymphoceles after robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection.

METHODS

We conducted a single surgeon, assessor blinded prospective randomized controlled trial (the Prospective Lymphocele Ultrasound Study) in men undergoing robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection. At the conclusion of the node dissection, patients were block randomized 1:1 to either standard of care (no bladder peritoneal flap) or to the creation of a bladder peritoneal flap. Lymphocele formation was assessed by pelvic ultrasound postoperatively. The primary outcome was lymphocele formation. Rates of lymphocele formation and complications were analyzed using chi-square. Other outcomes, including length of stay, number of lymph nodes removed, lymphocele volume, and quality of life measures, were analyzed by t-tests or Wilcoxon Ranked Sum Tests, as appropriate. An a priori power calculation was performed using O'Brien-Fleming alpha sharing for the interim analyses. Two preplanned interim analyses were performed when 45 and 90 patients per group had follow-up ultrasounds.

RESULTS

A statistically significant difference in lymphocele formation was seen on the second interim analysis for 183 patients (4.3% vs. 15.6%, p = .011) stopping enrollment; this remained significant in the final analysis of 216 patients (3.6% vs 14.2%, p = .006). No other significant differences were observed.

CONCLUSION

This prospective randomized trial supports the implementation of this simple modification for robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection.

Technical Outcome, Clinical Success, and Complications of Low-Milliampere Computed Tomography Fluoroscopy-Guided Drainage of Lymphoceles Following Radical Prostatectomy with Pelvic Lymph Node Dissection

To evaluate the technical outcome, clinical success, and safety of low-milliampere CT fluoroscopy (CTF)-guided percutaneous drain (PD) placement in patients with lymphoceles following radical prostatectomy (RP) with pelvic lymph node dissection (LND). This retrospective analysis comprised 65 patients with PD placement in lymphoceles following RP under low-milliampere CTF guidance. Technical and clinical success were evaluated. Complications within a 30-day time interval associated with CTF-guided PD placement were classified according to SIR. Patient radiation exposure was quantified using dose-length products (DLP) of the pre-interventional planning CT scan (DLPpre), of the sum of intra-interventional CT fluoroscopic acquisitions (DLPintra) and of the post-interventional control CT scan (DLPpost). Eighty-nine lymphoceles were detected. Seventy-seven CT-guided interventions were performed, with a total of 92 inserted drains. CTF-guided lymphocele drainage was technically successful in 100% of cases. For all symptomatic patients, improvement in symptoms was reported within 48 h after intervention. Time course of C-reactive protein and Leucocytes within 30 days revealed a statistically significant (p < 0.0001) decrease. Median DLPpre, DLPintra and DLPpost were 431 mGy*cm, 45 mGy*cm and 303 mGy*cm, respectively. Only one minor complication (self-resolving haematoma over the bladder dome; SIR Grade 2) was observed. Low-milliampere CTF-guided drainage is a safe treatment option in patients with lymphoceles following RP with pelvic LND characterized by high technical and good clinical success rates, which provides rapid symptom relief and serves as definite treatment or as a bridging therapy prior to laparoscopic marsupialisation.

Pelvic Lymph Node Dissection at Radical Prostatectomy for Intermediate Risk Prostate Cancer: Assessing Utility and Nodal Metastases Within a Statewide Quality Improvement Consortium

OBJECTIVE

To assess which patients with intermediate-risk PCa would benefit from a pelvic lymph node dissection (PLND) across the Michigan Urological Surgery Improvement Collaborative, given the discrepancy in recommendations. AUA guidelines for localized prostate cancer (PCa) state that PLND is indicated for patients with unfavorable intermediate-risk and high-risk PCa and can be considered in favorable intermediate-risk patients. NCCN guidelines recommend PLND when risk for nodal disease is ≥2%.

METHODS

Data regarding all robot-assisted radical prostatectomy (RARP) (March 2012-October 2020) were prospectively collected, including patient, and surgeon characteristics. Univariate and multivariate analyses of PLND rate and lymph node involvement (LN+) were performed.

RESULTS

Among 8,591 men undergoing RARP for intermediate-risk PCa, 80.2% were performed with PLND (n = 6883), of which 2.9% were LN+ (n = 198). According to the current AUA risk stratification system, 1.2% of favorable intermediate-risk PCa and 4.7% of unfavorable intermediate-risk PCa demonstrated LN+. There were also differences in the LN+ rates among the subgroups of favorable (0.0%-1.3%), and unfavorable (3.5%-5.0%) categories. Additional factors associated with higher LN+ rates include ≥50% cores positive, ≥35% involvement at any core, and unfavorable genomic classifier result, none of which contribute to the favorable/unfavorable subgroups.

CONCLUSION

These data support PLND at RARP for all patients with unfavorable intermediate-risk PCa. Our data also indicate patients with favorable intermediate-risk prostate cancer at greatest risk for LN+ are those with ≥50% cores positive, ≥35% involvement at any core, and/or unfavorable genomic classifier result.