Robotic pelvic lymph node dissection: A step-by-step approach

Abstract

Pelvic lymph node dissection (PLND) is primarily a staging procedure most commonly used in prostate and bladder cancer. The role of lymphadenectomy has been well studied in patients with other types of malignancies and there is a consensus that the accuracy of the staging improves as more nodes are removed. The rationale for a staging PLND in prostate cancer is to accurately detect micrometastases in order to judge the need for adjuvant therapy. Currently, there is no consensus in the literature when considering the anatomical extent of the PLND. Several studies have shown that an extended PLND detects about twice as many nodes compared to a limited, restricted to the obturator fossa, dissection. PLND can be omitted in patients with low risk disease (Gleason score 6 or less, PSA greaterthan 10 ng/ml, cT1c) where the risk of having positive lymph node is less than 10%. For patients with greater risk of having metastasis we recommend an extended pelvic lymph node dissection (ePLND) which includes the nodes along the obturator fossa, the internal, external and common iliac arteries up to the crossing of the ureter. In bladder cancer the presence of lymph node metastases is on of the most important predictors of patient outcomes. There is evidence that a meticulous PLND at the time of radical cystectomy also can be curative in locally advanced disease. The advantages of robotic surgery (ten times magnification, EndoWrist© dexterity, 3-D view etc.) have allowed a transition from open to minimally invasive surgery, preserving the classical surgical technique. The most frequent complications related to PLND are lymphocele and lymph edema due to disruption of lymphatic vessels. Venous thrombotic events (VTE) and pulmonary embolism (PE) are potential complications associated with PLND.