The deep vein thrombosis caused by lymphocele after endoscopic extraperitoneal radical prostatectomy and pelvic lymph node dissection

Pelvic lymphocele is a postoperative complications than can result after endoscopic extraperitoneal radical prostatectomy and pelvic lymph node dissection. Radical prostatectomy have many risk factors of deep vein thrombosis including location of target organ, malignancy, old age, Trendelenburg position, pelvic lymph node dissection, and long procedure time. A 57-year-old man with a localized prostate cancer was treated with endoscopic extraperitoneal radical prostatectomy and pelvic lymph node dissection. Deep vein thrombosis was detected as a first sign of pelvic lymphocele. Lymphocele was managed with a percutaneous drainage without sclerosant. We report a case of deep vein thrombosis due to pelvic lymphocele after endoscopic extraperitoneal radical prostatectomy.     

Frequency of lymphoceles after open and laparoscopic pelvic lymph node dissection in patients with prostate cancer

OBJECTIVE: To compare the frequencies of pelvic lymphocele formation after laparoscopic and open pelvic lymph node dissection in patients with prostate cancer. MATERIAL AND METHODS: A total of 132 patients operated on with pelvic lymph node dissection (PLND) underwent CT scanning of the abdomen and pelvis at a median of 29 days postoperatively. Open pelvic lymph node dissection (OPLND) was performed in 94 patients (71%) and 38 patients (29%) were operated on using a laparoscopic technique (LPLND). The frequency and size of pelvic lymphoceles were registered. Lymphoceles with a horizontal diameter of /=5.0 cm were classified as large. RESULTS: The overall frequency of lymphoceles was 54%. The frequencies in the OPLND and LPLND groups were 61% and 37%, respectively. A total of 27% of the OPLND patients had large lymphoceles, compared to 8% of the LPLND patients. Three patients (2.3%), all in the OPLND group, had clinically significant lymphoceles. CONCLUSIONS: Although the overall frequency of lymphocele formation was high, clinically significant lymphoceles were scarce. LPLND was associated with a statistically significant lower frequency of lymphocele formation compared to OPLND.     

Laparoscopic management of lymphocele after pelvic lymphadenectomy and radical retropubic prostatectomy.

A new method of managing pelvic lymphoceles after urologic procedures is described. A patient with a symptomatic pelvic lymphocele after pelvic lymph node dissection and radical retropubic prostatectomy was treated laparoscopically. Technical aspects of laparoscopic marsupialization of lymphoceles are described, and the laparoscopic approach is compared with other modalities available for treating lymphoceles.     

Pelvine Lymphadenektomie

Extended pelvic lymph node dissection allows exact lymph node staging and has the potential to improve prognosis. In addition to these advantages, there are some perioperative and postoperative complications. In case of transection of the obturator nerve, a microsurgical end-to-end anastomosis should be performed. The most frequent postoperative complication is (symptomatic) lymphocele which is predominantly diagnosed after extraperitoneal surgery. Meticulous lymph node dissection with clipping of lymphatic vessels, sparing the lateral wall of the external iliac artery from dissection, sufficient postoperative drainage, and application of low molecular weight heparin in the upper arm may reduce their incidence. Instillation of sclerosing agents and sufficient drainage are normally successful. If not, laparoscopic fenestration of lymphocele should be performed. Regular ultrasound examinations are necessary to diagnose and treat postoperative lymphocele in a timely manner.     

盆腔淋巴结清扫术后淋巴漏和淋巴囊肿的研究进展

淋巴漏和淋巴囊肿是泌尿外科盆腔淋巴结清扫术后常见的并发症,临床定义不明确,治疗方案多样而效果不确切,相关研究较少,无相关诊疗指南。本文主要对泌尿外科盆腔淋巴结清扫术后淋巴漏和淋巴囊肿的发生机制、高危因素、临床诊断、治疗方案和预防措施等方面进行综述。淋巴漏和淋巴囊肿发生机制包括淋巴液漏出和渗出;高危因素有高龄、开放手术和围手术期使用抗凝药物等;大部分患者通过营养管理、经皮导管硬化治疗等保守治疗可治愈;预防措施以封闭淋巴管及残端为主。     

Staging Pelvic Lymphadenectomy for Localized Carcinoma of the Prostate: A Comparison of 3 Surgical Techniques

Purpose

Pelvic lymph node dissection continues to be the most effective method of staging extracapsular adenocarcinoma of the prostate. Three principal methods of pelvic lymph node dissection are currently available: intraperitoneal laparoscopic, minilaparotomy and the standard open modified pelvic lymph node dissection. In the hope of determining some of the relative advantages and disadvantages associated with each technique a comparison of these approaches was made.

Materials and Methods

Of 68 patients with histologically proved clinical stage T3N0M0 adenocarcinoma of the prostate who underwent staging pelvic lymph node dissection 38 underwent modified open, 19 laparoscopic and 11 minilaparotomy procedures. The efficacy of node sampling, resource expenditure and complication rates were compared among the 3 groups.

Results

No statistically significant difference was observed in terms of the number of nodes harvested with each technique. Resource expenditure analysis revealed significantly increased operative and procedural time requirements for laparoscopic pelvic lymph node dissection compared to modified open and minilaparotomy procedures. Total hospital stay was significantly longer for the modified open pelvic lymph node dissection (mean plus or minus standard deviation 6.5 +/− 0.9 days) compared to the laparoscopic (mean 2.7 +/− 1.1 days) and minilaparotomy (mean 3.3 +/− 0.2 days) groups. Multiple complications, such as ileus, lymphocele and urinary retention, were observed in the modified open pelvic lymph node dissection group. No complications were noted in the other 2 groups.

Conclusions

Comparison of laparoscopic and minilaparotomy procedures to modified open pelvic lymph node dissection revealed similar staging efficacy, and decreased total hospital stay and complications. Laparoscopic pelvic lymph node dissection required increased operative time. Minilaparotomy should become the open surgical procedure of choice for pelvic lymph node dissection, particularly at institutions where the laparoscopy learning curve, equipment expense and time disadvantages cannot be overcome.     

Incidence of lymphoceles after robot-assisted pelvic lymph node dissection

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Lymphocele formation after open pelvic lymph‐node dissection is a known complication. However, reported incidences using the robotic approach are unclear and likely underestimated. The present study aims to better understand the true incidence of lymphocele formation after RARP.

OBJECTIVE

? To determine the incidence and predictive factors of lymphocele formation in patients undergoing pelvic lymph node dissection (PLND) during robot‐assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

? Between April and December 2008, 76 patients underwent PLND during RARP for ≥cT2c, prostate‐specific antigen level ≥10, Gleason score ≥7 prostate cancer. ? All patients were prospectively followed up with pelvic computed tomography 6–12 weeks after the procedure. ? All patients received s.c. heparin preoperatively and postoperatively. PLND was limited to zones 1 and 2 as defined by Studer. ? Plasma‐kinetic bipolar forceps were used for haemostasis during PLND.

RESULTS

? At a mean follow‐up of 10.8 weeks, 51% (39/76) of patients had developed a lymphocele. Of these 39 lymphoceles 32 (82%) were unilateral and seven (18%) were bilateral. ? The mean (range) lymphocele size was 4.3 × 3.2 (1.5–12.3) cm; 41% of lymphoceles were <4 cm, 53.9% were 4–10 cm, and 5.1% were >10 cm in diameter. Six of the 39 lymphoceles (15.4%) were clinically symptomatic. The symptoms were as follows: pelvic pressure in five patients, abdominal distension with ileus in three patients, leg pain/weakness in one patient and costovertebral tenderness in one patient. Two lymphoceles required intervention. ? On the logistic regression model the presence of nodal metastases, tumour volume in the prostate specimen and extracapsular extension (ECE) were independent risk factors for the development of a lymphocele. ? There was no correlation between estimated blood loss, body mass index, pathological Gleason score or number nodes dissected and the presence of lymphocele.

CONCLUSIONS

? The incidence of lymphoceles was higher than anticipated given the believed protective effect of the transperitoneal approach against lymphocele formation. ? The risk of lymphocele seemed to increase linearly with the presence of more extensive disease, particularly ECE and nodal involvement. ? The benefit of PLND during RARP should be weighed against the elevated risk of lymphocele formation and its potential complications.     

Complications of inguinal and pelvic lymphadenectomy for squamous cell carcinoma of the penis: a contemporary series

PURPOSE: We examined complications in a contemporary population of patients with penile cancer undergoing inguinal lymphadenectomy with or without pelvic lymphadenectomy. MATERIALS AND METHODS: The records of all patients treated for squamous cell carcinoma of the penis from January 1992 to May 2003 were reviewed. Complications and length of stay were examined. Complications were divided into early (30 days or less after surgery) and late (greater than 30 days). RESULTS: A total of 41 men were diagnosed with squamous cell carcinoma of the penis, of whom 22 underwent a total of 40 inguinal lymphadenectomies (ILs). Of the patients 13 underwent unilateral IL, 9 underwent simultaneous bilateral ILs and 10 underwent pelvic lymphadenectomy. Mean followup was 34.2 months (range 9.2 to 69.3). Early complications were lymphedema in 4 of 40 cases (10%), minor wound infection in 3 (7.5%) and minor wound separation in 3 (7.5%). Additionally, 5 of 40 patients (12.5%) had lymphoceles, which spontaneously resolved. Late complications were lymphedema in 2 of 40 patients (5%), flap necrosis in 1 (2.5%) and lymphocele in 1 (2.5%), requiring percutaneous drainage. There was no significant difference in the complication rates in patients with unilateral dissection compared to bilateral or pelvic lymph node dissection. Median length of stay was 2 days (range 1 to 9). There was no significant difference in hospital stay for unilateral dissection compared to bilateral or pelvic lymph node dissection. CONCLUSIONS: These data demonstrate the relative safety of a contemporary lymphadenectomy. We believe that these results lend support to early lymphadenectomy, including simultaneous bilateral dissections, when clinically indicated. Furthermore, these results demonstrate the benefits of a standard postoperative pathway using compression stockings, sequential compression devices and early ambulation with restricted anticoagulant use.     

Surgical Management of Peyronie’s Disease

The development of a lymphocele after pelvic surgery is a well-documented complication, especially where pelvic lymph node dissection (PLND) is part of the operation. However, not all lymphoceles are symptomatic and require treatment. Most lymphoceles spontaneously resolve, and even lymphoceles that become symptomatic may resolve without any intervention. Robotic assisted radical prostatectomy (RARP) is a common operation in urology where PLND is likely to be performed in intermediate and high-risk prostate cancer patients. The rationale for performing a PLND in prostate cancer is for accurate staging and potential therapeutic benefits. However, due to potential intraoperative and postoperative complications there is still a debate regarding the value of PLND in prostate cancer. In this review, we will discuss the potential risk factors to be aware of in pelvic surgery in order to minimize the formation of a lymphocele, along with the management for clinically significant lymphoceles.     

Limited pelvic lymph node dissection at the time of radical prostatectomy does not affect 5-year failure rates for low, intermediate and high risk prostate cancer: results from CaPSURE

PURPOSE: Limited bilateral pelvic lymph node dissection performed at radical prostatectomy provides staging information that is used to guide further disease management. Given the effects of widespread prostate specific antigen testing and stage migration, most procedures in the United States are performed for low risk disease, which has a low probability (less than 1%) of lymph node metastasis. We compared 5-year treatment failure rates in patients with low, intermediate and high risk disease who underwent radical prostatectomy with or without pelvic lymph node dissection. MATERIALS AND METHODS: We compared treatment failure rates for radical prostatectomy in 4,693 patients enrolled in the CaPSURE database who underwent radical prostatectomy with or without limited pelvic lymph node dissection. Secondary analysis was performed as a function of pelvic lymph node dissection and risk group based on pretreatment stage, grade and prostate specific antigen. Treatment failure rates were estimated by Kaplan-Meier analysis. RESULTS: The 5-year failure-free survival rate was 70% in the no pelvic lymph node dissection group and 74% in the limited pelvic lymph node dissection group (p = 0.11), while the rates in the low, intermediate and high risk groups were 81% and 82% (p = 0.83), 71% and 63% (p = 0.21), and 42% and 48% (p = 0.45) in the no vs limited pelvic lymph node dissection groups, respectively. Multivariate analysis demonstrated that pelvic lymph node dissection status was not a predictor of treatment failure (p = 0.93). CONCLUSIONS: This study demonstrates in a large cohort of patients that limited pelvic lymph node dissection at radical prostatectomy has no effect on treatment failure rates at 5 years in those at low, intermediate and high risk.     

Laparoscopic peritoneal drainage of symptomatic lymphoceles after pelvic lymph node dissection using methylene blue instillation

BACKGROUND: Lymphoceles are frequent complications of pelvic lymph node dissection. While small lymphoceles often remain undetected, larger ones can cause complications and require further treatment, e.g. percutaneous tube drainage alone or in combination with sclerotherapy. However, recurrence rates are considerable, and long-lasting drainage may lead to infection, prolonged hospitalization, and as a consequence, increased overall costs. We report the results of a simplified laparoscopic approach to drain lymphoceles after radical prostatectomy plus pelvic lymphadenectomy using methylene blue instillation. METHODS: 13 patients with large symptomatic pelvic/retroperitoneal lymphoceles refractory to percutaneous tube drainage and doxycycline sclerotherapy received a laparoscopic transperitoneal marsupialization following instillation of a sterile diluted methylene blue solution into the drained cavity to refill and mark the lymphocele. RESULTS: All lymphoceles were sterile and ranged in size from 7 x 6 x 4 to 15 x 12 x 6 cm. Clinical symptoms included lower abdominal swelling, tenderness in the iliac fossa, ipsilateral lymphedema, deep venous thrombosis, wound fistula, and hydronephrosis due to ureteral obstruction. After methylene blue instillation, the lymphoceles were easily identified and opened. Median total operative time was 50 (range 25-70) min; blood loss was negligible. There was one complication in the form of a metachronous infection in the operating field and no relapses. Patients were discharged 1-5 (median 3) days after the surgical procedure. CONCLUSIONS: Laparoscopic peritoneal drainage requires greater operative skill than percutaneous approaches. However, the instillation of a methylene blue solution simplifies this procedure as the extent and location of the lymphoceles can be precisely identified during laparoscopy. We recommend early application of laparoscopic peritoneal drainage following methylene blue instillation for patients with sterile lymphoceles after pelvic lymph node dissection in whom temporary percutaneous drainage and sclerotherapy failed to resolve the lymph fluid collection.     

Standard versus limited pelvic lymph node dissection for prostate cancer in patients with a predicted probability of nodal metastasis greater than 1%

PURPOSE: We determined the yield of standard vs limited pelvic lymphadenectomy in patients with a predicted risk of lymph node metastasis greater than 1% according to the Partin tables predicted probability of pathological stage. We also determined the feasibility of laparoscopic standard pelvic lymph node dissection. MATERIALS AND METHODS: Of 1,269 patients with clinically localized prostate cancer undergoing radical prostatectomy, 648 had a Partin's table predicted probability of lymph node invasion greater than 1%. Of the 648 patients 177 underwent limited pelvic lymph node dissection performed laparoscopically (group 1), and 471 underwent standard pelvic lymph node dissection performed open (367) or laparoscopically (104) (group 2). Templates of limited pelvic lymph node dissection included the external iliac lymph nodes whereas standard pelvic lymph node dissection included the external iliac, obturator and hypogastric lymph nodes. Multivariate logistic regression analyses were performed to compare the node positivity rate between groups 1 and 2. RESULTS: On multivariate logistic regression analysis controlling for prostate specific antigen, biopsy Gleason sum, clinical stage and surgical approach, the odds of node positivity were 7.15-fold higher (95% CI 2.49-20.5, p<0.001) for standard vs limited pelvic lymph node dissection. The median (mean) number of nodes retrieved was 9 (10) and 14 (15) after limited and standard pelvic lymph node dissection, respectively (p<0.001). A similar impact was observed in patients treated laparoscopically with standard vs limited pelvic lymph node dissection (odds ratio 15.6, 95% CI 3.7-66.4, p<0.001). CONCLUSIONS: Standard lymph node dissection yields positive nodes more frequently and retrieves a higher total nodal count than the often performed pelvic lymph node dissection limited to the external iliac nodes. Standard pelvic lymph node dissection is feasible through a transperitoneal laparoscopic approach.     

Staging pelvic lymphadenectomy for carcinoma of the prostate: review of 23 cases

Between June, 1982 and May, 1985, 37 patients underwent pelvic lymphadenectomy for carcinoma of the prostate, 23 patients as an independent procedure. Of these 23 patients 7 had pelvic node metastasis. Node involvement occurred in 60% with clinical stage C tumors. Correlation with tumor grade revealed nodal metastasis in none of the latients with well differentiated tumors, 33.3% of those with moderately differentiated lesions, and 75% of those with poorly differentiated tumors. Metastatic disease most commonly involved the obturator-hypogastric lymphnodes (85.7%). Of the 23 patients, 14 underwent conventional node dissection, and 9 limited node dissection. Complications of lymphocele, lymphfistula, penoscrotal edema and lower extremity edema occurred mostly in patients with conventional node dissection. Limited staging pelvic node dissection provides information similar to that identified after more extensive dissection and can be accomplished with little morbidity.     

Lymph node count threshold for optimal pelvic lymph node staging in prostate cancer

Objectives: To test the relationship between the extent of pelvic lymph node dissection at radical prostatectomy and the rate of lymph node metastases, and to identify the ideal number of lymph nodes that should be removed to achieve an optimal staging. Methods: We assessed 20 789 prostate cancer patients treated with radical prostatectomy and pelvic lymph node dissection between 2004 and 2006. Receiver operating characteristics analyses were used to define the probability of correctly staging lymph node metastases patients according to lymph node count. Univariable and multivariable regression analyses tested the relationship between lymph node count and lymph node metastases rate. Results: The average lymph node count was 6.4 (median 5.0). Overall, the lymph node metastases rate was 2.5%; and it resulted to be 0.2, 1.5 and 6.7% in low, intermediate and high‐risk tumors, respectively. The rate of lymph node metastases was 3.5 and 6.7% in patients with 10 and 20 lymph node count, respectively. Removing 20 lymph nodes yielded a 90% probability of correctly staging lymph node metastases, regardless of risk group. In multivariable analysis, lymph node count was an independent predictor of lymph node metastases stage (odds ratio: 1.07, P < 0.001). Conclusions: A direct relationship might exist between the extent of pelvic lymph node dissection and the lymph node metastases rate. An extended pelvic lymph node dissection with at least 20 lymph nodes would offer correct lymph node staging in 90% of cases, regardless of tumor characteristics. This cut‐off might be considered adequate by most surgeons. Such a high lymph node yield necessitates an anatomically extended pelvic lymph node dissection.     

Detection of pelvic lymph node metastases in patients with clinically localized prostate cancer: comparison of [18F]fluorocholine positron emission tomography-computerized tomography and laparoscopic radioisotope guided sentinel lymph node dissection

PURPOSE: Accurate detection of lymph node metastases in prostate cancer has important implications for prognosis and approach to treatment. We investigated whether preoperative [18F]fluorocholine combined in-line positron emission tomography-computerized tomography and intraoperative laparoscopic radioisotope guided sentinel pelvic lymph node dissection can detect pelvic lymph node metastases in patients with clinically localized prostate cancer as reliably as extended pelvic lymph node dissection. MATERIALS AND METHODS: A total of 20 patients (mean age 63.9 +/- 6.7 years, range 52 to 75) with clinically localized prostate cancer, prostate specific antigen greater than 10 ng/ml, and/or a Gleason score sum of 7 or greater and negative bone scan were enrolled in the study. [18F]fluorocholine combined in-line positron emission tomography-computerized tomography was performed before surgery. Sentinel pelvic lymph node dissection preceded extended pelvic lymph node dissection including the area of the obturator fossa, external iliac artery/vein and internal iliac artery/vein up to the bifurcation of the common iliac artery. Laparoscopic radical prostatectomy was performed afterward. RESULTS: In 10 of the 20 patients (50%) lymph node metastases were detected, and were exclusively found outside the obturator fossa in 62%. These metastases would not have been identified with standard lymph node dissection of the obturator fossa only. [18F]fluorocholine combined in-line positron emission tomography-computerized tomography was true positive in 1, false-positive in 2, false-negative in 9 and true negative in 8 patients. The largest lymph node metastasis not seen with [18F]fluorocholine combined in-line positron emission tomography-computerized tomography was 8 mm. Laparoscopic sentinel guided lymph node dissection revealed lymph node metastases in 8 of 10 patients. In the other 2 patients sentinel lymph node dissection was not conclusive. In 1 patient normal nodal tissue was completely replaced by cancer and, therefore, there was no tracer uptake in the involved pelvic sidewall/node, and the other patient had no tracer activity at all in the involved pelvic sidewall. Extended pelvic lymph node dissection missed 1 lymph node metastasis (2 mm diameter near pudendal artery) which was detected by sentinel pelvic lymph node dissection only. CONCLUSIONS: Extended pelvic lymph node dissection reveals a higher number of lymph node metastases as described for obturator fossa dissection only. [18F]fluorocholine combined in-line positron emission tomography-computerized tomography is not useful in searching for occult lymph node metastases in clinically localized prostate cancer. Sentinel guided pelvic lymph node dissection allows the detection of even small lymph node metastases. The accuracy of sentinel pelvic lymph node dissection is comparable to that of extended pelvic lymph node dissection when the limitations of the method are taken into consideration.     

AJCC与JSCCR对直肠癌盆腔侧方淋巴结定义演变的解读

侧方淋巴结清扫仍是直肠癌手术治疗的重要术式,但对于直肠癌的盆腔侧方淋巴结是否为区域淋巴结及侧方淋巴结清扫术的意义,欧美与日本专家有不同的观点。对盆腔侧方淋巴结的不同定义会导致直肠癌的分期不同,进而导致不同的治疗决策。不同时期的欧美学者及日本学者对盆腔侧方淋巴结的定义有一个演变过程,笔者根据现有资料对该演变做一解读。由于日本学者对侧方淋巴结研究较多,故重点阐述日本大肠癌研究会对侧方淋巴结的定义演变。     

Laparoscopic extended pelvic lymph node dissection for prostate cancer: description of the surgical technique and initial results

OBJECTIVE: In patients with prostate cancer, extended pelvic lymph node dissection (ePLND) yields a higher number of lymph node metastases (LNM) than standard pelvic lymph node dissection (PLND) of the obturator fossa only. We describe our laparoscopic technique of extended lymph node dissection and provide the number and locations of positive lymph nodes from our experience. METHODS: In a total of 35 selected patients with clinically localized prostate cancer, laparoscopic ePLND was performed prior to laparoscopic radical prostatectomy. The template included the genitofemoral nerve up to the bifurcation of the common iliac artery and down to the epigastric artery. In the "split and roll" technique the internal and external iliac arteries including the bifurcation and the external iliac vein were completely mobilized. After freeing the obturator nerve, the entire lymph node package was released from the pelvic side wall. RESULTS: Mean operative time was 90min/patient. The complications were two temporary and reversible neurapraxias (ischiatic nerve and obturator nerve), one deep vein thrombosis, and two lymphoceles. One lymphocele healed conservatively; the second was marsupialized laparoscopically. Eleven (31.4%) patients had lymph node metastases; their mean prostate-specific antigen (PSA) level was 20.3+/-7.0 ng/ml (range: 5.2-39.7 ng/ml) and their median Gleason sum in biopsy was 7 (range: 6-8). Mean size of the LNM was 3.1+/-1.0 mm (range: 0.2-8). In 5 of the 11 patients with LNM these were detected exclusively outside the obturator fossa. LNM were in the obturator fossa only in two (one bilateral), around the external iliac artery only in two, around the internal iliac artery only in two, and around the external iliac artery and internal iliac only in one patient. CONCLUSIONS: Laparoscopic ePLND can be combined with laparoscopic radical prostatectomy. Standardization of the technique facilitates surgery to a great extent. e-PLND detects LNM in a significant number of patients. The majority of LNM are outside the obturator fossa. The transperitoneal approach allows a wide exposure and is the most important factor to enable successful ePLND.     

Pelvic lymphadenectomy and brachytherapy for prostatic cancer. Analysis of early postoperative morbidity

Pelvic lymphadenectomy and interstitial radiotherapy of the prostate for early carcinoma is a procedure with a significant postoperative morbidity, depending on the extent of dissection, type of drainage, and use of heparin. Hematoma and lymphocele formation seem to be promoted by heparin. Limited lymph node dissection, appropriate drainage, and the abandonment of heparin for prophylaxis of thromboembolism can reduce the complications associated with pelvic lymphadenectomy.     

Combined inguinal and pelvic lymph node dissection for stage III melanoma

BACKGROUND: The incidence of melanoma is increasing in the UK and a significant number of patients are still presenting with primary lesions of poor prognosis. As a consequence there is likely to be an increasing number of patients with lymph node metastases for whom the appropriate extent of groin dissection remains controversial. This review summarizes the evidence to enable surgeons to make an informed decision about the management of patients with melanoma metastases to the groin lymph nodes. METHODS: A Medline search was performed to identify all English language articles about melanoma containing the words lymphadenectomy, lymph nodes, inguinal or lymphoedema. Eighty-seven relevant articles were selected from 3904 abstracts retrieved; 34 were related directly to the aim of this review. RESULTS: There are no randomized controlled trials comparing the outcome of combined inguinal and pelvic lymph node dissection (CLND) and superficial inguinal lymph node dissection (SLND). Excision of pelvic lymph node metastases is reported to yield a 5-year survival rate of 0-35 per cent. Recurrence within the pelvis occurs in 9-18 per cent of patients after SLND and in less than 5 per cent after CLND. Morbidity following either CLND or SLND is poorly reported. Major long-term lymphoedema limiting patient activity affects 6-20 per cent of patients after groin dissection. Cloquet's node was demonstrated in one study to be a useful predictor of pelvic lymph node involvement. Patients may be selected for pelvic node dissection on the basis of clinical findings, the results of pelvic computed tomography and the status of Cloquet's node. CONCLUSION: The controversy surrounding the appropriate management of cytologically positive inguinal nodes in melanoma can be resolved only by a prospective randomized trial comparing CLND with SLND. Morbidity and local disease control must be measured as outcomes in addition to disease-free and overall survival.     

Early complications of combined pelvic lymphadenectomy and radical prostatectomy versus lymphadenectomy alone

A comparison of the early morbidity of pelvic lymphadenectomy plus radical prostatectomy versus lymphadenectomy alone is reported. Fifty-one patients underwent the combined procedure; 26 had lymphadenectomy alone. Incidence of early complications was 35% in patients undergoing prostatectomy and node dissection and 27% in patients undergoing lymph node dissection only, a difference which is not statistically significant. Thrombophlebitis and pulmonary embolus occurred after the combined procedure. There was one postoperative death in the combined surgery group. The results of this study suggest that lymph node dissection may be performed at the time of radical prostatectomy rather than as a staging procedure, and emphasize the importance of pelvic lymph node dissection in the evaluation and treatment of clinically localized prostate cancer.