Pelvic lymphadenectomy for localized prostate cancer

In the era of prostate specific antigen, there is increasing proportion of patients with localized prostate cancer. Accurate preoperative determination of lymph node status is important for adequate selection of treatment option, monitoring of response to treatment and early detection of recurrence. Lymph node invasion (LNI) is crucial prognostic parameter for patients who underwent curative treatment. Despite of continuous improvments of radiological armamentarium, CT, MRI and PET scans are not absolutely reliable in lymph node staging. Many nomograms have been developed for prediction of lymph node status, but accuracy of these statistical models is not better than 78%. Surgery, either open or laparoscopic pelvic lymphadenectmy (PLND), remains a cornerstone in lymph node staging. However, there are several controversies regarding PLND 1) necessity for routine perfoming in each patient, 2) anatomic boundaries for PLND, 3) morbidity of PLND, and 4) diagnostic and therapeutic value.     

Local hyperthermia for prostate cancer.

Hyperthermia for treatment of cancer is known to be beneficial both in itself and in conjunction with other forms of treatment, particularly radiotherapy. We have developed a new machine for local hyperthermia (41-44 degrees C) to the prostate, by transmission of microwaves (915 MHz) via a rectal probe. Patients were treated on an outpatient basis and did not require any anesthesia or sedation. There were no complications. Good results, measured by local control, disappearance of malignancy, relief of obstructive symptoms and pain, have been obtained in a series of 44 cases. More studies with this promising new modality are in progress.     

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.     

Pelvic lymphadenectomy in prostate cancer

This review analyzes the anatomy of the prostate gland's lymphatic drainage, the optimal anatomic extend of pelvic lymph node dissection (PLND) and which dissection may be superior, who should undergo a PLND during prostatectomy, and its potential therapeutic benefits and complications. The prostate gland's lymphatic drainage can be variable, but frequently metastatic disease is found in the internal iliac chain. We conclude that the extended PLND yields the most lymph nodes and therefore may be superior. Some have demonstrated an unproven survival benefit after performing an extended PLND, possibly from removal of occult disease or from more accurate staging.     

Massive hemoptysis: what place for medical and surgical treatment.

OBJECTIVE: The objective of the study was to define timing of surgical treatment in management of massive hemoptysis. METHODS: We performed a retrospective review of all patients admitted for massive hemoptysis in the intensive care unit of our thoracic surgery department. Treatment was managed according to the patient's status, the etiology of bleeding, the findings of bronchoscopy and computed tomographic scan. Therapeutic measures available were medical treatment, tracheal intubation (single or double lumen tube), interventional endoscopy, arterial embolisation and surgical treatment. RESULTS: Between September 1996 and December 2001, 43 patients were treated (nine females and 34 males with mean age of 54 years, range from 32 to 79). The mean red cell blood transfusion per patient was 1.57 Units. The patients were classified into three groups: Group 1, 11 patients were operated on immediately close to the bleeding crise (five pneumonectomy and six lobectomy); Group 2, five patients for whom operation was delayed from the 7th to the 22nd day after cessation of bleeding (five lobectomy); Group 3, 27 patients were treated by non-surgical methods (medical treatment, endobronchial treatment, percutaneous embolisation). Fifteen patients underwent an arterial embolization, which was complete in 13 cases. Among the five patients of group 2, cessation of bleeding was obtained by bronchial embolisation in four cases. Considering the whole series, 10 (23%) patients died: three (19%) patients in group 1, zero in group 2, seven (26%) in group 3. In two patients who were suffering from tumor necrosis, hemoptysis relapsed leading to death. CONCLUSION: Emergency thoracotomy for massive hemoptysis is at high risk. In case of bleeding from the arterial bronchial vessels, embolization may enable to postpone surgery and operate secondarily. In case of bleeding from the pulmonary vessels (tumor necrosis), surgical treatment must be immediate. An algorithm for management is proposed.     

Role of lymphadenectomy for prostate cancer: indications and controversies

Pelvic lymph node dissection is the only reliable technique to detect low-volume lymph node involvement in prostate cancer. Extended lymph node dissections that include the internal iliac chain in addition to the external iliac and obturator packets have shown a significantly higher proportion of patients to have lymphatic involvement than previously recognized. The improved staging afforded by a more extended dissection raises several questions. Addressing these questions is the focus of this review.     

Local treatment for metastatic prostate cancer: A systematic review

The potential oncological benefit for radical treatment in the setting of oligometastatic prostate cancer has been under investigation and is frequently discussed. We carried out a systematic review of English language articles using the Medline database (January 2000 to May 2017) to identify studies reporting local treatment in men with metastatic prostate cancer at diagnosis. Primary end‐points were oncological outcomes, such as cancer‐specific and overall mortality. Secondary end‐points were non‐oncological outcomes, such as complications, operating room time, blood loss or length of hospital stay. Two independent authors reviewed and extracted all search results. Overall, 18 studies reporting on local treatment in metastatic prostate cancer patients were identified (14 original articles, three brief correspondences and one letter to the editor). All of them were retrospective; one partly included prospective data. All studies addressed oncological outcomes, 16 compared local treatment with no‐local treatment and 14 adjusted for confounders using multivariable regression models. All but one study concluded a survival benefit for local treatment in the metastatic setting. Due to heterogeneity of available data, a representative meta‐analysis could not be carried out. Five studies reported non‐oncological outcomes. Although local treatment in metastatic prostate cancer appears to be feasible, its oncological effect remains unclear due to high susceptibility of available studies to significant selection bias.     

Transperitoneal endosurgical lymphadenectomy in patients with localized prostate cancer.

The main appeal of radiotherapy for carcinoma of the prostate lies in the low morbidity and good subsequent quality of life. The handicap of this approach is the absence of adequate staging through pelvic lymphadenectomy. A new operation with minimal morbidity for the patient is presented and described in detail: endosurgical (laparoscopic) pelvic lymphadenectomy. This operation can be performed on an outpatient basis and is extremely well tolerated by the patient. The results of the first 12 consecutive cases indicate that, with experience, the procedure can be performed within a reasonable time limit (90 to 205 minutes) and that the number of lymph nodes removed (right and left obturator fossae mean 7.6 and 7.1, respectively) is adequate. Endosurgical lymphadenectomy adds only minimal morbidity to the radiotherapeutic treatment of prostatic cancer but permits more accurate staging and, therefore, counseling of the patients.     

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.     

The role of lymphadenectomy in prostate cancer

It has been shown that an adequate lymphadenectomy for exact staging of prostate cancer consists of removal of all the tissue along the external iliac vein, in the obturator fossa and along the internal iliac artery. Morbidity associated with this procedure is low, if certain technical details are respected. This review discusses in detail the indications for lymphadenectomy and the extent of dissection, based on the localization of the positive nodes. The potential therapeutic impact of extended lymph node dissection in men with prostate cancer is also addressed.     

Current controversies on the role of lymphadenectomy for prostate cancer

Lymph node dissection is part of the standard treatment protocol for various cancers, but its role in prostate cancer has been debatable for some time. Pelvic lymphadenectomy has been shown to better help stage prostate cancer patients, but has yet to be definitively proven to be of any benefit for survival. Various templates for lymph node dissections exist, and though some national guidelines have endorsed an extended pelvic node dissection, the choice of template is still controversial. Pelvic lymphadenectomy may lead to a slightly higher rate complications and operative time, and their use must be judiciously applied to patients with a high enough risk of lymph node involvement. We present a comprehensive review of the literature regarding the benefits and harms of lymph node dissection in prostate cancer.