盆腔淋巴结清扫数量与高危前列腺癌——文献回顾及基于单中心的初步研究

目的探讨腹腔镜下扩大盆腔淋巴结清扫对高危前列腺癌患者的意义,回顾相关文献并探讨淋巴结清扫数量对前列腺癌的诊断及治疗意义。方法对2017年1月至2018年6月期间15例接受腹腔镜下前列腺癌根治性切除及扩大盆腔淋巴结清扫高危前列腺癌患者的临床资料进行回顾性分析,分析淋巴结清扫情况及术后并发症发生情况。结果患者平均年龄(68.4±5.8)(60～79)岁,患者术前均诊断为高危前列腺癌,术中盆腔淋巴结清扫范围包括双侧闭孔神经、髂外血管和髂内血管周围的淋巴结和脂肪组织。扩大盆腔淋巴结清扫平均手术时间(94.3±10.2)(75～116)min,平均出血量(22.5±4.2)(10～40)mL。术中未发生重要血管及神经损伤。清扫淋巴结数目6～29枚,中位数为15枚。盆腔淋巴结阳性8例,阳性率53.3%;阳性淋巴结中位数5枚。清扫术后引流管拔除时间5～36d,中位数为7d。与盆腔淋巴结清扫相关的术后早期并发症主要有下肢深静脉血栓(2例)、淋巴囊肿(1例)、淋巴漏(8例)等。结论高危前列腺癌患者行扩大盆腔淋巴结清扫具有较高阳性率,有助于对前列腺癌进行准确分期,足够数量的淋巴结数量及范围是影响高危前列腺癌综合治疗疗效的重要因素。     

腹腔镜盆腔淋巴结活检术在前列腺癌分期中的意义

目的　评价腹腔镜盆腔淋巴结活检术在前列腺癌分期中的作用。　方法　对 36例临床分期T1b～T3a前列腺癌患者行腹腔镜盆腔淋巴结活检术 ,患者全身骨扫描均未见骨转移 ,盆腔CT或MRI未发现转移灶。血PSA 2 .7～ 2 30 .0ng/ml,平均 16 .0ng/ml。Gleason评分 5～ 10分 ,平均 6 .5分。　结果　 36例患者中 ,盆腔淋巴结活检阳性 6例 (16 .7% )。临床分期、PSA及Gleason评分与盆腔淋巴结活检的阳性率密切相关。手术时间 30～ 14 2min ,平均 82min。术后住院时间 1～ 10d ,平均 2d。并发症发生率 8.3% (3/36 )。　结论　腹腔镜盆腔淋巴结活检术安全、有效 ,对判断前列腺癌患者有无盆腔淋巴结转移、前列腺癌分期有重要意义。     

耻骨后根治性前列腺切除治疗淋巴结转移前列腺癌的疗效分析

目的:探讨耻骨后根治性前列腺切除结合辅助内分泌治疗或局部外放疗治疗20例前列腺癌伴盆腔淋巴结转移的安全性和疗效。方法:术前对20例前列腺癌患者均行双侧足背淋巴管造影,对其中11例盆腔可疑淋巴结穿刺抽吸淋巴液,进行实时定量PCR(RT-PCR)检测淋巴液PSA mRNA和前列腺特异膜抗原(PSMA)mRNA的表达。20例均行耻骨后根治性前列腺切除和扩大盆腔淋巴结清扫,对其中3例切端阳性者待尿失禁控制后给予外放疗。结果:11例经RT-PCR检测淋巴结液PSA mRNA和PSMA mRNA阳性表达中均经病理证实为前列腺癌淋巴结转移。术中失血量中位数575 ml,术中输血5例。手术切缘阳性3例,漏尿和淋巴漏各2例,无尿失禁、血管损伤和直肠损伤病例。经中位数42个月随访,术后6~48个月生化复发12例,复发时间中位数12个月。术后12个月和48个月分别死亡2例。结论:术前淋巴管造影后穿刺抽吸淋巴结液,用RT-PCR方法检测淋巴液PSA mRNA和PSMA mRNA表达有助于术前确定前列腺癌盆腔淋巴结转移。采用耻骨后根治性前列腺切除和扩大淋巴结清扫结合辅助内分泌治疗,对切端阳性者给予局部外放射治疗是治疗前列腺癌伴盆腔淋巴结转移患者安全、有效的方法。但对Gleason 10分的盆腔淋巴结转移前列腺癌采用根治性前列腺切除应慎重。     

膀胱癌根治术中的盆腔淋巴结清扫

目的 总结膀胱癌根治术盆腔淋巴结清扫的疗效. 方法 膀胱癌患者95例.男76例,女19例.年龄25～78岁.初发49例、复发46例.病理分类:尿路上皮癌87例、腺癌5例、鳞状细胞癌3例.病理分级:G117例、G2 39例、G3 31例.病理分期:Ta～T1 10例、T2 54例,T3 26例、T45例.95例均行膀胱癌根治术及标准的双侧区域盆腔淋巴结清扫术,清扫范围包括双侧髂内、髂外以及闭孔淋巴结. 结果 95例清扫手术平均时间20 min,平均出血量25 ml,术中未发生重要血管及神经损伤.清扫淋巴结数目1～20枚,平均10枚,淋巴结阳性率为17.9%(17/95).术后发生近期并发症12例(12.6%),包括盆腔淋巴瘘、盆腔感染、阴囊或下肢水肿.术后随访3～64个月,中位时间34个月,死亡16例,3年存活率84.5%. 结论 膀胱癌根治术中行标准的双侧区域盆腔淋巴结清扫能提高分期准确性和患者生存率,无严重并发症,是一种安全、有效的操作.     

盆腔淋巴结清扫在根治性前列腺切除术中的意义

目的:探讨盆腔淋巴结清扫在根治性前列腺切除术中的意义。方法:对266例接受前列腺癌根治性切除及盆腔淋巴结清扫的患者的临床资料进行回顾性分析。患者术前均诊断为局限性前列腺癌,平均年龄(66.5±5.5)(58~82)岁。高危者68例,中危者155例,低危者43例。130例行耻骨后根治性前列腺切除术(retropubic radical prostatectomy,RRP),33例行腹腔镜根治性前列腺切除术(laparoscopic radical prostatectomy,LRP),103例行达芬奇机器人辅助腹腔镜根治性前列腺切除术(robot assisted laparoscopic radical prostatectomy,RALRP)。其中标准盆腔淋巴结清扫(standard pelvic lymph node dissection,sPLND)者181例,扩大盆腔淋巴结清扫(extended pelvic lymph node dissection,ePLND)者85例。标准盆腔淋巴结清扫范围包括双侧闭孔及髂外淋巴结,扩大盆腔淋巴结清扫在标准盆腔淋巴结清扫的基础上尚切除髂内淋巴结及髂总淋巴结。淋巴结阳性患者术后均予辅助性内分泌治疗。结果:手术时间(operating time,OT)sPLND组(12.6±0.2)min,ePLND组(30.6±2.1)min(P=0.0012);平均失血量(estimated blood loss,EBL)sPLND组(25.7±5.5)ml,ePLND组(60.2±8.3)ml(P=0.0021);清扫淋巴结数目sPLND组(9.0±2.3)枚,阳性病例率8.3%,ePLND组(26.2±5.8)枚,阳性病例率17.6%(P=0.024)。术后平均住院天数(hospital stay,HS)sPLND组(7.8±0.2)d,ePLND组(9.8±0.4)d(P=0.11)。sPLND组11例(6.1%)出现淋巴清扫术后相关并发症,ePLND组11例(12.9%)出现淋巴清扫术后相关并发症(P=0.058)。在sPLND组和ePLND组分别计算低危组、中危组和高危组的手术时间、失血量、住院天数和并发症比率,其差异无统计学意义。在85例ePLND中,手术时间在RRP组、LRP组、RALRP组分别为(28.8±0.4)min、(47.8±0.9)min和(26.5±0.3)min(P=0.06);失血量在RRP组、LRP组、RALRP组分别为(30.3±2.5)ml、(62.7±5.2)ml和(38.1±3.7)ml(P=0.11);术后住院天数在RRP组、LRP组、RALRP组分别为(10.2±0.8)d、(8.8±0.5)d和(7.5±0.3)d(P=0.51)。结论:盆腔淋巴结清扫可以对前列腺癌提供精确的分期,同sPLND相比,ePLND耗时、失血量较多,但能获取更多的淋巴结,并发症也较多。低危前列腺癌患者,不必常规行淋巴结清扫,中危和高危患者,sPLND和ePLND均可选择,但推荐对高危患者行ePLND。是淋巴结清扫的范围,而不是危险度影响了手术的难度。以不同的手术方式行ePLND,机器人手术和开放手术具有一定的优势。淋巴结清扫的范围对患者预后的影响尚需长期随访。     

腔镜下阴茎癌双侧腹股沟淋巴结清扫术14例报告

目的探讨腔镜下阴茎癌双侧腹股沟淋巴结清扫术的效果。方法2009年9月～2011年11月对14例阴茎癌行腔镜下双侧腹股沟淋巴结清扫术。术前对腹股沟淋巴结和隐静脉进行多普勒超声扫描和盆腔淋巴CT检查,术中建立人工手术腔隙,置人腔镜以及操作器械,先用超声刀扩大皮下腔隙,向上至腹股沟韧带上方的腹外斜肌腱膜,外侧至缝匠肌外缘,内侧为长收肌内侧,下界为股三角顶端,解剖出股动静脉、大隐静脉及其分支,并切除该范围内的淋巴结和脂肪组织,从穿刺孔取出清扫的淋巴结和脂肪组织,术后置引流管引流。结果14例均顺利完成腔镜下腹股沟淋巴清扫术,术中未发生并发症。手术时间平均103min（95～112min）,术中出血量平均85ml（20～130m1）。双侧切除淋巴结共5—14枚,平均9枚,淋巴结均阴性。术后留置引流管平均5d（3～7d）。术后住院5～8d,平均6d。1例出现淋巴囊肿,2个月后消退,其余患者未发生股血管损伤、皮缘坏死、愈合延迟、皮下积液和淋巴漏等切口相关的并发症。14例术后随访6—20个月,平均9个月,患者无明显双下肢肿胀及活动障碍。结论腔镜下阴茎癌双侧腹股沟淋巴结清扫术可以保证清扫范围并减少标准开放手术带来的切口相关并发症。     

耻骨后前列腺癌根治术的技术改进(附32例报告)

目的　改进耻骨后前列腺癌根治术的手术技术 ,减少并发症。　方法　临床诊断为T1和T2 期前列腺癌患者 32例 ,平均年龄 6 8岁。改进耻骨后前列腺癌根治技术 ,包括广泛盆腔淋巴结清扫、保护神经血管束、缝扎背深静脉、多保留尿道后壁组织、膀胱尿道吻合时的膀胱颈部套叠等。　结果　手术时间平均 3.5h ,术中平均出血量 4 5 0ml,输血 1 7例。术后病理报告 :肿瘤局限于包膜内者30例 ,切缘阳性 1例 ,盆腔淋巴结转移 1例。随访 8～ 4 8个月 ,平均 2 2个月 ,均存活。PSA <1ng/ml者2 8例 ,1～ 3ng/ml者 4例。术后 3～ 6个月患者均恢复完全控尿。术后恢复勃起功能者 1 0 / 1 8(5 6 % )例。　结论　耻骨后前列腺癌根治术可有效切除肿瘤、保护控尿功能、保留性功能 ,是局限性前列腺癌的首选治疗方法。     

阴茎癌腹腔镜下和开放式腹股沟淋巴结清扫术的对比研究

目的 比较阴茎癌腹腔镜下与开放式双侧腹股沟淋巴结清扫术的临床效果. 方法 回顾性分析2007年6月至2011年6月收治的23例阴茎癌患者的临床资料,年龄40～75岁,平均57岁.病程7d～9年,平均18.6个月.术前临床分期T1期10例,T2期7例,T3期6例.10例腹股沟淋巴结肿大,其中3例有2枚肿大淋巴结.根据腹股沟淋巴结清扫方式将患者分为腹腔镜手术(laparoscopic surgery,LS)组10例和开放式手术(open surgery,OS)组13例,两组患者的年龄、病程、肿瘤分期和淋巴结肿大情况等比较差异均无统计学意义(P＞0.05).比较两组患者的手术时间、术中出血量、术后引流管留置时间、平均住院时间、切除淋巴结数量及并发症等情况. 结果 LS组手术时间(103.6±15.2)min、术中出血量(56.5±6.8)ml、术后引流管留置时间(5.8±0.8)d、住院时间(8.5±1.1)d,OS组手术时间(156.8±18.3) min、术中出血量(88.5±9.5)ml、术后引流管留置时间(12.5±1.3)d、住院时间(15.7±1.9)d,两组比较差异均有统计学意义(P＜0.05).LS组切除淋巴结数量为(9.5±1.3)枚、OS组为(10.3±1.5)枚;LS组病理阳性淋巴结数量为5处6枚,OS组为5处7枚,两组比较差异均无统计学意义(P＞0.05).两组均无输血病例,无败血症等严重并发症发生,无死亡病例.随访12～48个月,OS组出现肺转移1例,其余患者无原位复发及转移. 结论 与开放手术比较,阴茎癌腹腔镜下双侧腹股沟淋巴结清扫术具有术中出血量少、术后恢复快、住院时间短、并发症少等优点,是一项安全有效的手术.     

腹腔镜前列腺癌根治术治疗高危前列腺癌的临床体会

目的：探讨腹腔镜前列腺癌根治术在高危前列腺癌治疗中的价值。方法回顾性分析2012年3月～2014年11月本院腹腔镜前列腺癌根治术治疗26例高危前列腺癌的临床资料。患者平均年龄65．2岁,术前检查单独PSA≥20ng／mL者9例;兼具PSA≥20ng／mL并Gleason评分≥8分者17例;术前诊断T3 b和T4期各1例。3例患者因前列腺体积过大术前分别行3～6个月新辅助内分泌治疗。手术方式均采用经腹膜外路径腹腔镜前列腺癌根治术,同时行盆腔淋巴结清扫。结果26例手术均获成功,平均手术时间152min,平均出血量85mL,无输血病例。所有患者均于术后两周拔除导尿管,8例拔管后尿失禁,经盆底训练后于1周至3个月恢复控尿。术后病理T2a～T2b,Gleason评分≤7分者10例;T2c～T4,Gleason评分≥8分者16例。术中清扫淋巴结数目平均5．5个,淋巴结阳性3例;切缘阳性4例,术后控尿恢复后予局部放射治疗。19例获访3～30个月,所有患者均控尿良好,PSA≤0．2ng／mL。结论对高危前列腺癌患者采用以根治性前列腺癌切除术为核心的综合治疗策略安全有效,可使患者获益。     

进展期前列腺癌外科治疗25例临床分析

目的 探讨进展期前列腺癌的外科治疗.方法 回顾性分析2014年5月至2016年2月于本院收治的予以手术处理的25例进展期前列腺癌的患者临床资料,统计其年龄、术前PSA、病理分期、前列腺体积及术后PSA最低值和随访结果.结果 25例进展期前列腺癌患者平均年龄为68.1岁(56 ～ 83岁),术前PSA15.81～335 ng/mL,10例患者术前PSA大于100 ng/mL,术前PSA平均86 ng/mL.临床分期T3bN0期8例,N1期13例.临床诊断骨转移4例,这4例患者病理为2例T3bN0、2例T4N1.Gleason评分7分7例,≥8分18例.前列腺体积平均67.2 mL(50～145 mL),19例行腹腔镜下前列腺切除+扩大盆腔淋巴结清扫,6例为开放手术,术中清除淋巴结平均13枚(4～30枚),淋巴结平均转移率20％ (0％ ～94％).围手术期3例患者需要输血,1例患者引流管拔管延迟,未见其他重大并发症.外科手术后6周复查PSA明显降低,平均值1.20 ng/mL(0.32 ～ 4.60 ng/mL),外科治疗后3个月PSA降至平均0.08 ng/mL(0.003 ～0.450 ng/mL).随访时间5～23个月,所有患者目前均存活.1例患者出现生化复发,MRI检查及进一步经尿道膀胱肿物切除手术确诊为复发,电切病理同根治手术均为Gleason评分4+5 =9分;余患者目前PSA控制满意.结论 进展期前列腺癌外科处理是一种安全的治疗方式,前列腺切除+扩大淋巴结清扫并未见并发症明显升高,对于严格筛查入选的患者行外科治疗是控制肿瘤的一种合理方式.     

Limitations of radioguided surgery in high-risk prostate cancer

OBJECTIVES: To determine how many men with high-risk prostate cancer (prostate-specific antigen [PSA]>20 ng/ml or biopsy Gleason score 8-10) have positive lymph nodes (sentinel lymph nodes [SLNs] and nonsentinel lymph nodes [NSLNs]) and whether these positive nodes are localised in the region of SLN dissection or in other regions, too. METHODS: In 228 men with high-risk prostate cancer radical retropubic prostatectomy combined with radioguided pelvic lymph node dissection and extended lymphadenectomy were performed. Serial sections of the SLNs were analysed immunohistochemically. RESULTS: A median of 7 SLNs (mean, 7) and 11 NSLNs (mean, 11) were dissected per patient. Ninety-six of 228 men (42.1%) had lymph node metastases. Most men had positive lymph nodes along the internal iliac artery alone or in combination with other regions. Twenty-two men had only micrometastatic disease. In 94 of 96 men the SLNs were positive. Twenty-six of 96 men had also positive NSLNs. When SLNs and NSLNs were positive, in more than half the patients the NSLNs were localised outside the region of sentinel lymphadenectomy. CONCLUSIONS: The dissection of SLNs in prostate cancer has a high sensitivity in detecting positive nodes. When SLNs are negative, the other pelvic lymph nodes are also negative in a high percentage of men (sensitivity 97.1%). When the SLNs are positive, patients with high-risk disease also have a high incidence of positive NSLNs. Therefore, when it is aspired to remove all pelvic lymph node metastases sentinel and extended lymphadenectomy should be performed.     

Sentinel lymph node dissection for prostate cancer: experience with more than 1,000 patients

PURPOSE: We determined the incidence of positive pelvic lymph nodes in men undergoing radical retropubic prostatectomy and describe the correlation with prostate specific antigen, histological grade and stage. We examined whether tumor cells are localized in the sentinel nodes only or also in other nonsentinel lymph nodes. MATERIALS AND METHODS: A total of 1,055 men with prostate cancer underwent radio guided pelvic lymph node dissection and radical retropubic prostatectomy. In men with prostate specific antigen 20 ng/ml or less and biopsy Gleason score 7 or less only sentinel nodes were removed. In men with prostate specific antigen more than 20 ng/ml or Gleason score greater than 7 extended pelvic lymph node dissection was also performed. RESULTS: Positive lymph nodes were found in 207 men (19.6%). In 63.3% of the men these lymph nodes were detected outside of the region of standard lymphadenectomy. The percent of patients with positive nodes was greater than predicted by currently used nomograms. The higher the preoperative prostate specific antigen, pathological stage and grade, the greater the percent of men with positive sentinel and nonsentinel lymph nodes (p<0.001). CONCLUSIONS: When deciding on pelvic lymph node dissection, sentinel or extended lymphadenectomy should be performed since more than half of patients have positive nodes outside of the region of standard lymphadenectomy. In cases of positive sentinel nodes extended lymph node dissection should be performed since tumor cells are also detectable in nonsentinel lymph nodes.     

Is a limited lymphadenectomy targeting obturator nodes alone an adequate procedure for Japanese men undergoing radical prostatectomy?

BACKGROUND: The objective of the present study was to investigate the significance of pelvic lymphadenectomy during radical prostatectomy in Japanese men with prostate cancer. METHODS: A total of 178 consecutive patients who underwent radical prostatectomy and standard pelvic lymphadenectomy targeting the external iliac nodes and obturator fossa for clinically localized prostate cancer were studied. The median observation period of this series was 18 months (range: 3-36 months). RESULTS: Lymph node metastases were detected in 13 patients; that is, positive nodes were located in the external iliac nodes alone in seven patients, the obturator fossa alone in four patients, and both external iliac nodes and obturator fossa in two patients. Of these 13 patients, all of the seven with more than one positive node demonstrated biochemical recurrence, whereas five of the six with single node involvement remained without signs of biochemical recurrence. Furthermore, a single positive node was located in the external iliac region in five of the six patients. When a group at high-risk for lymph node metastasis was defined as those meeting more than two of the following three criteria: (i) pretreatment serum prostate specific antigen value > or = 20 ng/mL; (ii) biopsy Gleason sum > or = 8; or (iii) percentage of positive biopsy core > or = 50%, the incidence of lymph node metastasis was 24.5% in the high-risk group and 0.8% in the low-risk group. CONCLUSIONS: These findings suggest that limited dissection of the obturator node alone may not be sufficient for Japanese men undergoing radical prostatectomy; therefore, we recommend performing standard pelvic lymphadenectomy targeting both the external iliac nodes and the obturator fossa for patients at high-risk of lymph node involvement.     

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.     

Disease progression and survival of patients with positive lymph nodes after radical prostatectomy. Is there a chance of cure?

PURPOSE: In prostate cancer involvement of regional lymph nodes is regarded as a poor prognostic factor. Is this also true for micrometastasis if a meticulous lymph node dissection is performed? We determined progression rate and survival of patients with positive nodes following radical prostatectomy according to the number of metastases. MATERIALS AND METHODS: Between 1989 and 1999, 367 patients with clinically organ confined prostate cancer underwent meticulous pelvic lymph node dissection and radical prostatectomy. None of the patients received immediate adjuvant therapy. RESULTS: Of the patients 92 (25%) had histologically proven lymph node metastases. Followup of more than 1 year was available in 88 patients (96%), and median followup was 45 months (range 13 to 141). Of 19 patients (22%) who died of prostate cancer 16 had more than 1 positive node. Of the 39 patients with only 1 positive node 15 (39%) remained without signs of clinical or chemical progression. Whereas of the 20 and 29 patients with 2 or more positive lymph nodes only 2 (10%) and 4 (14%), respectively, remained disease-free. Time to prostate specific antigen relapse, symptomatic progression and tumor related death were significantly affected by the number of positive nodes. CONCLUSIONS: Meticulous lymph node dissection reveals a high rate of metastases (25%). In patients with positive nodes time to progression is significantly correlated with the number of diseased nodes. Some patients with minimal metastatic disease remain free of prostate specific antigen relapse for more than 10 years after prostatectomy without any adjuvant treatment. Meticulous pelvic lymph node dissection, particularly in patients with micrometastases, seems not only to be a staging procedure, but may also have a positive impact on disease progression and long-term disease-free survival.     

Is Pelvic Lymph Node Dissection Necessary in Patients with a Serum PSA < 10 ng/ml Undergoing Radical Prostatectomy for Prostate Cancer?

OBJECTIVE: Controversy persists concerning the role of pelvic lymph node dissection (PLND) in patients with preoperative PSA values <10ng/ml undergoing treatment for prostate cancer with a curative intent. The aim of this study was to determine the incidence of lymph node metastasis in this subgroup of patients. METHODS: Patients with clinically localized prostate cancer and a serum PSA<10ng/ml, without neoadjuvant hormonal or radiotherapy, with negative staging examinations who underwent radical retropubic prostatectomy with bilateral extended PLND and with >/=10 lymph nodes detected by the pathologist in the surgical specimen, were included in the study. RESULTS: A total of 231 patients with a median serum PSA of 6.7ng/ml (range 0.4-9.98) and a median age of 62 years (range 44-76) were evaluated. A median of 20 (range 10-72) nodes were removed per patient. Positive nodes were found in 26 of 231 patients (11%), the majority of which (81%) had a Gleason score >/=7 in the surgical specimen. Of the patients with a Gleason score >/=7 in the prostatectomy specimen 25% had positive nodes, whereas only 3% with a Gleason score /=7 in the prostatectomy specimen was 25% after extended PLND. It seems that in this patient group extended PLND, including removal of nodes along the internal iliac vessels, is warranted.     

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.     

EXTRAPERITONEAL ENDOSCOPIC PELVIC LYMPH NODE DISSECTION A REVIEW OF 125 PATIENTS

Purpose

We evaluated the efficacy of a totally extraperitoneal approach to endoscopic pelvic lymph node dissection.

Materials and Methods

Extraperitoneal endoscopic pelvic lymphadenectomy was performed in 125 patients with clinically localized prostate cancer. All patients were candidates for brachytherapy, cryotherapy or radical perineal prostatectomy. The first 65 patients underwent lymphadenectomy regardless of local clinical stage, prostate specific antigen (PSA) or tumor grade. The last 60 patients met 2 of 3 selection criteria, consisting of clinical local stage T2b or greater, prostate specific antigen greater than 20 and Gleason score 7 or higher. Patients were evaluated for morbidity and mortality, nodal yield, operative time, conversion rate to transperitoneal laparoscopic or open lymphadenectomy and hospital stay.

Results

Mean operative time was 104 minutes, mean length of stay was 2.1 days and mean nodal yield was 10.2. Of the patients 19.2% had positive nodes, and positive nodal yield increased to 32.9% when selection criteria were used. Of the cases 4% were converted to a transabdominal laparoscopic approach and 2.4% to open lymphadenectomy. Symptomatic lymphoceles required percutaneous drainage in 2.4% of the patients. One patient died of massive pulmonary embolism.

Conclusions

This study demonstrates that the extraperitoneal endoscopic pelvic lymph node dissection is an effective and relatively safe method of surgically staging prostate cancer. It compares favorably to other methods of surgical staging.     

Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis

PURPOSE: Lymphadenectomy for prostate cancer is limited to obturator and external iliac lymph nodes, although the internal lymph nodes represent the primary landing zone of lymphatic drainage. We performed anatomically adequate extended pelvic lymphadenectomy to assess the incidence of lymph node metastasis in cases of clinically localized prostate cancer. MATERIALS AND METHODS: A total of 103 consecutive patients underwent extended pelvic lymphadenectomy at radical retropubic prostatectomy comprising 9 selective fields, namely the external iliac, internal iliac, obturator and common iliac lymph nodes bilaterally, and the presacral lymph nodes. Histopathological findings were compared with serum prostate specific antigen (PSA), histopathological stage, preoperative biopsy and postoperative prostatectomy Gleason score. Extended pelvic lymphadenectomy was compared with radical retropubic prostatectomy and standard lymphadenectomy in 100 consecutive patients in terms of complications, the number of lymph nodes dissected and operative time. RESULTS: There were no significant differences in age, preoperative PSA or mean biopsy Gleason score in patients who underwent extended pelvic and standard lymphadenectomy. Metastases were diagnosed in 27 of the 103 patients (26.2%) who underwent the extended procedure. A mean of 28 lymph nodes (range 21 to 42) were dissected. Metastases were identified in the internal iliac and presacral regions despite negative obturator lymph nodes. Of the 27 patients 1 to 3 lymph nodes involved with metastasis were detected in 15, 9 and 1, respectively. In 26 of the 27 patients (95.8%) with lymph node metastasis PSA was greater than 10.5 ng./ml. and preoperative biopsy Gleason sum was 7 or greater. A low risk of 2% for lymph node disease was noted in patients with serum PSA less than 10.5 ng./ml. and biopsy Gleason sum less than 7. There were no significant differences in regard to intraoperative and postoperative complications, lymphocele formation or blood loss in the 2 groups. CONCLUSIONS: Extended pelvic lymphadenectomy is associated with a high rate of lymph node metastasis outside of the fields of standard lymphadenectomy in cases of clinically localized prostate cancer. Lymphadenectomy including the internal iliac lymph nodes should be performed in all patients with prostate cancer who are at high risk for lymph node involvement, as indicated by PSA greater than 10.5 ng./ml. and biopsy Gleason sum 7 or greater. In the low risk group pelvic lymphadenectomy can be omitted.     

Is a limited lymph node dissection an adequate staging procedure for prostate cancer?

PURPOSE: Generally lymph node dissection is only considered a staging procedure for prostate cancer. Therefore, the need for meticulous lymph node dissection is often questioned and only sampling is suggested. We performed a prospective study to identify the pattern of lymph node metastasis in prostate cancer and determine how extensive lymph node dissection must be not to under stage cases. MATERIALS AND METHODS: All patients with clinically organ confined prostate cancer, no prior hormonal treatment, negative preoperative staging computerized tomography and bone scan, who underwent radical prostatectomy between 1989 and 1999, were evaluated prospectively as to the number and location of lymph node metastasis. A meticulous lymph node dissection was performed along the external iliac vein, obturator nerve and internal iliac (hypogastric) vessels. Nodes from each location and side were submitted separately for histological evaluation. RESULTS: In 365 patients with a median serum prostate specific antigen of 11.9 ng./ml. (range 0.4 to 172) the median number of nodes removed was 21 (range 6 to 50). Lymph nodes were positive in 88 (24%) patients and the median number of positive nodes was 2 (range 1 to 19). Internal iliac lymph nodes were positive in 51 (58%) of the 88 patients, including 34 with additional positive lymph nodes along the external iliac vein and/or obturator nerve. Internal iliac lymph nodes alone were positive in 17 (19%) of 88 patients. CONCLUSIONS: There were significant numbers of lymph node metastases at all 3 different areas of lymphadenectomy. Positive lymph nodes were found along the internal iliac artery in more than half (58%) of the patients and exclusively in 19%. Therefore, we consider lymph node dissection along the internal iliac (hypogastric) vessels essential for representative staging. Without this dissection a fifth of node positive cases would have been under staged and diseased nodes would have remained in more than half of the cases.