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Pelvic Lymph Node Dissection: Open Benchmarks with Lymphoscintigraphy

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Robot-Assisted Radical Prostatectomy

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Abstract

Prior to 2002, prostate cancer surgery for PSA screened patients generally included no lymph node dissection, or a template limited to the obturator fossa. The group from Studer in Berne Switzerland published a key paper in 2002 demonstrating much higher than expected rates of pelvic lymph node metastases if the template included the hypogastric planes and a more thorough dissection within the obturator fossa. In this chapter we consider the extended series from this group and include recent lessons learned from drainage patterns observed with lymphoscintigraphy. The benefits of the extended template may include better cancer staging and disease control. Complications are increased and presented. The challenge for robotic surgeons is to match these templates.

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Authors and Affiliations

  1. Department of Urology, University Hospital of Bern, University of Bern, Anna-Seiler-Haus, Inselspital, Bern, 3010, Switzerland

    Daniel P. Nguyen, Philipp M. Huber, Tobias A. Metzger, Pascal Zehnder & George N. Thalmann M.D.

Authors
  1. Daniel P. Nguyen
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  2. Philipp M. Huber
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  3. Tobias A. Metzger
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  4. Pascal Zehnder
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  5. George N. Thalmann M.D.
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Correspondence to George N. Thalmann M.D. .

Editor information

Editors and Affiliations

  1. Department of Urology, Uro-surgical Prostate Cancer Program, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA

    John W. Davis

Editor’s Comments—Nguyen et al.

Editor’s Comments—Nguyen et al.

As detailed in the chapter to follow, the robotic technique to extended template lymph node dissection is part surgeon understanding of what nodes to obtain and part surgical skills. After years of developing the extended template technique with the robot from 2007 to 2012, I had sufficient data to show that the nodes and nodal yields increased [67]; however there was no way to know for sure that my technique was the same as developed by Studer and colleagues in Berne. Ultimately I had to travel there in person and observe cases and give some talks. What I learned was that the anatomy has to be moved around to find the nodes, and that the lymphoscintigraphy really identifies a wide, variable template of nodes. Attached are images from the visit showing how tedious learning process is—Figs. 14.3, 14.4, 14.5, 14.6, 14.7, and 14.8. For the rest of us, the knowledge gained can translate into an efficient extended template. In my hands I can do this in 30–45 min although early on this took around 90 min.

Fig. 14.3
figure 3

Through an open approach the lymphoscintigraphy is performed. The Geiger counter is quite large and not feasible for laparoscopic access

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Fig. 14.4
figure 4

The template is exposed with their open approach and extraperitoneal

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Fig. 14.5
figure 5

The template is dissected along the left external iliac artery

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Fig. 14.6
figure 6

A laptop software package shows the imaging progress—nodes with signaling are still present

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Fig. 14.7
figure 7

The lymph nodes removed are re-examined on the back table for signaling

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Fig. 14.8
figure 8

The field is re-examined for remaining signaling such as in the upper left corner, and the images re-checked until all tissue with signaling are removed

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Nguyen, D.P., Huber, P.M., Metzger, T.A., Zehnder, P., Thalmann, G.N. (2016). Pelvic Lymph Node Dissection: Open Benchmarks with Lymphoscintigraphy. In: Davis, J. (eds) Robot-Assisted Radical Prostatectomy. Springer, Cham. https://doi.org/10.1007/978-3-319-32641-2_14

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  • DOI: https://doi.org/10.1007/978-3-319-32641-2_14

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