ABSTRACT
Introduction:
Robot-assisted radical prostatectomy (RARP) has become a popular surgical approach for localized prostate cancer due to its favorable oncological and functional outcomes, as well as lower morbidity. In cases of intermediate- and high-risk prostate cancer, bilateral pelvic lymphadenectomy (PLND) is recommended as an adjunct to RARP (11 Sanda MG, Cadeddu JA, Kirkby E, Chen RC, Crispino T, Fontanarosa J, et al. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Part I: Risk Stratification, Shared Decision Making, and Care Options. J Urol. 2018;199:683-90. doi: 10.1016/j.juro.2017.11.095.
https://doi.org/10.1016/j.juro.2017.11.0...
–33 Alfano CG, Moschovas MC, Montagne V, Soto I, Porter J, Patel V, et al. Implementation and outcomes of Hugo(TM) RAS System in robotic-assisted radical prostatectomy. Int Braz J Urol. 2023;49:211-20. doi: 10.1590/S1677-5538.IBJU.2023.9902.
https://doi.org/10.1590/S1677-5538.IBJU....
). Despite its benefits, PLND can lead to surgical complications, with postoperative lymphocele formation being the most common. Most postoperative lymphoceles are clinically insignificant with variable incidence, reaching up to 60% of cases 4. However, a small percentage of patients 2-8% may experience symptomatic lymphoceles (SL), which can cause significant morbidity (44 Ploussard G, Briganti A, de la Taille A, Haese A, Heidenreich A, Menon M, et al. Pelvic lymph node dissection during robot-assisted radical prostatectomy: efficacy, limitations, and complications-a systematic review of the literature. Eur Urol. 2014;65:7-16. doi: 10.1016/j.eururo.2013.03.057.
https://doi.org/10.1016/j.eururo.2013.03...
, 55 Zorn KC, Katz MH, Bernstein A, Shikanov SA, Brendler CB, Zagaja GP, et al. Pelvic lymphadenectomy during robot-assisted radical prostatectomy: Assessing nodal yield, perioperative outcomes, and complications. Urology. 2009;74:296-302. doi: 10.1016/j.urology.2009.01.077.
https://doi.org/10.1016/j.urology.2009.0...
).
Surgical technique:
We perform our RARP technique with our standard approach in all patients (66 Moschovas MC, Patel V. Nerve-sparing robotic-assisted radical prostatectomy: how I do it after 15.000 cases. Int Braz J Urol. 2022;48:369-70. doi: 10.1590/S1677-5538.IBJU.2022.99.03.
https://doi.org/10.1590/S1677-5538.IBJU....
). After vesicourethral anastomosis a modified PF created to prevent symptomatic lymphocele. We start by suturing the peritoneal fold on the right side, medially to the vas deferens, followed by a similar stitch on the left side to approximate the edges in the midline. A running suture bunches the bladder peritoneum from both sides, passing through the pubic bone periosteum to secure it in place (77 Gamal A, Moschovas MC, Jaber AR, Saikali S, Sandri M, Patel E, et al. Peritoneal Flap Following Lymph Node Dissection in Robotic Radical Prostatectomy: A Novel "Bunching" Technique. Cancers (Basel). 2024;16:1547. doi: 10.3390/cancers16081547.
https://doi.org/10.3390/cancers16081547...
). This approach keeps the lateral pelvic gutters open for lymphatic drainage, while allowing fluid drainage from the true pelvis into the abdomen. A pelvic ultrasound was done for all patients at 6 weeks post operative, and additional clinical follow-up was carried out at 3 months following surgery.
Considerations:
We have demonstrated a modified technique of peritoneal flap (PBFB) with an initial decrease in postoperative symptomatic lymphoceles, the technique is feasible, safe, does not add significant morbidity, and does not require a learning curve.
Available at: http://www.intbrazjurol.com.br/video-section/20240278_Patel_et_al
Int Braz J Urol. 2024; 50 (Video #9): 657-8
REFERENCES
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1Sanda MG, Cadeddu JA, Kirkby E, Chen RC, Crispino T, Fontanarosa J, et al. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Part I: Risk Stratification, Shared Decision Making, and Care Options. J Urol. 2018;199:683-90. doi: 10.1016/j.juro.2017.11.095.
» https://doi.org/10.1016/j.juro.2017.11.095 -
2Briganti A, Blute ML, Eastham JH, Graefen M, Heidenreich A, Karnes JR, et al. Pelvic lymph node dissection in prostate cancer. Eur Urol. 2009;55:1251-65. doi: 10.1016/j.eururo.2009.03.012.
» https://doi.org/10.1016/j.eururo.2009.03.012 -
3Alfano CG, Moschovas MC, Montagne V, Soto I, Porter J, Patel V, et al. Implementation and outcomes of Hugo(TM) RAS System in robotic-assisted radical prostatectomy. Int Braz J Urol. 2023;49:211-20. doi: 10.1590/S1677-5538.IBJU.2023.9902.
» https://doi.org/10.1590/S1677-5538.IBJU.2023.9902 -
4Ploussard G, Briganti A, de la Taille A, Haese A, Heidenreich A, Menon M, et al. Pelvic lymph node dissection during robot-assisted radical prostatectomy: efficacy, limitations, and complications-a systematic review of the literature. Eur Urol. 2014;65:7-16. doi: 10.1016/j.eururo.2013.03.057.
» https://doi.org/10.1016/j.eururo.2013.03.057 -
5Zorn KC, Katz MH, Bernstein A, Shikanov SA, Brendler CB, Zagaja GP, et al. Pelvic lymphadenectomy during robot-assisted radical prostatectomy: Assessing nodal yield, perioperative outcomes, and complications. Urology. 2009;74:296-302. doi: 10.1016/j.urology.2009.01.077.
» https://doi.org/10.1016/j.urology.2009.01.077 -
6Moschovas MC, Patel V. Nerve-sparing robotic-assisted radical prostatectomy: how I do it after 15.000 cases. Int Braz J Urol. 2022;48:369-70. doi: 10.1590/S1677-5538.IBJU.2022.99.03.
» https://doi.org/10.1590/S1677-5538.IBJU.2022.99.03 -
7Gamal A, Moschovas MC, Jaber AR, Saikali S, Sandri M, Patel E, et al. Peritoneal Flap Following Lymph Node Dissection in Robotic Radical Prostatectomy: A Novel "Bunching" Technique. Cancers (Basel). 2024;16:1547. doi: 10.3390/cancers16081547.
» https://doi.org/10.3390/cancers16081547
Publication Dates
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Publication in this collection
09 Sept 2024 -
Date of issue
Sep-Oct 2024
History
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Received
12 May 2024 -
Accepted
16 May 2024 -
Published
31 May 2024