V05-12: Robot assisted extended pelvic lymph node dissection for bladder cancer: technique, extent and feasibility in minimal invasive era.
The standard of care for localized urothelial carcinoma invading bladder muscle is Radical cystectomy with extended pelvic lymph node dissection (ePLND). Minimal invasive surgery benefits have been applied in bladder cancer patients with the advent of robot with completion of urinary diversions intra-corporeally. Scepticism remains regarding whether an adequate node dissection can be performed as previously reported nodal yields of laparoscopic or robotic lymphadenectomy are well below those reported with open surgery. The extent of PLND has been shown to impact oncological outcomes. This video demonstrates the technical caveats of robotic ePLND with equivalent nodal yields to open series from centres of excellence.
A 72 year old gentleman presented with history of intermittent hematuria since 2 months. Histopathology on transurethral resection of bladder tumor (TURBT) was suggestive of high grade muscle invasive tumor. CECT abdomen showed heterogenously enhancing polypoidal mass measuring 5.5x4.5 cm arising from left postero-inferior wall with involvement of left ureteric orifice with moderate hydronephrosis. Faintly FDG avid, subcentimeter sized, left external iliac lymph nodes were seen on FDG PET with no other areas of FDG avid lesion in the body. After appropriate evaluation, he was planned for a robotic radical cystectomy with bilateral ePLND along with intracorporeal ileal conduit using the da Vinci Xi system. The patient was positioned in a supine Trendelenberg position and robotic and assistant ports were placed. The Xi system was docked from the side and superexteded template bilateral pelvic lymph node dissection was performed as a part of procedure.
The ePLND component of the procedure could be safely accomplished with a console time of 90 minutes with minimal bleeding and no blood transfusions. Per urethral foleys drain was removed on second post operative day. The patient recovered uneventfully and was discharged on sixth postoperative day. Final histopathology revealed absence of viable tumor in bladder specimen and none of the 45 nodes retrieved were positive. Till now we have a series of 19 cases in last 15 months with median lymph node yeild of 36.
Robot-assisted ePLND at the time of cystectomy can be safely and effectively performed on the robotic platform with comparable nodal yields to open series at centers of excellence for cystectomy. Nodal yields are likely to comprise a factor related to the effort of the surgeon, and not the method by which the lymphadenectomy is performed