V11-05: Standardized and Simplified Robot-Assisted Super-Extended Pelvic Lymph Node Dissection for Prostate Cancer: The Monoblock Technique
A super-extended lymph node dissection (sePLND) might be indicated in selected cases of oncological high risk prostate cancer patients. The sePLND template extends the ePLND template cranially along the common iliac vessels up to the aortic and caval bifurcation. This video demonstrates a standardised and simplified robot-assisted sePLND.
Robot-assisted sePLND and radical prostatectomy was performed in 15 prostate cancer patients in our institution with a risk for lymph-node invasion of 30% or higher (Briganti 2017 - Nomogram). Our 5-steps technique continues seamlessly after having performed a complete ePLND including the obturator region, internal and external iliac arteries and commune iliac arteries up to the ureteral crossing on both sides: (I) Right boundary Starting by gentle mobilisation of the sigma to the right side and opening of the retrosigmoideal space by caudocranial incision of the parietal peritoneum along the right common iliac vessels, the right boundary is dissected retrogradely along the adventitia of the right common iliac artery and medial aspect of the common iliac vein up to the aortic and caval bifurcation. (II) Cranial boundary The lymphatic tissue up to the aortic and caval bifurcation is being dissected using cautery and sharp dissection. (III) Left boundary The Prograsp Forceps is used to pivot the Sigma to the patient`s left side and lift it towards the anterior abdominal wall. Thereafter, the incision of the adventitia of the common iliac vessels on the left side is performed antegradely until the ureter-crossing is reached. (IV) Ventral boundary The lymphatic block is being dissected from the peritoneum covering the ventral surface of the template. (V) Dorsal boundary Starting from the aortic and caval bifurcation, the tissue-monoblock is being dissected craniocaudally from its dorsal boundary, clearing all prevertrebral lymph nodes until the promontorium is reached and the monoblock is being extracted in toto.
Median lymph node count was 23.5 (IQR 15.25-33) with 11 of 15 patients bearing positive nodes (73.3%). Median duration of sePLND (including ePLND) was 168 minutes (Range 132-202). One grade IIIa complication (infected lymphocele) and one grade IV complication (pulmonary embolism) occured.
This technique is safe and reproducible while offering a good overview of the sePLND template. It permits complete removal of the entire lymphatic tissue as a single monoblock and therefore reduces the risk of spreading single lymphatic nodes in the abdominal cavity.