Results of laparoscopic pelvic lymphadenectomy in patients at high risk for nodal metastases from prostate cancer

Diagnosis and treatment of prostate cancer

Many controversies surround the management of prostate cancer to include screening practices, diagnosis, and treatment options. The lack of randomized prospective studies comparing the various definitive treatment modalities currently available occasionally can make the decision process challenging for patients and their providers. In this setting of controversy, the cost of treating clinically localized prostate cancer is significant. In the face of these unanswered questions, this article summarizes some important principles regarding the diagnosis and treatment of prostate cancer. This review is limited to the diagnosis and management of clinically localized disease.

Laparoscopic lymph node sampling in locally advanced prostate cancer

OBJECTIVE

To assess the role of laparoscopic lymph node sampling in patients with locally advanced prostate cancer before radical radiotherapy, and to show that the procedure is safe when carried out by urologists with the appropriate training.

PATIENTS AND METHODS

Patients were selected prospectively using a combination of prostate-specific antigen (PSA) level, clinical stage and Gleason grade, which predicted a > 20% risk of lymph node metastases. Between October 1998 and March 2001, 50 patients (mean age 65 years, range 54-78) underwent laparoscopic pelvic lymphadenectomy. Age, presenting PSA level, Gleason grade, clinical stage, operative time, length of stay, and any adverse events were recorded. The histology reports were reviewed for the presence of nodal metastases. The selection criteria were compared between the groups with and with no nodal metastases.

RESULTS

The mean (range) PSA level of the men was 36.8 (4.4-184) ng/mL and the Gleason grade 6.8 (4-9); 58% had stage T3 disease and 12 patients (24%) had lymph node metastases. There were no statistically significant differences in PSA, Gleason grade or clinical stage between those with positive or negative nodes. The mean operative duration was 110 min, although this decreased from 133 min for the first 10 cases; one case was converted to an open procedure. The median (range) postoperative stay was 1 (1-12) days. There were two major (5%) and seven (17%) minor complications.

CONCLUSIONS

This study confirms that laparoscopic lymph nodes can be sampled safely by urologists with experience in laparoscopic surgery. Patients with a significant risk of metastases can be selected preoperatively using a combination of PSA, clinical stage and Gleason grade. Lymph node sampling in this group is necessary, as there is no other method of reliably identifying the subgroup of patients with metastatic disease in which radical conformal radiotherapy cannot be justified.

Outpatient radical prostatectomy: impact of standard perineal approach on patient outcome

PURPOSE

As managed care becomes more prevalent, urologists must critically evaluate the economic aspect of and patient satisfaction with urological practice patterns. We have previously reported the advantages of radical perineal prostatectomy, which decreases hospitalization and morbidity, and provides a more rapid return to normal activity, translating into cost savings. We have since evaluated the satisfaction of patients who underwent outpatient radical prostatectomy with and without laparoscopic pelvic lymph node dissection.

MATERIALS AND METHODS

We evaluated the charts of 250 consecutive patients who underwent outpatient radical perineal prostatectomy with less than 24 hours of hospitalization from 1992 to 1997. Complications, pain management, blood transfusion, and bowel and urinary dysfunction were assessed. Validated quality of life questionnaires were mailed to 200 patients several months postoperatively and a 62% response rate was achieved.

RESULTS

Mean followup in the series was 30 months. In the perioperative period there were rectal perforation in less than 2% of patients, anastomotic stricture in 3%, perineal fistula in 0.4% and blood transfusion in 11%. Some problems with bowel movements immediately after the procedure, such as diarrhea, constipation or soiled underwear, developed in 17% of patients, of whom up to 20% had had some bowel dysfunction before surgery. In the majority bowel problems resolved in an average of 7.3 weeks. Persistent new onset bowel trouble developed in 9 of the 124 patients (7%). The questionnaire demonstrated persistent significant urinary incontinence in 8 cases (7%). Nerve sparing was attempted in 54 patients, including 22 (41%) who achieve erection sufficient for vaginal penetration and are satisfied with sexual function. Of the patients 17% reported problems after hospital discharge that were mostly related to Foley catheter management. Overall 94.8% of patients were satisfied with treatment. Physical and social/family well-being appeared to be excellent according to the questionnaire. Only 12% of patients would have preferred longer hospitalization. The preferred method of pain control was nonsteroidal anti-inflammatory drugs.

CONCLUSIONS

Radical perineal prostatectomy is a low morbidity alternative for localized prostate cancer. Outpatient radical perineal prostatectomy may be performed with good patient satisfaction and safety. There appear to be few bowel problems after long-term followup.

Indications, technique, and results of laparoscopic pelvic lymphadenectomy

Despite considerable clinical research, there is still controversy about the optimal management of the pelvic lymph nodes in men with prostate cancer. This article reviews the creation and application of selection criteria for laparoscopic pelvic lymphadenectomy and describes the various techniques.

Should laparoscopy be the standard approach used for pelvic lymph node dissection?

Involvement of the pelvic lymph nodes in patients with prostate cancer worsens the overall prognosis of this common disease entity. Prior radiographic staging techniques, including fine-needle aspiration, are limited by a poor sensitivity and are not reliable. The gold standard for the evaluation of pelvic lymph nodes in men with prostate cancer involves performing a lymphadenectomy. Historically, this procedure was performed using an open surgical technique. Unfortunately, this invasive procedure is associated with significant morbidity. In response, modern surgical technology has provided newer, less invasive techniques, including laparoscopic pelvic lymphadenectomy (LPLND). Improved detection of localized prostate cancer through the institution of screening protocols and early detection programs has decreased the number of patients presenting with lymph node involvement. Various clinical indicators, including prostate-specific antigen, grade, and stage, have been used to improve the selection of "high-risk" patients that are appropriate candidates for pelvic lymph node dissection. The technique of LPLND is a valid option in the armamentarium for staging of prostate cancer. The laparoscopic approach provides the same staging accuracy as the open surgical technique and is superior with respect to morbidity. LPLND is limited to patients who present with a high risk of advanced prostate cancer. In addition, the urologist must accept the additional training, financial expense, and "learning curve" associated with this technique.

The influence of lymph node counts on the detection of pelvic lymph node metastasis in prostate cancer

The present study was done to determine the influence of tumor stage and the patients' age on the number of pelvic lymph nodes obtained during standard pelvic lymphadenectomy before radical retropubic prostatectomy. Furthermore, we assessed whether the number of pelvic lymph nodes examined affects the sensitivity of pN-classification. The data of 283 consecutive patients who had undergone standardized open pelvic lymphadenectomy and radical retropubic prostatectomy for clinically organ-confined prostate cancer were reviewed retrospectively. There were striking interindividual differences in the number of lymph nodes (5-40; median: 16). The quantity was independent of pathologic tumor stage (pT) and the patients' age. In cases with 13 or more lymph nodes examined, the rate of metastatic involvement was twice as high as in lower lymph node counts. The detection of lymph node metastases--and consequently the prognostic accuracy of pN-classification--is mainly influenced by the total number of lymph nodes examined. These data suggest that at least 13 lymph nodes should be investigated to achieve optimum information.