Influence of low-molecular-weight heparin dosage on red blood cell transfusion, lymphocele rate and drainage duration after open radical prostatectomy

Robot-Assisted Treatment of Symptomatic Lymphocele Postradical Prostatectomy and Lymphadenectomy in the Era or Robotic Surgery: Narrative Review

Background: Pelvic lymphnode dissection (PLND) is an integral part of surgical treatment for localized intermediate and high-risk prostate cancer. The most common complication of PLND is lymphocele formation. In the majority of cases the development of lymphoceles is clinically asymptomatic but in case of symptomatic/infected lymphocele an active treatment is required. The aim of this article is to analyse the current evidence on the treatment of symptomatic/infected lymphocele trough robotic approach. Materials and Methods: The search was applied to PubMed, EMBASE, and Cochrane databases with following terms: "lymphocele", "symptomatic", "infected", "robot-assisted AND radical prostatectomy", "robot-assisted", "treatment". Results: The search identified three series focusing on the treatment by robot-assisted approach of symptomatic and/or infected lymphocele. The main and most frequent reason for performing the robotic treatment was an infected lymphocele, the median time from robot-assisted radical prostatectomy and PLND to robotic treatment of lymphocele was 118 days (range 30-240). Robot-assisted treatment was successful in all reports. Conclusions: The drainage of lymphocele with the robot-assisted approach appeared safe, feasible, and with satisfactory outcomes for the definitive treatment of symptomatic/infected lymphocele.

Occurrence of symptomatic lymphocele after open and robot-assisted radical prostatectomy

Introduction

The aim of this article was to evaluate the prevalence and predictors of symptomatic lymphocele after open retropubic radical prostatectomy (RRP) and robot-assisted radical prostatectomy (RARP).

Material and methods

A total of 472 patients undergoing RRP (n = 241) or RARP (n = 231) were retrospectively analyzed with a 2-year follow-up for age, body mass index (BMI), total serum prostate-specific antigen (PSA), lymphocele formation and histopathological features. Univariate and multivariate logistic regression models were used to identify independent predictors of symptomatic lymphocele.

Results

Patients undergoing RRP developed significantly less overall lymphoceles than after RARP (8.2% vs 16.7%; p = 0.049), but no difference was determined for symptomatic events requiring intervention (7.4% vs 11.7%, p = 0.315). Although more pelvic lymph node dissections (PLND) were performed during RARP (70.1% vs 50.6%; p <0.001), significantly more cases with lymphatic invasion were observed after RRP (18% vs 6.2%, p = 0.002). The median lymph node yield during RRP and RARP were 11 and 10, respectively (p = 0.381). In multivariate logistic regression, we identified the number of dissected lymph nodes (n = 11) (OR 1.1; 95% Cl 1.055 - 1.147; p = 0.001), the Gleason score ≥ 8 (OR 4.7; 95% Cl 2.365 – 9.363; p = 0.001) and the total PSA ≥10 ng/ml (OR 1.05; 95% Cl 1.02 – 1.074; p = 0.001) as independent predictors for the development of symptomatic lymphocele.

Conclusions

Next to an extended lymph node yield, high-grade disease was associated with a higher risk to develop symptomatic lymphocele irrespective of the technical approach. The identification of risk factors might prove valuable in clinical practice when assessing and counselling patients considering surgical treatment of prostate cancer.

Significant reduction of lymphoceles after radical prostatectomy and pelvic lymph node dissection

OBJECTIVES

To reduce the risk of symptomatic lymphocele (SLC), we present a technique using peritoneal fenestration that allows lymphatic fluid to drain into the abdomen, as SLC formation after open retropubic radical prostatectomy (ORP) with pelvic lymph node dissection (PLND) is a common adverse event.

PATIENTS AND METHODS

We identified 1513 patients who underwent ORP with PLND between July 2018 and November 2019. Of those, 307 patients (20.3%) received peritoneal fenestration and 1206 (79.7%) no fenestration. The rate of LCs and the necessity for intervention were analysed by uni- and multivariable logistic regression (MLR) models. A propensity score matching was performed, as well.

RESULTS

The median (interquartile range [IQR]) age was 65 (60-70) years. A median (IQR) of 16 (10-22) lymph nodes were dissected, 22 vs 14 lymph nodes in the fenestration vs non-fenestration group (P < 0.001). Overall, 189 patients (12.5%) were diagnosed with a LC after ORP, while 21 patients (6.8%) in the fenestration and 168 (13.9%) in the non-fenestration group had LCs (P = 0.001). In 70 patients (4.7%), LCs required further intervention, categorised as Clavien-Dindo Grade IIIa/b, with a smaller proportion in the fenestration group (2.9% vs 5.0% in the non-fenestration group, P < 0.001). There were no Clavien-Dindo Grade IV or V complications, in particular no abdominal complications in association with peritoneal fenestration observed. In MLR, peritoneal fenestration was associated with a reduced risk of LCs (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.2-0.5; P < 0.001). The risk reduction was also shown after propensity score matching (OR 0.38, 95% CI 0.21-0.68; P = 0.001). The number needed to treat was 14.

CONCLUSIONS

Peritoneal fenestration may decrease the rate of SLC after ORP with (extended) PLND. Therefore, it should be part of the operative strategy.

Peritoneal flap for lymphocele prophylaxis following robotic-assisted laparoscopic radical prostatectomy with pelvic lymph node dissection: study protocol and trial update for the randomized controlled PELYCAN study

Background

Data from interventional studies suggest that a peritoneal flap after pelvic lymph node dissection (LND) during laparoscopic, robotic-assisted radical prostatectomy (RARP) may reduce the rate of symptomatic lymphoceles in transperitoneal approach. However, most of these studies are not conducted in a randomized controlled fashion, thus limiting their scientific value. A recent prospective, randomized, controlled trial (RCT) did not show superiority of a peritoneal flap while further trials are lacking. Therefore, the aim of the presented RCT will be to show that creating a peritoneal flap decreases the rate of symptomatic lymphoceles compared to the current standard procedure without creation of a flap.

Methods/design

PELYCAN is a parallel-group, patient- and assessor-blinded, phase III, adaptive randomized controlled superiority trial. Men with histologically confirmed prostate cancer who undergo transperitoneal RARP with pelvic LND will be randomly assigned in a 1:1 ratio to two groups—either with creating a peritoneal flap (PELYCAN) or without creating a peritoneal flap (control). Sample size calculation yielded a sample size of 300 with a planned interim analysis after 120 patients, which will be performed by an independent statistician. This provides a possibility for early stopping or sample size recalculation.

Patients will be stratified for contributing factors for the development of postoperative lymphoceles. The primary outcome measure will be the rate of symptomatic lymphoceles in both groups within 6 months postoperatively. Patients and assessors will be blinded for the intervention until the end of the follow-up period of 6 months. The surgeon will be informed about the randomization result after performance of vesicourethral anastomosis. Secondary outcome measures include asymptomatic lymphoceles at the time of discharge and within 6 months of follow-up, postoperative complications, mortality, re-admission rate, and quality of life assessed by the EORTC QLQ-C30 questionnaire.

Discussion

The PELYCAN study is designed to assess whether the application of a peritoneal flap during RARP reduces the rate of symptomatic lymphoceles, as compared with the standard operation technique. In case of superiority of the intervention, this peritoneal flap may be suggested as a new standard of care.

Trial registration

German Clinical Trials Register DRKS00016794. Registered on 14 May 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05168-x.

Impact of Pelvic Lymph Node Dissection and Its Extent on Perioperative Morbidity in Patients Undergoing Radical Prostatectomy for Prostate Cancer: A Comprehensive Systematic Review and Meta-analysis

CONTEXT

Pelvic lymph node dissection (PLND) yields the most accurate staging in patients undergoing radical prostatectomy (RP) for prostate cancer (PCa), although it can be associated with morbidity.

OBJECTIVE

To systematically evaluate the impact of PLND extent on perioperative morbidity in patients undergoing RP. A new PLND-related complication assessment tool is proposed.

EVIDENCE ACQUISITION

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) was conducted. MEDLINE/PubMed, Scopus, Embase and Web of Science databases were searched to yield studies discussing perioperative complications following RP and PLND. The extent of PLND was classified according to the European Association of Urology PCa guidelines. Studies were categorized according to the extent of PLND. Intra- and postoperative complications were classified as "strongly," "likely," or "unlikely" related to PLND. Anatomical site of perioperative complications was recorded. A cumulative meta-analysis of comparative studies was conducted using Review Manager 5.3 (Cochrane Collaboration, Oxford, UK).

EVIDENCE SYNTHESIS

Our search generated 3645 papers, with 176 studies meeting the inclusion criteria. Details of 77 303 patients were analyzed. Of these studies, 84 (47.7%), combining data on 28 428 patients, described intraoperative complications as an outcome of interest. Overall, 534 (1.8%) patients reported one or more intraoperative complications. Postoperative complications were reported in 151 (85.7%) studies, combining data on 73 629 patients. Overall, 10 401 (14.1%) patients reported one or more postoperative complication. The most reported postoperative complication strongly related to PLND was lymphocele (90.6%). The pooled meta-analysis revealed that RP + limited PLND/standard PLND had a significantly decreased risk of experiencing any intraoperative complication (risk ratio [RR]: 0.55; p =  0.01) and postoperative complication strongly related to PLND (RR: 0.46; p =  <0.00001), particularly for lymphocele formation (RR: 0.52; p =  0.0003) and thromboembolic events (RR: 0.59; p =  0.008), when compared with extended/superextended PLND. The extent of PLND was confirmed to be an independent predictor of lymphocele formation (RR: 1.77; p <  0.00001).

CONCLUSIONS

The perioperative morbidity of PLND in patients undergoing RP and PLND for PCa significantly correlates with the extent of PLND. More standardized reporting of intra- and postoperative complications is needed to better estimate the direct impact of PLND extent on perioperative morbidity.

PATIENT SUMMARY

Pelvic lymph node dissection (PLND) is the most accurate method for staging in patients undergoing radical prostatectomy for prostate cancer, although it can be associated with complications. This study aims to systematically evaluate the impact of PLND extent on perioperative complications in these patients. We found that intra- and postoperative complications correlate significantly with the extent of PLND. A more rigorous assessment and thorough reporting of perioperative complications are recommended.

Extended versus inpatient thromboprophylaxis with heparins following major open abdominopelvic surgery for malignancy: a systematic review of efficacy and safety

Background

Patients undergoing open abdominopelvic procedures for malignancy are at high risk of postoperative venous thromboembolism (VTE). This risk can be mitigated with prophylaxis; however, optimum duration in this population remains unknown. Our objective was to conduct a systematic review of contemporary literature on the use of heparin thromboprophylaxis following major open pelvic surgery for malignancy, comparing the efficacy and safety of extended duration to inpatient treatment.

Methods

A study protocol describing search strategy and inclusion and exclusion criteria was developed and registered with PROSPERO. A literature review was conducted in accordance with the protocol.

Results

Literature review identified only 4 studies directly comparing extended and inpatient duration prophylaxis, with a combined population of 3198 and 3135 patients for VTE rate and bleeding events, respectively. Despite many studies reporting lower VTE rates in patients receiving extended prophylaxis, no statistically significant difference in rates of postoperative VTE (p = 0.18) or bleeding complications (p = 0.43) was identified between patients receiving extended duration prophylaxis and those receiving inpatient only prophylaxis.

Conclusion

On the review of contemporary literature, no significant difference was found in rates of postoperative VTE or bleeding complications between patients receiving extended duration heparin VTE prophylaxis and those receiving inpatient prophylaxis after open abdominopelvic surgery for malignancy.

This raises the question of how extended duration prophylaxis has become common practice in this population, and whether this needs to be re-evaluated.

Serum Albumin-Peptide Conjugates for Simultaneous Heparin Binding and Detection

Heparin is a polysaccharide-based anticoagulant agent, which is widely used in surgery and blood transfusion. However, overdosage of heparin may cause severe side effects such as bleeding and low blood platelet count. Currently, there is only one clinically licensed antidote for heparin: protamine sulfate, which is known to provoke adverse effects. In this work, we present a stable and biocompatible alternative for protamine sulfate that is based on serum albumin, which is conjugated with a variable number of heparin-binding peptides. The heparin-binding efficiency of the conjugates was evaluated with methylene blue displacement assay, dynamic light scattering, and anti-Xa assay. We found that multivalency of the peptides played a key role in the observed heparin-binding affinity and complex formation. The conjugates had low cytotoxicity and low hemolytic activity, indicating excellent biocompatibility. Furthermore, a sensitive DNA competition assay for heparin detection was developed. The detection limit of heparin was 0.1 IU/mL, which is well below its therapeutic range (0.2-0.4 IU/mL). Such biomolecule-based systems are urgently needed for next-generation biocompatible materials capable of simultaneous heparin binding and sensing.

Complications of Retroperitoneal Lymph Node Dissection

Retroperitoneal lymph node dissection is an integral part of the management of testicular cancer. Surgical approach and outcomes have improved over the past decades. Several factors influence the complexity of the operation, including numerous patient characteristics and disease-related characteristics. An important consideration lies in the fact that this is largely a vascular operation, and techniques of vascular control should be comfortable for the urologic surgeon performing the procedure. This article discusses the known surgical complications related to this operation and their relative incidence reported throughout the literature.

Risk factors, complications and management of lymphocele formation after radical prostatectomy: A mini-review

Lymphocele formation is the most common adverse event of pelvic lymphadenectomy during radical prostatectomy for prostate cancer. Previous studies failed to favor one surgical technique over the other in terms of minimizing its rate. Data on risk factors for its development are still conflicting and warranting further research. In this mini-review, we aimed to scrutinize available evidence on these aspects and outline current achievements in lymphocele prevention approaches.

Neoadjuvant Platinum-Based Chemotherapy is an Independent Predictor for Preoperative Thromboembolic Events in Bladder Cancer Patients Undergoing Radical Cystectomy

INTRODUCTION

Neoadjuvant chemotherapy (NAC) confers a significant survival benefit in patients with muscle invasive bladder cancer. Platinum-based chemotherapy increases the risk of thromboembolic events (TEE). We determined the effect of cisplatin-based NAC on the incidence of preoperative TEEs in radical cystectomy patients.

MATERIALS AND METHODS

A retrospective matched case-control study was performed on 55 patients undergoing radical cystectomy for muscle invasive bladder cancer. Group 1 (n = 20) included patients that received NAC prior to radical cystectomy and Group 2 (n = 35) included patients that underwent radical cystectomy without NAC. Logistic regression analyses tested potential predictors for TEEs in both groups (age, American Society of Anesthesiologists grade, use of NAC, histological subtype, pathological stage).

RESULTS

In total, 6 patients of 55 developed a TEE. Five patients of 20 (25%) treated with NAC prior to radical cystectomy developed TEEs, while 1 of 35 (2.9%) treated with radical cystectomy alone developed a TEE. On univariate and multivariate regression analysis, NAC prior to radical cystectomy was an independent predictor for TEE prior to radical cystectomy (p = 0.033 and p = 0.043, respectively). The effect of perioperative anticoagulation on operative blood loss and postoperative hemoglobin level was not statistically significant between both groups (p = 0.22 and p = 0.08, respectively).

CONCLUSION

Neoadjuvant cisplatin-based chemotherapy is a significant predictor for preoperative TEE in patients undergoing radical cystectomy.

The Benefits and Harms of Different Extents of Lymph Node Dissection During Radical Prostatectomy for Prostate Cancer: A Systematic Review

CONTEXT

There is controversy regarding the therapeutic role of pelvic lymph node dissection (PLND) in patients undergoing radical prostatectomy for prostate cancer (PCa).

OBJECTIVE

To systematically review the relevant literature assessing the relative benefits and harms of PLND for oncological and non-oncological outcomes in patients undergoing radical prostatectomy for PCa.

EVIDENCE ACQUISITION

MEDLINE, MEDLINE In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched up to December 2015. Comparative studies evaluating no PLND, limited, standard, and (super)-extended PLND that reported oncological and non-oncological outcomes were included. Risk-of-bias and confounding assessments were performed. A narrative synthesis was undertaken.

EVIDENCE SYNTHESIS

Overall, 66 studies recruiting a total of 275,269 patients were included (44 full-text articles and 22 conference abstracts). Oncological outcomes were addressed by 29 studies, one of which was a randomized clinical trial (RCT). Non-oncological outcomes were addressed by 43 studies, three of which were RCTs. There were high risks of bias and confounding in most studies. Conflicting results emerged when comparing biochemical and clinical recurrence, while no significant differences were observed among groups for survival. Conversely, the majority of studies showed that the more extensive the PLND, the greater the adverse outcomes in terms of operating time, blood loss, length of stay, and postoperative complications. No significant differences were observed in terms of urinary continence and erectile function recovery.

CONCLUSIONS

Although representing the most accurate staging procedure, PLND and its extension are associated with worse intraoperative and perioperative outcomes, whereas a direct therapeutic effect is still not evident from the current literature. The current poor quality of evidence indicates the need for robust and adequately powered clinical trials.

PATIENT SUMMARY

Based on a comprehensive review of the literature, this article summarizes the benefits and harms of removing lymph nodes during surgery to remove the prostate because of PCa. Although the quality of the data from the studies was poor, the review suggests that lymph node removal may not have any direct benefit on cancer outcomes and may instead result in more complications. Nevertheless, the procedure remains justified because it enables accurate assessment of cancer spread.

Prospective Randomized Trial Comparing Titanium Clips to Bipolar Coagulation in Sealing Lymphatic Vessels During Pelvic Lymph Node Dissection at the Time of Robot-assisted Radical Prostatectomy

Lymphocele is the most common complication after pelvic lymph node dissection (PLND). Over the years, various techniques have been introduced to prevent lymphocele, but no final conclusion can be drawn regarding the superiority of one technique over another. In this prospective study, 220 patients undergoing robot-assisted radical prostatectomy between 2012 and 2015 were randomized to receive titanium clips (group A, n=110) or bipolar coagulation (group B, n=110) to seal lymphatic vessels at the level of the femoral canal during extended PLND (ePLND). Ultrasound examination was used to detect lymphoceles at 10 and 90 d after surgery. Lymphocele was defined as any clearly definable fluid collection and was considered clinically significant when requiring treatment. There were no statistically significant differences between groups A and B regarding overall lymphocele incidence (47% vs 48%; difference -0.91%, 95% confidence interval [CI] -2.6 to 0.7; p=0.9) and the rate of clinically significant lymphocele [5% vs 4%; difference 0.75%, 95% CI, 0.1-3.2; p=0.7]. The two groups were comparable regarding mean (±SD) lymphocele volume (30±32 vs 35±39ml; p=0.6), lymphocele location (unilateral, 37% vs 35%, p=0.7; bilateral, 13% vs 14%, p=0.9), and time to lymphocele diagnosis (95% vs 98% on postoperative day 10; p=0.5). In conclusion, this trial failed to identify a difference in lymphocele occurrence between clipping and coagulation of the lymphatic vessels at the level of the femoral canal during robot-assisted ePLND for prostate cancer.

PATIENT SUMMARY

In this study we compared the frequency of postoperative complications after sealing lymphatic vessels from the leg to the abdomen using metallic clips or electrical coagulation during robot-assisted surgery for prostate cancer. We found no difference in postoperative complications between the two methods.

What Are the Risk Factors for Lymphocyst Formation Apart From Lymphnode Dissection and Lymphnode Count in Gynecologic Malignancy?

Aim: Lymphocyst is one of the most common complications of lymphadenectomy and generally encountered during uro-gynecological oncology surgeries. We aimed to define the risk factors for formation of a lymphocyst in patients with various gynecological cancer types in whom a lymphadenectomy was performed. Methods: This retrospective study was performed on 206 patients. Of the 206 patients, 100 were diagnosed with a lymphocyst, and 106 were assigned to a control group. Laboratory findings and surgical characteristics of the patients were compared. Results: No differences were observed in age, pre-operative hemoglobin; platelet, white blood cell, and lymphocyte counts; or pre-operative albumin level (p = 0.315, 0.500, 0.525, 0.683, 0.740, and 0.97, respectively). A significant effect of the heparin dose × heparin days interaction and lymphocyst formation was observed (p = 0.002). Lymphocysts were most frequently detected in the ovarian cancer subgroup (49 %). Significant differences were detected between the groups in the percentages of patients who underwent CT only and RT only treatments (p = 0.001 and 0.002, respectively). The logistic regression analysis revealed a relationship between the LMWH dose × days interaction and formation of a lymphocyst (OR, 1.10; 95 % CI, 1.0-1.13; p = 0.01). Conclusion: The association between total LMWH dose administered and the formation of lymphocysts in patients with gynecological pelvic cancer was investigated for the first time. Significant relationship between heparin dose × days and lymphocyst formation was found. Although anticoagulation with LMWH is essential for preventing thromboembolism, it should be used appropriately to prevent other complications, such as bleeding and lymphocysts.

The incidence and sequela of lymphocele formation after robot-assisted extended pelvic lymph node dissection

OBJECTIVE

To determine an accurate incidence of lymphocele formation and its sequela after robot-assisted radical prostatectomy (RARP) and extended lymph node dissection (eLND) in a contemporary prostate cancer cohort.

PATIENTS AND METHOD

Consecutive patients who underwent RARP and eLND and had a minimum follow-up of 3 months were included. All surgeries were performed by one surgeon via a transperitoneal approach, with patients uniformly receiving low-molecular-weight heparin. Patients were followed with serial ultrasonography (US) based on a predetermined schedule for lymphocele surveillance. Incidence and sequelae of lymphoceles were retrospectively assessed.

RESULTS

In all, 521 patients were analysed. The mean (sd) follow-up was 33.5 (22.8) months. Lymphocele developed in 9% and became symptomatic in 2.5%. All except one were detected at the 1-month postoperative US; however, 76% regressed by the 3-month US. If lymphocele persisted at 3 months, 64% developed symptoms associated with infection and required drainage. Having diabetes mellitus was significantly associated with a higher risk of developing an infected lymphocele. Other symptoms related to lymphocele were rare. Comparisons of patient characteristics between patients with and without lymphoceles did not show any significant prognostic indicators to predict the occurrence of lymphocele in neither univariate nor multivariate analysis in the present cohort.

CONCLUSION

The incidence of symptomatic lymphocele after transperitoneal RARP and eLND is rare. However, during follow-up, US imaging at 3 months after surgery appears advisable. If a lymphocele is detected at the 3-month follow-up US discussing percutaneous external drainage with the patient appears to be wise, as it may prevent the development of a symptomatic lymphocele in two-thirds of such patients.

Open and robot-assisted radical retropubic prostatectomy in men receiving ongoing low-dose aspirin medication: revisiting an old paradigm?

OBJECTIVE

To assess blood loss, transfusion rates and 90-day complication rates in patients receiving ongoing 100 mg/day aspirin medication and undergoing open radical prostatectomy (RP) or robot-assisted RP (RARP).

PATIENTS AND METHODS

Between February 2010 and August 2011, 2061 open RPs and 400 RARPs were performed. All patients received low-molecular-weight heparin for thrombembolism prophylaxis. Aspirin intake during surgery was recorded in 137 patients (5.5%). Descriptive statistics and multivariable analyses after propensity-score matching for balancing potential differences in patients with and without aspirin medication were used to assess the risk of blood loss above the median in patients undergoing open RP or RARP.

RESULTS

The median blood loss in the open RP cohort with and without aspirin medication was 750 and 700 mL, respectively, and in the RARP cohort it was 200 and 150 mL, respectively. Within the same cohorts, transfusions were administered in 21 and 8% and 0 and 1% of patients, respectively. The 90-day complication rates in patients with ongoing aspirin medication were 5.8, 4.4, 7.3 and 0% for Clavien grades I, II, III and IV complications, respectively. In multivariable analyses and after propensity-score matching, prostate volume (odds ratio 1.03; 95% CI 1.02-1.04; P < 0.01) but not ongoing aspirin medication achieved independent predictor status for the risk of blood loss above the median.

CONCLUSIONS

Major surgery such as open RP and RARP can be safely performed in patients with ongoing aspirin medication without greater blood loss. Higher 90-day complication rates were not detected in such patients. Differences in transfusion rates between the groups receiving and not receiving ongoing aspirin medication may be explained by a higher proportion of patients with coronary artery disease in the group receiving ongoing aspirin medication. This comorbidity may result in a higher peri-operative threshold for allogenic blood transfusion.