How can we predict lymphorrhoea and clinically significant lymphocoeles after radical prostatectomy and pelvic lymphadenectomy? Clinical implications

Impact of peritoneal reconfiguration on lymphocele formation after robot-assisted radical prostatectomy with pelvic lymph node dissection: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Different strategies have been proposed to prevent lymphocele (LC) formation after radical prostatectomy (RARP) with pelvic lymph node dissection (PLND). According to several recently published randomized control trials (RCTs) on the topic, peritoneal reconfiguration appears to be associated with promising results. This systematic review aimed to assess the impact of peritoneal reconfiguration on LC formation in patients undergoing RARP and PLND.

METHODS

A comprehensive bibliographic search was conducted in August 2023. Studies assessing patients with prostate cancer undergoing RARP with PLND (P) and concomitant peritoneal reconfiguration (I) compared or not with other techniques (C) to prevent LC formation (O) were included. Original prospective and retrospective studies (S) were selected. LC and symptomatic LC rates were chosen as co-primary outcomes. Only RCTs were included in the meta-analysis.

RESULTS

Eleven studies investigating 2991 patients were included in the systematic review, and five RCTs evaluating 1712 subjects were deemed eligible for meta-analysis. Peritoneal flap (PF) was the most common surgical technique used for LC prevention (9 studies). A significantly lower likelihood of LC was observed after PF (OR 0.82, 95% CI 0.27-1.37, I2 = 74.54%), with no significant difference in terms of symptomatic LC (OR 0.21, 95% CI -0.41-0.84, I2 = 0%). Probability of LC-related complications (OR 0.36, 95% CI 0.04-0.67, I2 = 0%), Clavien-Dindo ≥ 3 overall complications (OR 0.61, 95% CI 0.21-1.0, I2 = 0%), and Clavien-Dindo ≥ 3 LC-related complications (OR 0.98, 95% CI 0.29-1.67, I2 = 0%) were significantly lower after PF.

CONCLUSIONS

PF after RARP with PLND reduces LC formation, LC-related complications, and severe postoperative adverse events.

Pelvic Lymph Node Dissection With Polymer Ligation Clips Significantly Reduces Hospital Stay Compared to Vessel Sealer: A Retrospective Study

Introduction Lymphocele is a typical complication of pelvic lymph node dissection (PLND) in robot-assisted radical prostatectomy (RARP). This study aimed to compare postoperative lymphatic leakage between the polymer ligation clip and vessel sealer, and evaluated the costs associated with the former. Methods The study enrolled patients who underwent RARP with PLND at our institution between April 2018 and March 2023 and were treated with a vessel sealer (LigaSure Blunt Tip 44 NCTM; Medtronic, Dublin, Ireland) until September 2021, and Hem-o-lok polymer ligation clipsTM (Teleflex, Wayne, PA, USA) thereafter. The drain was removed on the third postoperative day or later, when the daily drainage volume was less than 200 mL. Results A total of 81 patients underwent RARP with PLND, which resulted in a significant increase in the operative (p = 0.016) and lymph node dissection times (p = 0.008) in the clip group. The total drainage volume (p = 0.048) was smaller, and the drain removal time (p = 0.039) and postoperative hospital stay (p < 0.001) were shorter in the clip group. Moreover, the device costs for the clips were lower than those for the vessel sealer. Conclusion Polymer ligation clips are associated with improved postoperative lymphatic leakage, shorter length of hospitalization, and lower costs, compared with vessel sealers.

Urinary continence outcomes, surgical margin status, and complications after radical prostatectomy in 2,141 German patients treated in one high-volume inpatient rehabilitation clinic in 2022

PURPOSE

To identify independent predictors of urinary continence and report early complications after radical prostatectomy (RP) in a large, contemporary German cohort.

METHODS

Urinary incontinence data of patients undergoing 3-week inpatient rehabilitation (IR) after RP were prospectively assessed by 24-hr pad test and uroflowmetry at the beginning and the end of IR, respectively. Lymphoceles were assessed prospectively by ultrasound. Tumor and patient characteristics, and information on urinary leakage on initial cystography were retrospectively extracted from discharge letters and surgical reports. Regression analyses were performed to identify predictors of urinary continence at the beginning of IR.

RESULTS

Overall, 2,141 patients were included in the final analyses. Anastomotic leakage on the initial cystography and lymphoceles were found in 11.4% and 30.8% of patients, respectively. Intervention for a symptomatic lymphocele was required in 4.2% of patients. At the end of IR, 54.2% of patients were continent, while the median urine loss decreased to 73 g (interquartile range 15-321). Multivariable logistic regression analysis identified age and diabetes mellitus as independent negative predictors, but nerve-sparing surgery as an independent positive predictor of urinary continence (each p < 0.001). Multivariable linear regression analysis showed that 24-hr urine loss increased by 7 g with each year of life (p < 0.001), was 79 g higher in patients with diabetes mellitus (p = 0.007), and 175 g lower in patients with NS (p < 0.001).

CONCLUSION

Age, diabetes mellitus, and NS are significantly associated with continence outcomes in the early period after RP. Our analyses may help clinicians to pre-operatively counsel patients on potential surgical outcomes.

Benefit and harm of lymphadenectomy in intermediate risk prostate cancer: comparison of five nomograms

BACKGROUND

Pelvic lymph node dissection (PLND) is recommended method for detecting prostate cancer (PCa) nodal metastases although associated with serious complications. In this study, we aimed to assess benefit/harm of routine PLND in intermediate risk PCa patients and to compare diagnostic yield of five different nomograms in predicting lymph node invasion (LNI).

METHODS

Retrospective analysis of consecutive PCa patients with intermediate risk of biochemical recurrence who underwent open radical prostatectomy (RP) with bilateral PLND between January 2017 and December 2019 at our institution. Partin, 2012-Briganti, 2018-Briganti, Cagiannos and Memorial Sloan Kettering Cancer Center (MSKCC) values were calculated. To compare accuracy, sensitivity, specificity, and area under receiver-operating curve (AUC) were calculated and then optimal cutoff values were estimated, analyses repeated and compared. To assess benefit and harm of PLND, relative risk (RR) and number need to treat (NNT) with LNI and complications set as outcome were calculated.

RESULTS

Total 309 subjects. Average age 62.2 years, average PSA 7.2 ng/mL; 18 (5.8%) had LNI; 88 (28.5%) suffered Clavien-Dindo grade 3-5 complication. AUC for predicting LNI: 0.729 for 2012-Briganti, 0.660 for MSKCC, 0.521 for 2018-Briganti, 0.486 for Cagiannos, and 0.424 for Partin. None of pairwise AUC comparisons based on default and newly established cutoff values were statistically significant. Lowest NNT was for Partin and Cagiannos with default cutoff (≥ 5%). Risks of serious complications between higher/lower than cutoff values were non-significant across nomograms.

CONCLUSIONS

2012-Briganti nomogram outperforms, although not significantly, MSKCC, 2018-Briganti, Cagiannos, and Partin nomograms in classifying LNI in intermediate risk PCa patients. Routine PLND in these patients should be avoided, due to high rate and severity of complications.

High BMI and Surgical Time Are Significant Predictors of Lymphocele after Robot-Assisted Radical Prostatectomy

Lymphoceles (LC) occur in up to 60% after robot-assisted radical prostatectomy (RARP) and pelvic lymphadenectomy (PLND). In 2-10%, they are symptomatic and may cause complications and require treatment. Data on risk factors for the formation of lymphoceles after RARP and PNLD remain sparse in the urologic literature and are inconclusive to date. The underlying data of this secondary analysis were obtained from the prospective multi-center RCT ProLy. We performed a multivariate analysis to focus on the potential risk factors that may influence lymphocele formation. Patients with LC had a statistically significant higher BMI (27.8 vs. 26.3 kg/m², p < 0.001; BMI ≥ 30 kg/m²: 31 vs. 17%, p = 0.002) and their surgical time was longer (180 vs. 160 min, p = 0.001) In multivariate analysis, the study group (control vs. peritoneal flap, p = 0.003), BMI (metric, p = 0.028), and surgical time (continuous, p = 0.007) were independent predictors. Patients with symptomatic lymphocele presented with higher BMI (29 vs. 26.6 kg/m², p = 0.007; BMI ≥ 30 kg/m²: 39 vs. 20%, p = 0.023) and experienced higher intraoperative blood loss (200 vs. 150 mL, p = 0.032). In multivariate analysis, BMI ≥ 30 kg/m² vs. < 30 kg/m² was an independent predictor for the formation of a symptomatic lymphocele (p = 0.02). High BMI and prolonged surgical time are general risk factors for the development of LC. Patients with a BMI ≥ 30 kg/m² had a higher risk for symptomatic lymphoceles.

Complications of extraperitoneal robot-assisted radical prostatectomy in high-risk prostate cancer: A single high-volume center experience

Introduction

The role of robot-assisted radical prostatectomy (RARP) in high-risk prostate cancer (PCa) has been debated over the years, but it appears safe and effective in selected patients. While the outcomes of transperitoneal RARP for high-risk PCa have been already widely investigated, data on the extraperitoneal approach are scarcely available. The primary aim of this study is to evaluate intra- and postoperative complications in a series of patients with high-risk PCa treated by extraperitoneal RARP (eRARP) and pelvic lymph node dissection. The secondary aim is to report oncological and functional outcomes.

Methods

Data of patients who underwent eRARP for high-risk PCa were prospectively collected from January 2013 to September 2021. Intraoperative and postoperative complications were recorded, as also perioperative, functional, and oncological outcomes. Intraoperative and postoperative complications were classified by employing Intraoperative Adverse Incident Classification by the European Association of Urology and the Clavien–Dindo classification, respectively. Univariate and multivariate analyses were performed to evaluate a potential association between clinical and pathological features and the risk of complications.

Results

A total of 108 patients were included. The mean operative time and estimated blood loss were 183.5 ± 44 min and 115.2 ± 72.4 mL, respectively. Only two intraoperative complications were recorded, both grade 3. Early complications were recorded in 15 patients, of which 14 were of minor grade, and 1 was grade IIIa. Late complications were diagnosed in four patients, all of grade III. Body mass index (BMI) &gt; 30 kg/m2, Prostate-Specific Antigen (PSA) &gt; 20 ng/mL, PSA density &gt;0.15 ng/mL2, and pN1 significantly correlated with a higher rate of overall postoperative complications. Moreover, BMI &gt;30 kg/m2, PSA &gt;20 ng/mL, and pN1 significantly correlated with a higher rate of early complications, while PSA &gt;20 ng/mL, prostate volume &lt;30 mL, and pT3 were significantly associated with a higher risk of late complications. In multivariate regression analysis, PSA &gt;20 ng/mL significantly correlated with overall postoperative complications, while PSA &gt; 20 and pN1 correlated with early complications. Urinary continence and sexual potency were restored in 49.1%, 66.7%, and 79.6% of patients and in 19.1%, 29.9%, and 36.2% of patients at 3, 6, and 12 months, respectively.

Conclusions

eRARP with pelvic lymph node dissection in patients with high-risk PCa is a feasible and safe technique, resulting in only a few intra- and postoperative complications, mostly of low grade.

The Effect of a Peritoneal Iliac Flap on Lymphocele Formation After Robotic Radical Prostatectomy: Results From the PLUS Trial

OBJECTIVE

To assess the effectiveness of a peritoneal flap on the formation of lymphoceles after robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection.

METHODS

We conducted a single surgeon, assessor blinded prospective randomized controlled trial (the Prospective Lymphocele Ultrasound Study) in men undergoing robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection. At the conclusion of the node dissection, patients were block randomized 1:1 to either standard of care (no bladder peritoneal flap) or to the creation of a bladder peritoneal flap. Lymphocele formation was assessed by pelvic ultrasound postoperatively. The primary outcome was lymphocele formation. Rates of lymphocele formation and complications were analyzed using chi-square. Other outcomes, including length of stay, number of lymph nodes removed, lymphocele volume, and quality of life measures, were analyzed by t-tests or Wilcoxon Ranked Sum Tests, as appropriate. An a priori power calculation was performed using O'Brien-Fleming alpha sharing for the interim analyses. Two preplanned interim analyses were performed when 45 and 90 patients per group had follow-up ultrasounds.

RESULTS

A statistically significant difference in lymphocele formation was seen on the second interim analysis for 183 patients (4.3% vs. 15.6%, p = .011) stopping enrollment; this remained significant in the final analysis of 216 patients (3.6% vs 14.2%, p = .006). No other significant differences were observed.

CONCLUSION

This prospective randomized trial supports the implementation of this simple modification for robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection.

Risk factors for lymphorrhea and lymphocele after radical prostatectomy: a retrospective case-control study

PURPOSE

To investigate the risk factors for postoperative lymphorrhea or/and lymphocele (PLL) in patients undergoing radical prostatectomy (RP).

MATERIALS AND METHODS

The clinical data of 606 patients were retrospectively collected. The receiver operating characteristic (ROC) curve was utilized to identify the optimal cutoff value. Multivariable logistic regression analysis was used to screen the independent predictors of PLL.

RESULTS

Univariate analysis showed that nine factors differed between the PLL and non-PLL group. Multivariable logistic regression analysis showed that low preoperative fibrinogen level, extraperitoneal surgery, robot-assisted laparoscopic radical prostatectomy (RALRP), and hypoalbuminemia were risk factors and the use of fibrin glue was a protective factor. Correlation analysis showed that the scope of LN dissection (LND) and number of lymph nodes (LNs) dissected were positively correlated with PLL in the extraperitoneal approach, but were not significantly correlated with PLL in the transperitoneal approach. The use of fibrin glue was negatively associated with PLL in the overall procedure and the extraperitoneal approach, but not significantly so in the transperitoneal approach. Comparison of LNs clearance between the two surgical approaches revealed that the extent of LND and number of LNs dissected in the extraperitoneal approach were less than in the transperitoneal approach.

CONCLUSION

During RALRP, more attention should be paid to fully clotting the broken end of lymphatic vessels. The use of fibrin glue could reduce the probability of PLL. The extent of LND or number of LNs dissected were positively correlated with PLL in the extraperitoneal approach.

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.

Intranodal Lymphangiography and Embolization for the Treatment of Early Postoperative Lymphatic Leaks after Pelvic Surgery

PURPOSE

To assess outcome and predictors of outcome after lymphatic embolization (LE) for early postoperative lymphatic leak after pelvic surgery.

MATERIAL AND METHODS

Lymphangiography (LG) procedures performed between May 2015 and February 2020 for postoperative intraperitoneal lymphatic leaks after pelvic surgery were reviewed. Treatment indication was lymphatic drainage of >500 mL/d persisting for >1 week. LE was performed by injecting glue into the iliac lymph node. Fisher exact and Wilcoxon rank-sum tests were used for comparative analysis, and logistic regression was used to assess predictors of outcome.

RESULTS

LG was performed in 71 patients. A leak was demonstrated in 69 patients who underwent LE. The mean drainage was 1,329 mL/d ± 773. Catheters were removed in 49 (69.0%) patients after 1 procedure and in 69 (97.2%) patients after a mean of 1.3 procedures. The mean drainage at the time of catheter removal was 157 mL/d ± 100. Failure occurred in 12 (16.9%) cases, including 2 (2.8%) cases of unsuccessful catheter removal and 10 (14.1%) cases of catheter reinsertion owing to recurrent ascites (n = 3) and lymphoceles (n = 7). Older age and drainage of >1,500 mL/d were associated with failure (P = .004). Drainage of >1,500 mL/d was associated with a post-LE catheter dwell time of longer than 1 week (P = .024). Minor adverse events were noted in 4 (5.6%) patients who presented with transient leg swelling.

CONCLUSIONS

LE was effective for treating pelvic surgery-related lymphatic leaks. Reintervention may be required. Drainage of >1,500 mL/d was associated with clinical failure and a post-LE catheter dwell time of longer than 1 week.

[Morbidity of extended pelvic lymphadenectomy during robot-assisted laparoscopic prostatectomy for localized cancer prostate]

OBJECTIVES

To assess the morbidity specific of extended pelvic lymphadenectomy during robot-assisted laparoscopic radical prostatectomy in a 8 year retrospective study.

MATERIAL

We carried out a single-center, single-surgeon retrospective study on 342 consecutive patients who underwent a robot-assisted laparoscopic radical prostatectomy and extended pelvic lymphadenectomy, from July 2010 to March 2018. Postoperative complications were recorded up to 3 months after the operation.

RESULTS

Thirty (8.8%) patients had at least one complication related to lymphadenectomy including 1 vascular injury (0.3%), 7 injuries of the obturator nerve (2%), 5 venous thromboembolic complications (1.5%) including 4 pulmonary embolisms, 10 symptomatic lymphoceles (2.9%) and 8 lymphoedemas (2.3%). Of these complications, 13 were classified Clavien 1 (43.3%), 8 Clavien 2 (26.7%), 7 Clavien 3a (23.3%) and 2 Clavien 3b (6.7%). In univariate analysis a high age (P=0.04), high BMI (P<0.01) and pT stage (P=0.02) were significantly associated with complication whereas in multivariate analysis, only age (P=0.02) and BMI (P<0.01) lived were. In univariate analysis high BMI (P=0.04) and lymph node involvement (P=0.04) were associated with lymphatic complication. We did not find any other specific risk factor for the other complications.

CONCLUSION

With 8.8% of overall complications related to lymphadenectomy and 5% of complication classified Clavien grade 2 or higher, extended pelvic lymphadenectomy was not very morbid. Age and BMI were risk factors for a overall complication. BMI and lymph node involvement were risk factors for lymphatic complications.

LEVEL OF PROOF

4.

Pelvic lymph node dissection in high-risk prostate cancer

INTRODUCTION

The therapeutic role of pelvic lymph node dissection (PLND) in prostate cancer (PCa) is unknown due to absence of randomized trials.

OBJECTIVE

to present a critical review on the therapeutic benefits of PLND in high risk localized PCa patients.

MATERIALS AND METHODS

A search of the literature on PLND was performed using PubMed, Cochrane, and Medline database. Articles obtained regarding diagnostic imaging and sentinel lymph node dissection, PLND extension, impact of PLND on survival, PLND in node positive "only" disease and PLND surgical risks were critically reviewed.

RESULTS

High-risk PCa commonly develops metastases. In these patients, the possibility of presenting lymph node disease is high. Thus, extended PLND during radical prostatectomy may be recommended in selected patients with localized high-risk PCa for both accurate staging and therapeutic intent. Although recent advances in detecting patients with lymph node involvement (LNI) with novel imaging and sentinel node dissection, extended PLND continues to be the most accurate method to stage lymph node disease, which may be related to the number of nodes removed. However, extended PLND increases surgical time, with potential impact on perioperative complications, hospital length of stay, rehospitalization and healthcare costs. Controversy persists on its therapeutic benefit, particularly in patients with high node burden.

CONCLUSION

The impact of PLND on biochemical recurrence and PCa survival is unclear yet. Selection of patients may benefit from extended PLND but the challenge remains to identify them accurately. Only prospective randomized study would answer the precise role of PLND in high-risk pelvis confined PCa patients.

Percutaneous Lymphatic Embolization as Primary Management of Pelvic and Retroperitoneal Iatrogenic Lymphoceles

PURPOSE

To evaluate the efficacy of lymphatic embolization (LE) in decreasing catheter output and dwell time in iatrogenic lymphoceles after percutaneous catheter drainage.

MATERIALS AND METHODS

Retrospective review of patients who underwent intranodal lymphangiography (INL) with or without LE for management of iatrogenic lymphoceles between January 2017 and November 2020 was performed. Twenty consecutive patients (16 men and 4 women; median age, 60.5 years) underwent a total of 22 INLs and 18 LEs for 15 pelvic and 5 retroperitoneal lymphoceles. Lymphatic leaks were identified in 19/22 (86.4%) of the INLs. Three patients underwent INL only because a leak was not identified or was identified into an asymptomatic lymphocele. One patient underwent repeat INL and LE after persistent high catheter output, and 1 patient underwent repeat INL with LE after the initial INL did not identify a leak. Catheter output was assessed until catheter removal, and changes in output before and after the procedure were reported. The patients were followed up for 2-30 months, and procedural complications were reported.

RESULTS

The median catheter output before the procedure was 210 mL/day (50-1,200 mL/day), which decreased to a median of 20 mL/day (0-520 mL/day) 3 days after the procedure, with a median output decrease of 160 mL (0-900 mL). The median time between INL with LE and catheter removal was 6 days, with no recurrence requiring redrainage. Four patients experienced minor complications of low-grade fever (n = 2) and lower limb edema (n = 2).

CONCLUSIONS

Lymphangiogram and LE are safe and effective methods for the management of lymphoceles.

Robotic Vessel Sealer Device for Lymphocele Prevention After Pelvic Lymphadenectomy: Results of a Randomized Trial

Introduction: Pelvic lymph node dissection (PLND) during robotic prostatectomy is associated with potential complications. The most common complication of PLND is lymphoceles, occurring in up to 50% of patients in studies with screening imaging but usually asymptomatic. We performed a prospective randomized trial to evaluate whether using advanced bipolar energy for PLND via the robotic vessel sealer can prevent lymphoceles. Methods: A total of 120 patients were enrolled in the trial with each patient serving as their own control. Robotic PLND was randomly performed using the vessel sealer on one side and standard PLND using clips on the other side. All patients underwent screening computed tomography scan 3 months postoperatively with radiologists blinded to the assigned technique. Significant lymphoceles were defined as fluid collections ≥3 cm in any plane. Results: Of those enrolled, 114 completed the study. The mean nodal yield was 6.5 nodes, with 3.1 versus 3.4 nodes for vessel sealer side versus standard technique (P = .35), respectively. The mean operative time for PLND was 11.3 versus 11.1 minutes (P = .62), respectively. Twenty-two lymphoceles were identified. Ten occurred on the vessel sealer side versus 12 on the standard side (8.8% versus 10.5%, P = .412). All lymphoceles were asymptomatic. Conclusions: While the robotic advanced bipolar device did not appear to prevent lymphoceles, the vessel sealer also did not increase the rate of lymphoceles compared with a standard technique using clips. Both techniques were equally efficacious, efficient, and safe for PLND such that surgeons who prefer to avoid clips can reasonably use the vessel sealer, although at increased cost. Clinical Trial Registration number: NCT02035475.

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.

Examination of Necessity for Pelvic Drain Placement After Robot-assisted Radical Prostatectomy

BACKGROUND/AIM

Pelvic drain (PD) placement is commonly performed after robot-assisted radical prostatectomy (RARP), but the need for PD placement is unclear. This study aimed to assess the need for PD placement after RARP.

PATIENTS AND METHODS

This retrospective study analysed the effect of PD placement on postoperative complications in patients who underwent RARP between 2009 and 2018. All patients prior to October 1, 2016 had a PD placed; those after did not.

RESULTS

Of the 308 study patients, 231 received a PD (PD group) and 77 did not (ND group). The incidence of ileus, urinary tract infection and anastomotic leak did not differ significantly between the groups; nor did the incidence of asymptomatic and symptomatic lymphocele at 2 weeks and 1 year after surgery. Multivariate analysis showed that lymph node dissection is a predictor of asymptomatic lymphocele development two weeks after surgery.

CONCLUSION

PD placement is not necessary after RARP.

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.

Preoperative Parameters to Predict the Development of Symptomatic Lymphoceles after Radical Prostatectomy

INTRODUCTION

Symptomatic lymphoceles (SLs) represent the most common complication after radical prostatectomy (RP) and pelvic lymph node dissection (PLND). To date, preoperative risk factors are missing.

METHODS

Clinical and pathological data of 592 patients who underwent RP and PLND were evaluated. Included parameters were age, BMI, prostate-specific antigen (PSA), PSA ratio, PSA density, number of resected and/or positive lymph nodes, previous abdominal surgery/pelvic radiotherapy, anticoagulation, and surgical approach.

RESULTS

Fifty-nine patients (10%) developed an SL, of which 57 underwent open retropubic radical prostatectomy (RRP) and 2 underwent robot-assisted radical prostatectomy (RARP). Multivariate logistic regression revealed the following parameters as statistically significant risk factors: PSA (odds ratio [OR] = 2.23; 95% CI [1.25; 5.04], p = 0.04), number of resected lymph nodes (OR = 1.47; 95% CI [1.10; 1.97], p < 0.01), previous abdominal surgery (OR = 2.58; 95% CI [1.38; 4.91], p < 0.01), and surgical approach (OR = 0.08; 95% CI [0.01; 0.27], p < 0.01). Previous oral anticoagulation showed almost statistically significant results (OR = 2.39 [0.92; 5.51], p = 0.05).

CONCLUSION

The risk for SL might be predictable considering preoperative risk factors such as PSA, previous abdominal surgery and anticoagulation. To avoid SL, RARP should be the procedure of choice. If RRP is considered, patients at risk for SL may benefit from peritoneal fenestration during RP.

High BMI, Aggressive Tumours and Long Console Time Are Independent Predictive Factors for Symptomatic Lymphocele Formation after Robot-Assisted Radical Prostatectomy and Pelvic Lymph Node Dissection

INTRODUCTION

Lymphocele (LC) formation is a common complication which may cause severe symptoms after robot-assisted radical prostatovesiculectomy (RARP) with concomitant pelvic lymph node dissection (PLND). Compared to open radical prostatectomy, the amount of data on potential risk factors for LC formation is still limited. The aim of the present study was to identify risk factors for symptomatic LC formation (sLC) after RARP with PLND.

METHODS

We used the data of a prospective multicentre series of 232 RARP patients which were treated between March 2017 and December 2017. The primary endpoint was the presence of sLC within 90 days. Asymptomatic LC (aLC) formation was also recorded. We evaluated clinical, perioperative, and histopathological criteria and compared their distribution in patients with and without post-operative sLC. Uni- and multivariable logistic regression analyses (MVAs) were performed to identify potential predictors for LC formation. Regarding the influence of patients' BMI, 2 models were calculated: BMI continuously (model 1) and BMI dichotomized with cut-off 30 kg/m2 (WHO definition, model 2).

RESULTS

Post-operative sLC was present in 21 patients (9.1%), while aLC was detected in 49 patients (21.1%) 90 days after RARP with PLND. Patients with sLC showed higher median baseline PSA levels (9.8 vs. 8.1 ng/mL), higher prevalence of obesity (BMI >30; 42.9 vs. 19.9%), and longer median console time (180 vs. 165 min) compared to patients without sLC. On MVA higher BMI {model 1: OR 1.145 (confidence interval [CI] 1.025-1.278); model 2: OR 2.761 (1.045-7.296)}, longer console time (model 1: OR 1.013 [1.005-1.021]; model 2: OR 1.013 [1.005-1.020]) and an ISUP grade ≥3 (model 1: OR 3.247 [1.182-8.917]; model 2: OR 2.791 [1.050-7.423]) were identified as independent predictors for sLC development.

CONCLUSION

Patients with aggressive tumours and higher BMI should be informed about a potentially increased risk for sLC formation. In case of a long console time, a close and regular follow-up should be considered to check for LC development.

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.

Epidemiology and therapy of symptomatic lymphoceles after robot-assisted radical prostatectomy (RARP)

Background

Lymphoceles are a common postoperative complication after radical prostatectomy with pelvic lymphadenectomy. Therapeutic options include cannulation and drainage (CD), drainage and instillation (DI), or laparoscopic fenestration (LF). The aim of this study was to investigate the epidemiology of symptomatic lymphoceles (SLC) and evaluate the treatment options.

Methods

We retrospectively analysed all patients who underwent robot-assisted radical prostatectomy (RARP) at our clinic from January 1, 2014 to December 31, 2018. All documented lymphoceles of these patients were recorded and analysed with regard to symptoms, possible infection and the treatment option (or options) chosen.

Results

We were able to include all 1,029 patients who underwent RARP in the aforementioned period of time. Of these, 18.1% were diagnosed with a lymphocele either when discharged or when readmitted and 6.9% experienced an SLC requiring treatment. Thirteen-point-seven percent of patients readmitted with SLC showed an accompanying thrombosis. Due to recurring or bilateral SLCs receiving different treatment options for each side, there was a total of 115 SLCs treated. CD was carried out in 102 cases. Twenty-point-six percent of patients were sufficiently treated this way, the rest required further treatment or experienced recurrences not requiring further treatment. DI was carried out in 56 cases. Of those patients, 46.4% were sufficiently treated. LF was carried out in 54 cases (either after CD, or after DI, or primarily). Of those patients, 98.1% were treated sufficiently. LF had a statistically significant higher success rate compared to CD and DI (P<0.001 respectively).

Conclusions

The study confirmed the significance of SLC as a common complication after RARP. LF turned out to be the most effective treatment option for SLC, while CD as well as DI have not been proven effective.

Can we predict the development of symptomatic lymphocele following robot-assisted radical prostatectomy and lymph node dissection? Results from a tertiary referral Centre

Objectives: Robot-assisted radical prostatectomy (RARP) has been established as first-line surgical therapy for organ-confined prostate cancer (PCa). Pelvic lymph node dissection (PLND) is recommended in case of intermediate and high-risk localized PCa however symptomatic lymphocele (SL) formation is a common complication. Still no certain clinical and surgical predictors of SL have been found in the robotic era. Aim of this study was to identify clinical and surgical predictors of SL after RARP and PLND.Methods: We retrospectively evaluated all consecutive patients undergone RARP and PLND from 01/2017 to 06/2019, at our institution. All procedures were performed by experienced robotic surgeons. Baseline patients' characteristics, as well as peri- and post-operative features, were recorded and compared among those patients experiencing SL after surgery and those who did not.Results: Overall, 282 patients were included. Of these, 21 (7.5%) developed SL after surgery. Patients with SL showed higher median BMI (30.4 vs 25.8) and a more frequent history of vascular surgery or lymph-vascular disease (23.8% vs 8.4%) compared to patients without SL (p < 0.05). The lymphadenectomy technique adopted during the surgery was also found different in patients diagnosed with SL. At the multivariable analysis (MVA), only the increase of BMI (OR 1.72; CI: 1.47 - 2.81) was found predictor of developing SL.Conclusion: In our experience, the increase of BMI was a significant predictor of SL development in pCa patients submitted to RARP and PLND. This further evidence may be of great help for clinicians in daily clinical practice, in particular during preoperative counseling.

Surgical Strategies for Lymphocele Prevention in Minimally Invasive Radical Prostatectomy and Lymph Node Dissection: A Systematic Review

Purpose: Pelvic lymph node dissection is an important step during robotic radical prostatectomy. The collection of lymphatic fluid (lymphocele) is the most common complication with potentially severe impact; therefore, different strategies have been proposed to reduce its incidence. Materials and Methods: In this systematic review, EMBASE, MEDLINE, Cochrane Library, and NIH Registry of Clinical Trials were searched for articles including the following interventions: transperitoneal vs extraperitoneal approach, any reconfiguration of the peritoneum, the use of pelvic drains, and the use of different sealing techniques and sealing agents. The outcome evaluated was the incidence of symptomatic lymphocele. Randomized, nonrandomized, and/or retrospective studies were included. Results: Twelve studies were included (including one ongoing randomized clinical trial). Because of heterogeneity of included studies, no meta-analysis was performed. No significant impact was reported by different sealing techniques and agents or by surgical approach. Three retrospective, nonrandomized studies showed a potential benefit of peritoneal reconfiguration to maximize the peritoneal surface of reabsorption. Conclusion: Lymphocele formation is a multistep and multifactorial event; high-quality literature analyzing risk factors and preventive measures is rather scarce. Peritoneal reconfiguration could represent a reasonable option that deserves further evaluation; no other preventive measure is supported by current evidence.

Regular vs. selective use of closed suction drains following robot-assisted radical prostatectomy: results from a regional quality improvement collaborative

BACKGROUND

Closed suction drain (CSD) placement is common in robot-assisted radical prostatectomy (RARP). Our goal is to quantify outcomes of RARP for patients undergoing RARP by surgeons who regularly or selectively use CSDs.

METHODS

Patients undergoing RARP (4/2014-7/2017) were prospectively entered into the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry. Outcomes included length of stay (LOS) >2 days, >16-day catheterization, 30-day readmission, and clinically significant urine leak or ileus. Retrospective analysis of each adverse event was performed comparing groups using chi-square tests.

RESULTS

In all, 6746 RARPs were performed by 115 MUSIC surgeons. CSDs were used in 4451 RARP (66.0%), with wide variation in surgeon CSD use (median: 94.7%, range: 0-100%, IQR: 45-100%). The cohorts of patients treated by surgeons with regular vs. selective CSD usage were similar. CSD use pattern was not associated with rates of prolonged catheterization (4.6% vs. 3.9%, p = 0.17) or readmission (4.5% vs. 4.0%, p = 0.35) and multivariable analysis confirmed these findings (each p > 0.10). Regular CSD use was associated with LOS >2 days (8.4% vs. 6.3%, p = 0.001) and multivariable analyses indicated an odds ratio (OR) of 1.42 (95% CI: 1.12-1.79; p = 0.017) and increased likelihood of clinically significant ileus (OR: 1.64; CI: 1.14-2.35; p = 0.008).

CONCLUSIONS

Although there are specific situations in which CSDs are beneficial, e.g. anastomotic leak or observed lymphatic drainage, regular CSD use during RARP was associated with a greater likelihood of LOS >2 days and clinically significant ileus. Our data suggest that CSD should be placed selectively rather than routinely after RARP.

Can we predict who will need lymphocele drainage following robot assisted laparoscopic prostatectomy (RALP)?

Pelvic lymph node dissection (PLND) can cause lymphoceles. Lymphocele formation following PLND can reach up to 60% and are symptomatic in 0.4 to 16% of patients. The aim of the study was to identify factors that are significantly associated with lymphocele drainage. We retrospectively analysed all men that underwent RALP between April 2010 and November 2018 from our prospectively collected IRB approved database. All patients who developed lymphoceles were grouped into two groups, the ones who were drained and those not drained. Chi-square test was used to perform univariate analysis for categorical variables and student's t test for continuous variables. Odds ratio was calculated using logistic multiple regression analysis. A P value of less than 0.05 was considered significant. The size of the lymphocele, the number of nodes retrieved, and BMI were significant factors that led to the drainage of lymphocele. The patients with lymphoceles larger than 10 cm had an odds ratio of 47.5 and those between 5 and 10 had an odds ratio of 10.7. The odds ratio of drainage in patients with BMI above 30 was 2.1. The odds of drainage were 8.8 when more than 10 nodes were taken. After PLND ultrasound could be effective in early identification of patients who could potentially need drainage. Early elective drainage should be offered to patients who have more than 10 lymph nodes removed with a lymphocele size more than 10 cm in size and BMI above 30.

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.

Endolymphatic Ethiodized Oil Intranodal Lymphangiography and Cyanoacrylate Glue Embolization for the Treatment of Postoperative Lymphatic Leak After Robot-Assisted Laparoscopic Pelvic Resection

Purpose: To report the approach, technical success, clinical outcomes, complications, and follow-up of ethiodized oil intranodal lymphangiography with cyanoacrylate glue embolization for the treatment of lymphatic leak after robot-assisted laparoscopic pelvic resection.

Materials and Methods: Four men with mean age 68.7 ± 14.3 years were treated with ethiodized oil intranodal lymphangiography with cyanoacrylate embolization for postoperative lymphatic leak. Patients underwent either (1) cystoprostatectomy with ileal conduit and bilateral extensive pelvic lymph node dissection for muscle-invasive urothelial carcinoma and presented with postoperative lymphatic ascites (n = 2) or (2) prostatectomy with bilateral standard pelvic lymph node dissection for prostate carcinoma and presented with postoperative pelvic lymphoceles (n = 2). Intranodal lymphangiography and embolization procedural details, technical success, clinical outcomes, and follow-up were recorded.

Results: In four patients, a total of six ethiodized oil intranodal lymphangiograms were performed, two procedures being repeated interventions. Inguinal lymph node catheterization and ethiodized oil lymphangiography was technically effective in all procedures. A mean of 5.2 ± 2.0 mL of ethiodized oil was used for lymphatic opacification. Cyanoacrylate was diluted to 24.2% with ethiodized oil and 0.44 mL of cyanoacrylate was instilled during first time interventions. On repeat procedures, cyanoacrylate was diluted to 51.7%, and 0.52 mL was instilled. The primary clinical success rate was 50% (n = 2/4). Clinical success was achieved in all patients after two interventions (n = 4; 100%). No complications were reported at mean follow-up of 134.7 ± 79.2 days (range: 59–248 days).

Conclusion: Ethiodized oil intranodal lymphangiography with direct cyanoacrylate glue embolization is a minimally invasive treatment option for lymphatic leak after pelvic resection.

An unusual localization of seven months delayed pelvic lymphocele following radical retropubic prostatectomy: Case report and literature review

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Lymphocele after radical prostatectomy leading major complications is rare.

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Lymphocele is the most common cause of hospital readmission after radical prostatectomy.

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Lymphocele can be seen in atypical regions after radical prostatectomy.

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Percutaneous interventions can be used for pelvic lymphocele treatment.

Introduction

A pelvic lymphocele is a collection of lymphatic fluid that develops after extensive lymphadenectomies in surgeries such as urological malignancies or renal transplantation. Pelvic lymphoceles may cause complications such as fever, abdominal pain, leg swelling, genital swelling and flank pain. This report summarizes the management of a pelvic lymphocele after open radical retropubic prostatectomy with bilateral lymphadenectomy.

Presentation of case

Herein, we present a case in which a pelvic lymphocele developed seven months post-radical open retropubic prostatectomy and through this patient we discussed the lymphocele following radical prostatectomy. The pelvic lymphocele occurred along the sciatic nerve from the sciatica foramen to the intergluteal muscles. The patient was treated with three drainage catheters. This localization is an atypical and unusual for lymphocele after radical retropubic prostatectomy.

Discussion

Lymphocele formation that leads to major complications after radical prostatectomy is rare. Lymphocele formation is most commonly seen in the early postoperative period, but it should be considered in patients with fever, abdominal pain or leg swelling during the late postoperative period. Lymphocele formation was the most common cause of hospital readmission after radical prostatectomy.

Conclusion

Lymphocele formation can be seen in atypical regions and can lead to unexpected complications after radical prostatectomy. Therefore, it should be brought to mind when complaints such as fever and lower extremity swelling occurred in patients underwent extensive lymph node dissection. Surgical treatment options are available, but percutaneous interventions can also be used.

Rate of Symptomatic Lymphocele Formation After Extraperitoneal vs Transperitoneal Robot-Assisted Radical Prostatectomy and Bilateral Pelvic Lymphadenectomy

INTRODUCTION AND OBJECTIVE

With the peritoneum acting as a natural surface for lymphatic reabsorption, transperitoneal robot-assisted radical prostatectomy (tRARP) is thought to be associated with a lower incidence of symptomatic lymphoceles (SLs) compared with its extraperitoneal counterpart (eRARP) when bilateral pelvic lymph node dissection (BPLND) is performed. In this study, we aim to determine if there is a difference in SL formation and characteristics between the two approaches.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients who underwent eRARP or tRARP and BPLND by a single surgeon at a tertiary care academic center from July 1, 2003, to May 31, 2016. Patients with a history of prior pelvic radiotherapy, concomitant inguinal hernia repair, RARP without BPLND, or nonadenocarcinoma of the prostate were excluded. The resulting eRARP and tRARP groups were propensity matched for age, body mass index (BMI), American Association of Anesthesiologists (ASA) score, D'Amico risk classification, and pathological lymph node (LN) count.

RESULTS

A total of 3183 RARPs were performed during this time period. After applying exclusion criteria and propensity score matching, 671 patients remained in each group. No statistically significant differences were noted between the groups with regard to age, BMI, ASA, pre-RARP prostate-specific antigen, D'Amico risk classification, biopsy and pathological Gleason sum score, pathological T stage, or margin status. The tRARP group had a higher clinical T stage (p = 0.0015), length of stay (LOS; p = 0.005), pathological N stage (4.92% vs 1.36%, p = 0.0002), and high total LN count (7.22 ± 5.54 vs 5.78 ± 4.18 LNs, p < 0.0001). The eRARP group had higher operating room times (197.4 ± 48.96 minutes vs 192.2 ± 44.12 minutes, p = 0.04) and estimated blood loss (218.4 ± 152.0 mL vs 179.9 ± 119.4 mL, p < 0.0001). No differences were noted in the frequency of SL formation [eRARP: 19/671 (2.83%) vs tRARP: 10/671 (1.49%), p = 0.09] or any clinical characteristics of the SL. Logistic regression analysis showed no effect of LN count (p = 0.071), pathological N stage (p = 0.111), or both combined (p = 0.085) on SL formation.

CONCLUSIONS

In this cohort, the rate and clinical characteristics of SL were similar among patients treated with eRARP or tRARP and BPLND. The low event rate of SL in each group and trends favoring higher SL with LN yield and pN1 disease in the tRAPR group may deem the study underpowered to make definitive conclusions.

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.

A Clinician's Guide to Avoiding and Managing Common Complications During and After Robot-assisted Laparoscopic Radical Prostatectomy

CONTEXT

Robot-assisted radical prostatectomy (RARP) is on the advance globally, and it is essential for surgeons and patients to know the rates of perioperative complications.

OBJECTIVE

To provide evidence-based clinical guidance on avoiding and managing common complications during and after RARP in the context of a comprehensive literature review.

EVIDENCE ACQUISITION

In concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis 2015 statement guidelines, a literature search of the PubMed database from August 1, 2011, to August 31, 2015, using the predefined search terms robot* AND radical prostatectomy, was conducted. The search resulted in 653 unique results that were subsequently uploaded to DistillerSR (Evidence Partners, Ottawa, Canada) for team-based screening and processing of references.

EVIDENCE SYNTHESIS

Overall, 37 studies met the inclusion criteria and were included. Median rate of overall complication was 12.6% (range: 3.1-42%). Most of the complications were minor (Clavien-Dindo grades 1 and 2). Grade 3 complications comprised the bulk of the major complications with a median rate of 2.7%; grade IV and V complications were exceedingly rare in all reports.

CONCLUSIONS

Despite continued adoption of the RARP technique globally, rates of overall complication remain low. Many of the complications experienced during and after RARP can be mitigated and prevented by experience and the implementation of safe techniques.

PATIENT SUMMARY

Despite continued adoption of the robot-assisted radical prostatectomy (RARP) technique globally, rates of overall and major complications remain low at 12.6% and 2.7%, respectively. Complications can be minimized and successfully managed using established techniques. RARP is a safe and reproducible technique.

How to minimize lymphoceles and treat clinically symptomatic lymphoceles after radical prostatectomy

The development of a lymphocele after pelvic surgery is a well-documented complication, especially where pelvic lymph node dissection (PLND) is part of the operation. However, not all lymphoceles are symptomatic and require treatment. Most lymphoceles spontaneously resolve, and even lymphoceles that become symptomatic may resolve without any intervention. Robotic assisted radical prostatectomy (RARP) is a common operation in urology where PLND is likely to be performed in intermediate and high-risk prostate cancer patients. The rationale for performing a PLND in prostate cancer is for accurate staging and potential therapeutic benefits. However, due to potential intraoperative and postoperative complications there is still a debate regarding the value of PLND in prostate cancer. In this review, we will discuss the potential risk factors to be aware of in pelvic surgery in order to minimize the formation of a lymphocele, along with the management for clinically significant lymphoceles.

A combined index to classify prognostic comorbidity in candidates for radical prostatectomy

BACKGROUND

In patients with early prostate cancer, stratification by comorbidity could be of importance in clinical decision making as well as in characterizing patients enrolled into clinical trials. In this study, we investigated several comorbidity classifications as predictors of overall mortality after radical prostatectomy, searching for measures providing complementary prognostic information which could be combined into a single score.

METHODS

The study sample consisted of 2205 consecutive patients selected for radical prostatectomy with a mean age of 64 years and a mean follow-up of 9.2 years (median: 8.6). Seventy-four patients with incomplete tumor-related data were excluded. In addition to age and tumor-related parameters, six comorbidity classifications and the body mass index were assessed as possible predictors of overall mortality. Kaplan-Meier curves and Mantel-Haenszel hazard ratios were used for univariate analysis. The impact of different causes of death was analyzed by competing risk analysis. Cox proportional hazard models were calculated to analyze combined effects of variables.

RESULTS

Age, Gleason score, tumor stage, Charlson score, American Society of Anesthesiologists (ASA) physical status class and body mass index were identified a significant predictors of overall mortality in the multivariate analysis regardless whether two-sided and three-sided stratifications were used. Competing risk analysis revealed that the excess mortality in patients with a body mass index of 30 kg/m2 or higher was attributable to competing mortality including second cancers, but not to prostate cancer mortality.

CONCLUSION

Stratifying patients by a combined consideration of the comorbidity measures Charlson score, ASA classification and body mass index may assist clinical decision making in elderly candidates for radical prostatectomy.

Contemporary lymphadenectomy templates: kidney, prostate and bladder cancer

PURPOSE OF REVIEW

Lymph node dissection (LDN) at the time of a primary malignant resection varies in therapeutic and staging outcomes between organs of origin. The purpose of our review is to provide new updates and a key summary on the developments in lymphadenectomy templates in kidney, prostate and bladder cancer.

RECENT FINDINGS

There are still evolving definitions for LDN templates, means of pathologic diagnosis of lymph nodes, as well as implications on staging/cancer-free survival after LND though trends are still emerging.

SUMMARY

Routine lymphadenectomy does not appear to yield benefit in kidney cancer but maybe helpful in those with grossly identifiable disease. For high-risk prostate cancer as well as bladder cancer, extended lymphadenectomy with resection of external and internal iliac and obturator nodes as well as some common iliac nodes can yield survival benefit.

Management of pelvic lymphoceles following robot-assisted laparoscopic radical prostatectomy

Pelvic lymphocele is a potential complication of radical prostatectomy. Although lymphoceles often regress spontaneously, many may progress, precipitate clinical symptoms, and ultimately require intervention. To date, the best treatment of pelvic lymphoceles has not yet been fully defined. However, laparoscopic marsupialization is a definitive and efficacious surgical alternative to percutaneous drainage. It is effective, results in minimal patient morbidity, and allows for rapid recovery. We report our experience with management of clinically symptomatic pelvic lymphoceles following robotic-assisted prostatectomy using laparoscopic marsupialization.