The effect of peritoneal re-approximation on lymphocele formation in transperitoneal robot-assisted radical prostatectomy and extended pelvic lymphadenectomy

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.

The effect of peritoneal flap fixation with curling technique on postoperative lymphocele formation in robot-assisted radical prostatectomy

BACKGROUND

In robot-assisted radical prostatectomy (RARP), the peritoneal edges isolate the extended pelvic lymph node dissection bed from the peritoneal cavity. We studied the effect of peritoneal re-configuration through peritoneal flap fixation (PFF) with curling technique on lymphocele development.

METHOD

We included 2087 patients who underwent RARP between 2010 and 2022. Two hundred and thirty patients whose operation was performed using the PFF with curling technique were matched in a 1:1 ratio with non-PFF patients based on age, body mass index, initial prostate-specific antigen, and number of removed lymph nodes. Demographic, clinical, intraoperative and postoperative characteristics were collected. Complications were classified using the Clavien-Dindo system and the presence of lymphocele was documented.

RESULTS

The two groups were similar in respect to matching parameters. Fifteen (6.5%) patients in the non-PFF group and two (0.9%) patients in the PFF group suffered from symptomatic lymphocele with symptoms such as abdominal pain, fever, lower extremity and/or genital oedema (p = 0.001). Asymptomatic lymphocele was diagnosed by ultrasonography in 19 (8.3%) patients in the non-PFF group and eight (3.5%) patients in the PFF group (p = 0.029).

CONCLUSION

The results of our study support this concept by providing solid indications of the clinical benefits and safety of PFF with the curling technique.

Peritoneal interposition flap reduces symptomatic lymphocele following transperitoneal robot-assisted radical prostatectomy and pelvic lymph node dissection: An updated meta-analysis

Background

Robot-assisted radical prostatectomy with intraoperative pelvic lymph node dissection is the criterion standard for surgical treatment of nonmetastatic intermediate- and high-risk prostate cancer. However, this method is associated with symptomatic lymphocele (SLC), which is an important morbidity factor. To overcome this complication, several modifications of the technique have been developed, including the peritoneal interposition flap (PIF). We performed an updated systematic review and meta-analysis to investigate the efficacy and safety of this technique for preventing SLC and lymphocele (LC) formation.

Materials and methods

Searches were performed using databases and references from included studies and previous systematic reviews. Only randomized controlled trials and nonrandomized cohorts were included. Primary outcomes were the incidence of SLC and LC formation, and safety outcomes were defined as operation time, estimated blood loss, length of hospital stay, and urinary incontinence. Quality assessment was performed using the Newcastle-Ottawa Scale and Cochrane Collaboration's tool. Pooled treatment effects were estimated using odds ratios with 95% confidence intervals (CIs) for binary endpoints. Heterogeneity was examined using Cochran's Q test and I 2 statistics; p values < 0.10 and I 2 > 25% were considered significant for heterogeneity. We used Mantel-Haenszel fixed-effect models in the analyses with low heterogeneity. Otherwise, the DerSimonian and Laird random-effects model was used.

Results

The initial search yielded 510 results. After the removal of duplicate records and application of the exclusion criterion, 9 studies were fully reviewed for eligibility. Three randomized controlled trials and 5 retrospective cohorts met all the inclusion criteria, comprising 2261 patients, of whom 1073 (47.4%) underwent PIF. Six studies reported a significant reduction in SLC in the PIF group, and 3 of the 4 studies reported LC formation yielded significant results in preventing this complication. The incidence of SLC and LC formation in a follow-up of ≥3 months was significantly different between the PIF and no PIF group (odds ratio, 0.34 [95% CI, 0.16–0.74; p = 0.006] and 0.48 [95% CI, 0.31–0.74; p = 0.0008]), respectively. The safety outcomes did not differ significantly between the 2 groups.

Conclusions

These results suggest that PIF is an effective and safe technique for preventing LC and SLC in patients undergoing transperitoneal robot-assisted radical prostatectomy and pelvic lymph node dissection.

The efficacy of peritoneal flap fixation on symptomatic lymphocele formation following robotic-assisted laparoscopic radical prostatectomy with pelvic lymph node dissection: a systematic review and meta-analysis

BACKGROUND

Pelvic lymphocele is the most common complication after robot-assisted radical prostatectomy (RARP) with pelvic lymph node dissection (PLND), of which symptomatic lymphocele (sLC) ranges up to 10% and is associated with poorer perioperative outcomes. Peritoneal flap fixation (PFF) is a promising intraoperative modification to reduce sLC formation but the clinical evidence failed to reach consistency.

MATERIALS AND METHODS

Randomized and nonrandomized comparative studies comparing postoperative sLC occurrence with or without PFF after RARP with PLND were identified through a systematic literature search via MEDLINE/PubMed, Embase, Web of Science, and CENTRAL up to July 2023. Outcome data of sLC occurrence (primary) and major perioperative events (secondary) were extracted. Mean difference and risk ratio with 95% CI were synthesized as appropriate for each outcome to determine the cumulative effect size.

RESULTS

Five RCTs and five observatory studies involving 3177 patients were finally included in the qualitative and quantitative analysis. PFF implementation significantly reduced the occurrence of sLC (RR 0.35, 95% CI: 0.24-0.50), and the specific lymphocele-related symptoms, without compromised perioperative outcomes including blood loss, operative time, and major nonlymphocele complications. The strength of the evidence was enhanced by the low risk of bias and low inter-study heterogeneity of the eligible RCTs.

CONCLUSION

PFF warrants routine implementation after RARP with PLND to prevent or reduce postoperative sLC formation.

Impact of Peritoneal Interposition Flap on Patients Undergoing Robot-assisted Radical Prostatectomy and Pelvic Lymph Node Dissection: A Systematic Review and Meta-analysis of Randomized Controlled Trials

CONTEXT

Symptomatic lymphocele (sLC) occurs at a frequency of 2-10% after robot-assisted radical prostatectomy (RARP) with pelvic lymph node dissection (PLND). Construction of bilateral peritoneal interposition flaps (PIFs) subsequent to completion of RARP + PLND has been introduced to reduce the risk of lymphocele, and was initially evaluated on the basis of retrospective studies.

OBJECTIVE

To conduct a systematic review and meta-analysis of only randomized controlled trials (RCTs) evaluating the impact of PIF on the rate of sLC (primary endpoint) and of overall lymphocele (oLC) and Clavien-Dindo grade ≥3 complications (secondary endpoints) to provide the best available evidence.

EVIDENCE ACQUISITION

In accordance with the Preferred Reporting Items for Meta-Analyses statement for observational studies in epidemiology, a systematic literature search using the MEDLINE (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE databases up to February 3, 2023 was performed to identify RCTs. The risk of bias (RoB) was assessed using the revised Cochrane RoB tool for randomized trials. Meta-analysis used random-effect models to examine the impact of PIF on the primary and secondary endpoints.

EVIDENCE SYNTHESIS

Four RCTs comparing outcomes for patients undergoing RARP + PLND with or without PIF were identified: PIANOFORTE, PerFix, ProLy, and PLUS. PIF was associated with odds ratios of 0.46 (95% confidence interval [CI] 0.23-0.93) for sLC, 0.51 (95% CI 0.38-0.68) for oLC, and 0.41 (95% CI 0.21-0.83) for Clavien-Dindo grade ≥3 complications. Functional impairment resulting from PIF construction was not observed. Heterogeneity was low to moderate, and RoB was low.

CONCLUSIONS

PIF should be performed in patients undergoing RARP and simultaneous PLND to prevent or reduce postoperative sLC.

PATIENT SUMMARY

A significant proportion of patients undergoing prostate cancer surgery have regional lymph nodes removed. This part of the surgery is associated with a risk of postoperative lymph collections (lymphocele). The risk of lymphocele can be halved via a complication-free surgical modification called a peritoneal interposition flap.

Robot-assisted Surgery in the Field of Urology: The Most Pioneering Approaches 2015-2023

Robot-assisted surgery has emerged as a transformative technology, revolutionizing surgical approaches and techniques that decades ago could barely be imagined. The field of urology has taken charge in pioneering a new era of minimally invasive surgery with the ascent of robotic systems which offer enhanced visualization, precision, dexterity, and enabling surgeons to perform intricate maneuvers with improved accuracy. This has led to improved surgical outcomes, including reduced blood loss, lower complication rates, and faster patient recovery. The aim of our review is to present an evidence-based critical analysis on the most pioneering robotic urologic approaches described over the last eight years (2015-2023).

Effect of Peritoneal Interposition Flap to Prevent Symptomatic Lymphoceles in Robot-Assisted Radical Prostatectomy with Pelvic Lymphadenectomy: A Meta-Analysis and Systematic Review

Background: This systematic review and meta-analysis investigated whether peritoneal interposition flap (PIF) prevent lymphocele formation after robot-assisted radical prostatectomy with extended pelvic lymph node dissection. Materials and Methods: We performed a systematic review and cumulative meta-analysis of the primary outcomes according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Assessing the Methodological Quality of Systematic Reviews guidelines and risk-of-bias tool. Five databases, including Medline, PubMed, Cochrane Library, Scopus, and Web of Science, were systematically searched. The time frame of the search was set from the creation of the database to February 2023. Results: Meta-analysis of symptomatic lymphoceles (sLCs) rates revealed significant difference between PIF and no PIF group (eight studies pooled; p = 0.005), The sLCs rates account for 2.6% (28/1074) and 7.1% (85/1186) in the PIF and no PIF group, respectively. The resulting odds ratio was 0.34 (95% confidence interval: 0.16-0.73), taking into account the heterogeneity of these studies (Q = 14.32, p = 0.05; I2 = 51%). Conclusion: PIF is an effective intraoperative modification on the prevention or reduction of sLC, which is worthy of further clinical promotion. Systematic Review Registration: National Institute for Health and Care Research, identifier CRD42022364461.

Effect of Peritoneal Fixation (PerFix) on Lymphocele Formation in Robot-assisted Radical Prostatectomy with Pelvic Lymphadenectomy: Results of a Randomized Prospective Trial

BACKGROUND

Symptomatic lymphoceles present the most common complication of robot-assisted radical prostatectomy (RARP) with extended pelvic lymph node dissection (ePLND). No surgical technique has so far shown success in reducing the incidence rate, but several retrospective studies have shown the beneficial effect of the fixation of the peritoneum.

OBJECTIVE

To introduce a modification in the technique of fixing the peritoneum to the pubic bone and to confirm whether this intervention reduces the incidence of lymphoceles.

DESIGN, SETTING, AND PARTICIPANTS

A prospective randomized (1:1) single-center one-sided blind study was conducted in patients with localized prostate cancer (cT1-2cN0M0) indicated for RARP with ePLND operated between December 2019 and June 2021. In the intervention group, the free flap of the peritoneum was fixed to the pubic bone. In the control group, the peritoneal flap was left free without fixation.

SURGICAL PROCEDURE

In the intervention group, the free flap of the peritoneum was fixed to the pubic bone (PerFix) so that lateral holes were left, allowing drainage of lymph from the pelvis into the abdominal cavity, where it would be resorbed. The iliac vessels and obturator fossa remained uncovered by the peritoneum and the bladder.

MEASUREMENTS

The primary objective was to evaluate the frequency of symptomatic lymphoceles during follow-up. The secondary endpoints were the radiological presence of lymphoceles on computed tomography of the pelvis carried out 6 wk after surgery, the volume of the lymphoceles, and the degree of severe (Clavien-Dindo ≥3) complications.

RESULTS AND LIMITATIONS

Of the 260 randomized patients, 245 were evaluated in the final analysis-123 in the intervention and 122 in the control group. The median follow-up was 595 d. There were no differences between the groups regarding clinical and pathological variables. The median of 17 nodes removed was the same in both groups (p = 0.961). Symptomatic lymphoceles occurred in 17 patients (6.9%), while in the intervention group these were found in three (2.4%) versus 14 (11.5%) in the control group (p = 0.011). The number of radiologically detected asymptomatic lymphoceles did not differ (p = 0.095). There was no significant difference in lymphocele volume between the two groups (p = 0.118). The rate of serious complications (Clavien 3a and 3b) was 4.8% in the intervention group and 9.1% in the control group (p = 0.587). A multivariate logistic regression model of symptomatic lymphocele occurrence was created with significant factors: body mass index (odds ratio [OR] = 1.1, 95% confidence interval [CI] = [1.03, 1.26], p = 0.012) and intervention (OR = 4.6, 95% CI = [1.28, 16.82], p = 0.02).

CONCLUSIONS

Fixation of the peritoneum (PerFix) reduced the incidence of symptomatic lymphoceles in RARP with ePLND. We found no difference in the frequency of asymptomatic lymphocele development. The volume of the detected lymphoceles was similar.

PATIENT SUMMARY

In this study, we compared the rate of development of postoperative complications using the peritoneal fixation technique with that of a nonfixation control group for robot-assisted radical prostatectomy with extended pelvic lymphadenectomy. Fixation of the peritoneum should obviate the development of severe complications in the postoperative period.

Effect of prostate and bony pelvic dimensions measured by preoperative magnetic resonance imaging on robot-assisted radical prostatectomy

Bone pelvic dimensions and body habitus may have effects on robot-assisted radical prostatectomy (RARP). In this study, we examined the effects of body mass index, bone pelvis measurements and prostate measurements on console time (CT), decrease in postoperative hemogram level (DHL) and surgical margin(SM) in patients who underwent RARP for clinically localized prostate cancer in our institution. The data of transperitoneal RARP cases performed by a single surgeon between November 2016 and August 2020 were analyzed retrospectively. It was included in 125 patients who met the study criteria. Bone and soft tissue measurements were made on magnetic resonance imaging T2-weighted imaging in the mid-sagittal and transvers plane. In multivariate linear regression analyzes, only soft tissue width/transverse diameter of the prostate and CT were found to be correlated (p = 0.026). For the DHL, no pelvic dimension and body habitus had a significant association on multivariate linear regression analysis. In multivariate analyzes, a statistically significant difference was found only between pathological Gleason Score and SM (p = 0.008). Although we found statistically significant associations between prostate diameters and pelvic bone measurements and operative difficulties, we believe that further studies are needed to confirm these results. Such information can help identify patients with challenging anatomy and can be used in robotic surgery training to achieve optimal patient outcomes after RARP.

Should Peritoneal Re-Approximation be Performed After Transperitoneal Robot-Assisted Radical Prostatectomy?

Background: The aim of the study is to examine the effect of peritoneal re-approximation or non-approximation on the postoperative course of patients at the end of transperitoneal robot-assisted radical prostatectomy (tRARP).It is also aimed to examine the relationship between peritoneal re-approximation or non-approximation and drain removal time, need for analgesics, passage of flatus, and length of hospital stay. Methods: A total of 247 patients who underwent tRARP by 2 different experienced surgeons were included in the study. At the end of the tRARP procedure, 1 surgeon performed peritoneal re-approximation (Group 1, n = 108), whereas the other performed peritoneal non-approximation (Group 2, n = 139). The effect of the procedures on drain removal time, passage of flatus, need for analgesics, and length of hospital stay were compared between the groups. Results: There was no significant difference between the groups in terms of preoperative parameters including age, body mass index, and preoperative prostate-specific antigen levels (P > .05) (P = .622, P = .126 and P = .591, respectively). No statistically significant difference was found between the two groups in terms of comorbidity, Gleason score, clinical stage, and lymph node dissection (P = .086, P = .344, P = .318, P = .587, respectively). There was no statistically significant difference between the groups in terms of drain removal time, need for analgesics, passage of flatus, and length of hospital stay (P = .095, P = .142, P = 95, P = .389, respectively). Conclusion: This study did not demonstrate any additional postoperative benefit of peritoneal re-approximation. It has been shown that peritoneal re-approximation has no effect on the length of hospital stay, the need for pain relievers, and passage of flatus, drain duration, day. Therefore, we do not recommend re-approximation of the peritoneum.

Retroperitoneal robot-assisted laparoscopic partial nephrectomy for posterior located renal tumours: Technique and early term outcomes

BACKGROUND

Traditionally, the trans-peritoneal approach is preferred for robot-assisted partial nephrectomy (RPN). However, retroperitoneal RPN (RP-RPN) has recently become widespread because of the advantages of easier access to the hilum, ease dissection of posterior tumours, and lower probability of intra-peritoneal organ injury. We aimed to present our initial experience of the RP-RPN series in posteriorly located renal tumours.

METHODS

Twenty-one patients were included in the study, who underwent RP-RPN by a single surgeon between July 2019 and January 2020. RP-RPN was carried out only in posteriorly located renal tumours with ischemic (on-clamp) or zero ischemic (off-clamp) techniques. Patients with solitary kidney and a history of previous retroperitoneal surgery in the lumbodorsal region were excluded from the study.

RESULTS

All cases completed without any operative complication and conversion to open or radical nephrectomy. Seven cases were completed as zero ischemic and 14 cases as ischemic technique. The mean operation time was 157.86 ± 64.24 minutes and estimated blood loss was 173.81 ± 136.84 mL. The mean warm ischemia time was 15.81 ± 12.42 minutes. Positive surgical margin observed in 4.8% of the patients. The mean length of stay was 3.33 ± 0.79 days. The mean estimated glomerular filtration rate (eGFR) change in the 3rd postoperative month was -3.71 ± 8.57 ml/min/1.73 m² (4.6%). Mean follow-up period was 10.29 ± 4.86 months. New-onset stage 3-4 chronic kidney disease (eGFR < 60 m /min/1.73m² ) was not observed during the follow-up period.

CONCLUSION

RP-RPN is a safe and feasible approach with acceptable oncological and functional results. We think that RP-RPN can be applied as an alternative to the trans-peritoneal approach for selected cases, especially in renal tumours with the posterior location.