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Abstract: Background: Accurate staging of prostate cancer is enhanced by a thorough evaluation of the pelvic lymph nodes. Limited data are available regarding robotic extended pelvic lymphadenectomy (PLA) in this setting. Objective: Analyze our experience performing robotic extended PLA. Design, setting, and participants: A total of 143 consecutive men with intermediate- or high-risk clinically localized adenocarcinoma of the prostate underwent robotic extended PLA and radical prostatectomy between September 2010 and November 2011 by a single surgeon. Surgical procedure: Lymph node packets were sent separately from bilateral common, external, and internal iliacs, obturators, node of Cloquet, and anterior prostatic fat. Measurements: Descriptive statistics were used to summarize lymph node yields and positive nodes. Clinical variables were examined in logistic regression models to predict lymph node positivity. Results and limitations: Median lymph node yield was 20 (range: 9–65, interquartile range: 15–25). Eighteen patients (13%) were found to have metastatic prostate cancer in the lymph nodes. The mean number of positive nodes found was 2.9 (range: 1–11). In 14 of 18 node-positive patients (78%), the extent of nodal invasion was outside the boundaries of a limited PLA. For four patients with positive nodes (22%), prostate biopsy predicted unilateral disease but PLA revealed contralateral positive lymph nodes. A total of 82% of patients experienced no complications, and most Clavien grade 1–2 complications consisted of anastomotic leakage, urinary retention, ileus, and lymphocele. Only 4% of patients experienced a grade 3 complication. Under multivariate regression analysis, prostate-specific antigen (PSA), clinical stage, and maximum biopsy core tumor volume were identified as significant predictors of finding positive pelvic lymph nodes (area under the curve: 91%). The main limitations include short follow-up and lack of randomization. Conclusions: Robotic extended bilateral PLA for prostate cancer up to the common iliac bifurcation increases nodal yield and positive nodal rate and can be performed safely. PSA, clinical stage, and maximum biopsy core volume are predictors for lymph node invasion. Long-term follow-up is needed to evaluate for therapeutic benefit. [Copyright &y& Elsevier]

Abstract: Background: The extent of lymphadenectomy needed to optimize oncologic outcomes after radical cystectomy (RC) for patients with regionally advanced bladder cancer (BCa) is unclear. Objective: Evaluate the effect of the location of lymph node metastasis on recurrence-free survival (RFS) and cancer-specific survival (CSS) for patients undergoing RC with a mapping pelvic lymph node dissection (PLND). Design, setting, and participants: A study of 591 patients undergoing RC with mapping PLND was completed between 2000 and 2010. Median follow-up was 30 mo. Intervention: RC with mapping PLND. Measurements: We evaluated the impact of lymph node involvement by location on disease outcomes using the 2010 TNM staging system. Survival estimates were described using Kaplan-Meier methods. Gender, age, pathologic stage, histology, number of positive nodes, location of positive nodes, node density, use of perioperative chemotherapy, and grade were evaluated as predictors of RFS and CSS using multivariate Cox proportional hazard regression. Results and limitations: Overall, 114 patients (19%) had lymph node involvement, and 42 patients (7%) had pN3 disease. On multivariate analysis, the number of positive lymph nodes (one or two or more) was significantly associated with increased risk of cancer-specific death (hazard ratio [HR]: 1.9 [95% confidence interval (CI), 1.04–3.46], p =0.036; versus HR: 4.3 [95% CI, 2.25–8.34], p <0.0005). Positive lymph node location was not an independent predictor of RFS or CSS. Five-year RFS for pN3 patients undergoing RC with PLND was 25% (95% CI, 10–42). This finding was not statistically different from our pN1 and pN2 patients (38% [95% CI, 22–54] and 35% [95% CI, 11–60], respectively). This study is limited by the lack of prospective randomization and a control group. Conclusions: The outcome for patients with involved common iliac lymph nodes was similar to the outcome for patients with primary nodal basin disease. These data support inclusion of the common iliac lymph nodes (pN3) in the nodal staging system for BCa. Lymph node location was not an independent predictor of outcome, whereas the number of positive lymph nodes was an independent predictor of worse oncologic outcome (pN1, pN2). Further refinements of the TNM system to provide improved prognostication are warranted. [Copyright &y& Elsevier]

Abstract: Objective: We hypothesized that the information stemming from biopsy cores can enhance the ability to predict the rate of lymph node invasion (LNI) at radical retropubic prostatectomy (RRP) in men subjected to extended pelvic lymphadenectomy (ePLND). Materials and methods: A cohort of 278 consecutive patients (mean age: 66.2 yr) underwent a RRP and an ePLND, in which 10 or more nodes were removed and examined. The median PSA was 7.5ng/ml. Clinical stage was mostly T1c (59.4%) and T2 (37.8%). Biopsy Gleason sum was 2–5 in 26.6%, 6 in 39.2%, 7 in 27%, and 8–10 in 7.2%. The number of positive cores was 1–19 (median: 4), whilst percentage of positive cores was 7.1–100% (median: 37.5%). Logistic regression models tested the association between the above predictors and LNI. Testing of PSA was coded as either a continuous variable (CV) or a cubic spline (CS). Individual variables and combined accuracy were tested in regression-based nomograms, which were subjected to 10,000 bootstrap resamples to reduce overfit bias. Results: Mean number of lymph nodes examined was 17.5 (range: 10–38); 29 patients (10.4%) had LNI. Percentage of positive cores (78.5%) and biopsy Gleason sum (78.4%) were the most informative predictors of LNI. A nomogram based on clinical stage, PSA (CV), and biopsy Gleason sum was 79.7% accurate versus 83% (3.3% gain, p <0.001) when percentage of positive cores was added. A 2.7% gain (83.7% vs. 81%; p <0.001) was recorded after the addition of the percentage of positive cores when PSA was coded as a CS. Conclusions: Percentage of positive biopsy cores should be considered in prediction of LNI at ePLND, because it significantly improves the combined accuracy of established clinical predictors such as PSA, clinical stage, and biopsy Gleason sum. [Copyright &y& Elsevier]

Abstract: Objectives: Some patients with localized prostate cancer are at risk of nonobturator lymph node invasion (NOLNI) and may require an extended pelvic lymph node dissection (ePLND). We explored the rate of exclusive NOLNI and developed a nomogram to predict it. Material and methods: We mapped all ePLND specimens according to their anatomic location (obturator, external iliac, internal iliac lymph nodes) and assessed the location-specific rate of LNI in 565 patients. A multivariate logistic regression-based nomogram predicting NOLNI was then internally validated with 200 bootstrap resamples. Results: Overall, 11.1% (63 of 565) had LNI and 21 (3.7%) had exclusive NOLNI. The nomogram predicting exclusive NOLNI was 80.2% accurate. The nomogram''s negative predictive value was 99%, when it predicted 0–10% probability of NOLNI. This approach could allow the omission of an ePLND in 350 of 565 (61.9%) patients and still correctly stage 85.8% of NOLNI cases. Conclusions: Our nomogram-based approach offers the possibility of identifying men who are at virtually zero risk of exclusive NOLNI. In these men, an ePLND may be safely avoided. [Copyright &y& Elsevier]

Abstract: Objectives: More-extensive pelvic lymph node dissection (PLND) may be associated with a higher rate of complications and a longer hospital stay than more limited PLND. Methods: Before radical retropubic prostatectomy, PLNDs were performed in 963 patients. Of these, 767 (79.6%) had ≥10 lymph nodes removed and examined (extended PLND [ePLND]), while 1–9 nodes (limited PLND [lPLND]) were removed in the remaining 196 (20.4%). Limits included external iliac, obturator, internal iliac, and iliac bifurcation. PLND-related complications and the length of hospital stay were recorded prospectively and analyzed according to the extent of PLND. Results: In patients subjected to ePLND, the overall rate of complications was 19.8% versus 8.2% in those treated with lPLND (p <0.001). In individual analyses of specific complications, only the lymphocele rate was significantly higher after ePLND (10.3% vs 4.6%; p =0.01). Similarly, ePLND translated into a longer hospital stay (9.9 vs 8.2 d; p <0.001). These differences persisted when adjustment was made for prostate-specific antigen and either clinical or pathologic tumor characteristics. Conclusions: Our data indicate that, even in the hands of experienced urologic surgeons, ePLNDs are associated with higher complication rates and longer hospital stay. These detriments need to be taken into account when the staging benefit associated with ePLND is considered. [Copyright &y& Elsevier]

Abstract: Introduction: Our goal was to develop and internally validate a nomogram for prediction of lymph node invasion (LNI) in patients with clinically localized prostate cancer undergoing extended pelvic lymphadenectomy (ePLND). Methods: 602 consecutive patients (mean age 65.8 years) underwent an ePLND, where 10 or more nodes were removed. PSA was 1.1–49.9 (median 7.2). Clinical stages were: T1c in 55.6%, T2 in 41.4% and T3 in 3%. Biopsy Gleason sums were: 6 or less in 66%, 7 in 25.4%, 8–10 in 8.6%. Multivariate logistic regression models tested the association between all of the above predictors and LNI. Regression-based coefficients were used to develop a nomogram predicting LNI and 200 bootstrap resamples were used for internal validation. Results: Mean number of lymph nodes removed was 17.1 (range 10–40). LNI was detected in 66 patients (11.0%). Univariate predictive accuracy for total PSA, clinical stage and biopsy Gleason sum was 63%, 58% and 73%, respectively. A nomogram based on clinical stage, PSA and Biopsy Gleason sum demonstrated bootstrap-corrected predictive accuracy of 76%. Conclusions: A nomogram based on pre-treatment PSA, clinical stage and biopsy Gleason sum can highly accurately predict LNI at ePLND. [Copyright &y& Elsevier]