Search

Lymphatic ascites after pelvic lymphadenectomy is a rare complication and is rarely reported after urologic surgery. We report a case of delayed and refractory lymphatic ascites following robotic-assisted laparoscopic radical prostatectomy.

Objective To report the functional results of continent cutaneous ileal urinary diversion using modified W-pouch with non-isolated extra limb for continence. Patients and Methods From January 2013 to January 2016, 21 patients with muscle-invasive bladder cancer with median (interquartile range) of 59 (56.5-62.5) years old underwent radical cystectomy with pelvic lymphadenectomy; they then had an ileal continent cutaneous pouch constructed from W-pouch with non-isolated extra limb for continence. The technique entails the creation of a detubularized ileal W-pouch with extra limb fashioned from 59 cm of the terminal ileum. This extra limb is not isolated from the pouch. The proximal part of this limb is tailored and fixed in a subserous extramural tunnel for continence, whereas the distal part is left continuous with the pouch. The median (interquartile range) of follow up was 12 (8-17) months. Evaluation of the technique included operative time, continence efficiency, overall complications, and quality of life questionnaire for the patients. Results The median (interquartile range) of operative time of the operation was 4.7 (3.9-5.4) hours. The median (interquartile range) of operative time of the cutaneous pouch creation was 39 (33-43) minutes. No perioperative mortality had occurred. The incidence of continence was 95.2%. The overall complications were 42.8%, and most of them were grade 1 or 2 on Clavien-Dindo classification system. Conclusion Modification of W-pouch with non-isolated extra limb as continent cutaneous pouch can simplify the technique and shorten the operative time with efficient continence, less side effects, and good quality of life.

We present the first published case of a pediatric robot-assisted prostatectomy and pelvic lymphadenectomy for refractory prostatic embryonal rhabdomyosarcoma. The patient is a 7-year-old male who had been treated with 3 cycles of chemotherapy and radiation, who underwent prostatectomy and lymphadenectomy for a recurrent mass. Surgery was uncomplicated and yielded negative surgical margins. We highlight the surgical technique and feasibility of utilizing robotic surgery for pediatric prostatectomy.

OBJECTIVES The number of lymph nodes obtained through lymphadenectomy during radical cystectomy has prognostic and therapeutic value. We analyzed the number of nodes obtained during laparoscopic radical cystectomy to assess whether this approach allows satisfactory lymphadenectomy. METHODS A total of 80 consecutive laparoscopic radical cystectomies with lymphadenectomy were performed by the same surgical team from 2005 to 2008. The male/female ratio was 5.7: 1, the mean age was 65.3 years (range 47-87), and average body mass index was 26.7 kg/m(2) (range 20.6-40.1). Iliac-obturator lymphadenectomy up to the aortic bifurcation was performed after excising and pocketing the bladder. We analyzed the total number of lymph nodes identified by the pathologist and investigated a possible correlation with the variables presumably related to anatomic characteristics and other circumstances. RESULTS The mean operative time of this step was 32 minutes (range 17-70). Minor vascular morbidity was present in 5 cases (6.25%). The average number of lymph nodes obtained was 22.3 (range 7-74, median 21). In 75 cases (93.8%), >= 10 nodes were obtained, and in 33 cases (41.2%), lymph node metastasis was diagnosed. No association or correlation was found in the number of nodes extracted regarding age, body mass index, or number of positive nodes. Also, no differences were found in association with gender, use of induction therapy, or the indication for cystectomy. CONCLUSIONS Laparoscopic lymphadenectomy performed at radical cystectomy achieved an adequate number of lymph nodes. This technique did not entail an important increase in the duration of surgery. The complication rate was low. In experienced hands, laparoscopic lymphadenectomy is feasible and seems a secure oncologically correct procedure. UROLOGY 76: 759-763, 2010. (C) 2010 Elsevier Inc. 2.334 JCR (2010) Q2, 26/69 Urology & nephrology

In a mini-laparotomy staging pelvic lymphadenectomy mini-lap) a 6-cm lower midline abdominal incision is used to perform a complete pelvic lymphadenectomy. If the pelvic lymph nodes were positive for prostate cancer, the incision was closed without pelvic drains. If the pelvic lymph nodes were clinically negative for disease, the incision was extended, and a radical retropubic prostatectomy was done under the same anesthetic. The minilap was performed on 16 patients. Three patients who had grossly positive pelvic lymph nodes confirmed by frozen section examination were denied a radical retropubic prostatectomy and had a two to three-day hospital stay. The other 13 patients had an uneventful radical retropubic prostatectomy. We conclude that the minilap is an attractive alternative for patients requiring staging pelvic lymphadenectomy.

Pelvic lymphadenectomy is the final staging procedure before institution of therapy patients with clinically locally confined adenocarcinoma of the prostate, a normal acid phosphatase and a bone scan free of metastatic disease. The pathologic information it provides cannot be accurately acquired at the present time by any other method. Extraperitoneal lymphadenectomy is associated with some morbidity intraoperatively and in the early postoperative period. We enumerate our results with 284 extraperitoneal lymphadenectomies.

A 61-year-old man with bilateral Gleason score 7 (3+4) clinical Stage T1c prostate cancer was treated with laparoscopic bilateral pelvic lymphadenectomy and radical prostatectomy. The left obturator nerve was inadvertently transected during left obturator lymph node dissection and repaired by laparoscopic reapproximation.

A case of obturator nerve injury with delayed manifestation following laparoscopic pelvic lymphadenectomy is presented. While the incidence of obturator nerve injury does not appear to differ between open surgical and laparoscopic approaches, the laparoscopic approach demands unequivocal visualization of the nerve when utilizing electrocautery because of the risk of nerve injury from thermal conduction through apposed tissues.

During a seven-year period 202 patients with primary bladder cancer had radical cystectomy with bilateral pelvic lymphadenectomy and urinary diversion. Lymph node metastases were found in 28.7 per cent. No significant differences in overall survival owing to age were apparent. Only extension and grade of histopathologic differentiation of the tumor proved to be an important prognostic factor. The five-year survival rates for p T1, p T2, p T3, and p T4 tumors were 76, 56, 19, and 0 per cent, respectively. In patients with deep invasive (T3 and T4) tumors no significant differences of survival rate depending on N and M categories were found. Nevertheless in pT3 tumors the probability of remaining alive was significantly decreased in those patients with histologic grade 3 compared with grade 2 tumors (P < 0.01). The prognosis for patients submitted to radical cystectomy for bladder cancer has been classified as (1) good: tumors confined to superficial muscle (pT1 and pT2); (2) intermediate: tumors mildly differentiated infiltrating the deep muscle (pT3G2); (3) fairly poor: tumors undifferentiated infiltrating deep muscle (pT3G3); and (4) poor: adjacent invasive bladder tumors (pT4).

We analyzed the operative experience and postoperative and late complications of pelvic lymphadenectomy and radical retropubic prostatectomy in 27 consecutive cases in which the modifications of prostatectomy described by Walsh were employed, and compared the results with those of 29 cases performed in the preceding three years when the Campbell technique of prostatectomy was employed. The mean operative time, mean blood loss, and incidences of early postoperative complications and incontinence were less for patients treated with the Walsh technique than with the Campbell technique. After surgery 85 per cent of evaluable patients remained potent with the Walsh technique compared with 16 per cent of patients treated with the Campbell technique. Although other factors besides operative approach may have biased our results, we are persuadec that the innovations of radical retropubic prostatectomy detailed by Walsh constitute importani advances in surgical technique, and we now use this procedure in all suitable patients electing treatment by radical prostatectomy for localized prostatic cancer.

The complications experienced by 205 consecutive patients who underwent bilateral pelvic lymphadenectomy and radical retropubic prostatectomy for surgical Stages C and D1 prostate cancer were analyzed. One hundred five patients had pathologic Stage C disease, and 100 patients had pathologic Stage D1 disease. Seven patients had thromboembolic complications. Wound or pelvic hematomas developed in 6 patients. Only two lymphoceles were detected. Rectal injuries occurred in 6 patients, of whom 4 required colostomies. The overall incidence of perioperative complications was 17 per cent. There was one postoperative death.

All patients who underwent pelvic lymphadenectomy for prostatic carcinoma over a five-year period were reviewed to evaluate the effect of minidose heparin prophylaxis on lymphocele formation and postoperative complications. The overall incidence of complications was found to be consistent with that reported in the current literature. However, when the rate of lymphocele occurrence was correlated with perioperative minidose heparin therapy, the incidence rose from 2.5 per cent in those receiving no heparin to 38 per cent in patients receiving both pre- and postoperative prophylactic heparinization. Other major postoperative complications were also significantly increased when minidose heparin was pre- or postoperatively administered. A strong recommendation is made for caution in the routine use of prophylactic low-dose heparin during pelvic surgery.

A series of 105 patients with surgical Stage C adenocarcinoma of the prostate underwent pelvic lymphadenectomy and radical retropubic prostatectomy and were followed up from one and one-half to fifteen years; 33 (31%) of the 105 had clinical Stage C disease. Of the 105 patients, 92 were at risk for greater than or equal to two years, 42 for greater than or equal to five years, and 12 for greater than or equal to ten years. Survival and disease progression were related to tumor grade (Mayo grades 1 through 4) and tumor bulk (less than 3, 3 to 10, greater than 10 cm3) but not to seminal vesicle involvement. Twenty-seven patients received adjuvant treatment (orchiectomy, DES, radiation, or combinations of these); it was administered to patients with higher tumor grades, larger tumor bulk, and/or residual cancer. Overall actuarial survival at five and ten years was 85 per cent and 72 per cent, respectively; five-year nonprogression rate was 64 per cent. Local recurrence was noted in only 8 patients (7.6%). Radical surgical treatment for nonbulky Stage C disease of the prostate is associated with favorable survival results and good local control. Adjuvant treatment may favorably affect disease outcome. Clinical seminal vesicle involvement with negative urethrocystoscopy should not necessarily deter the surgeon from planning radical prostatectomy. Prospective adjuvant treatment protocols need to be developed to identify the value of adjuvant hormone and/or radiation therapy.

Pelvic lymphadenectomy is used widely for staging prostatic or bladder carcinoma. In 9 of 187 patients (4.7 per cent) who underwent bilateral pelvic lymphadenectomy for urologic cancer pelvic lymphocele diveloped. The management of these patients is presented along with review of causes, clinical features, diagnosis, and treatment. Pelvic CT scan is a noninvasive modality which aids in the diagnosis of this complication. Minidose heparin used for prophylaxis of thromboembolic complications may increase lymphocele formation.

Single-stage radical cystectomy without pelvic lymphadenectomy and ileal conduit urinary diversion was performed on 241 consecutive patients over a three and one-half-year period. Operative mortality rate was 2.5 per cent; early and late complications occurred in 32 and 34 percent of patients, respectively. In general, complications were less severe than in the past. Wound complications remain a major source of morbidity, but wound disruption and anastomotic leaks have been virtually eliminated.

Pelvic lymphadenectomy was performed in 187 patients as a staging procedure for carcinoma of the prostate. Clinical impression of lymph nodes during dissection appears to be inaccurate in a large number of patients. We therefore believe that if radical surgery is planned for clinically localized tumor, the histologic status of the removed nodes should be confirmed before surgical extirpation of the tumor.

A retrospective comparison of patients undergoing pelvic lymphadenectomy and iodine-125 implantation for localized prostatic cancer was undertaken. A control group of 276 patients was compared with 105 patients in a mini-dose heparin group. No protective benefit in the prevention of thromboembolic events was demonstrated. Operative and postoperative complications are reviewed.

A technique for sequential, unilateral, extraperitoneal pelvic lymphadenectomy is described. The procedure is advocated for staging patients with localized prostatic carcinoma in whom all laboratory test results for metastases are negative and in whom definitive radiation therapy or radical prostatectomy is contemplated. This procedure allows complete excision of the regional lymphatic drainage of the prostate with minimal surgical morbidity.

The clinical course of 75 males subjected to radical prostatectomy after pelvic lymphadenectomy were compared with that of 29 males receiving radical prostatectomy without lymphadenectomy. The adverse survival impact of positive pelvic nodes and the impact of pelvic lymphadenectomy are discussed.

Pelvic lymphadenectomy was accomplished in 75 patients with localized prostatic cancer at the time of retropubic prostatic implantation with iodine-125. Twelve (16 per cent) surgical complications were encountered in 11 patients and included 1 death. Late complications which persisted six months or longer occurred in 5 (8 per cent) of 61 patients. The most serious and as yet unquantitated complication appears to be pelvic vein thrombosis and pulmonary emboli. Pelvic lymphadenectomy may be accomplished safely and with minimal morbidity in the vast majority of prostatic cancer patients.

Pelvic lymphadenectomy as a staging procedure in clinically apparent prostatic adenocarcinoma has long been recognized and its value appreciated. Twenty-three recent cases from the University of Colorado of clinically unapparent carcinoma of the prostate were studied with this modality, 5 Stage A1 and 18 Stage A2 tumors. Four of the 18 Stage A2 tumors but none of the A1 lesions after negative staging procedures revealed metastatic disease to the pelvic lymph nodes. Our experience indicated this modality should be employed in selected cases of incidental adenocarcinoma of the prostate.

Insertion of either a semirigid or inflatable penile prosthesis at the completion of surgery for various malignancies was performed. Twelve men had implants and were followed at least one year with excellent results. Careful preoperative sexual counseling with the patient's spouse is recommended and adds immeasurably to the mental well-being of the patient in the postoperative period. Penile prostheses can be placed easily after radical cystectomy, radical prostatectomy (perineal or retropubic), urethrectomy, and bilateral orchiectomy. Penile prosthesis placement may also be recommended for patients with less than adequate erectile function who may be undergoing pelvic lymphadenectomy with 1251 implantation for prostatic carcinoma.

A retrospective review of 100 patients undergoing pelvic lymphadenectomy alone or with additional surgery was done to assess the morbidity and to help identify factors contributing to a high wound morbidity. Major wound morbidity occurred in 8 per cent of patients, while 16 per cent had minor wound problems. Factors contributing to wound morbidity included urinary tract infection, altered metabolic states, and the use of wound drains. Other morbid events are tabulated.