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Extended Pelvic Lymph Node Dissection (ePLND) remains the most accurate technique for the detection of occult lymph node metastases (LNMs) in prostate cancer (CaP) patients. Here we aim to examine whether free-Indocyanine Green (F-ICG) could accurately assess the pathological nodal (pN) status in CaP patients during real-time lymphangiography as a potential replacement for ePLND.219 consecutive patients undergoing F-ICG-guided PLND, ePLND and radical prostatectomy (RP) for clinical-localized CaPwere included in this prospective single-center study. The pathological outcomes of F-ICG-guided PLND were compared to confirmatory ePLND. Parameters of a binary diagnostic test for the proper classification of the pN status of patients ('per-patient' analysis) and for the probability of detecting all the metastatic LNs ('per-node' analysis) were calculated. Outcome measures were prevalence, accuracy (Acc), sensitivity (Se), negative predictive value (NPV), and likelihood ratio of a negative F-ICG-guided PLND test result [LR(-)].F-ICG-guided PLND successfully visualized LNs in all procedures with no adverse events. The overall per-patient F-ICG staging Acc was 97.7%, Se was 91.4%, with a NPV of 97.0%, and LR(-) of 8.6%. At the overall per-node level, 4,780 LNs were removed and 1,535 (32.1%) were fluorescent in vivo. F-ICG-guided PLND identified LNMs with a Se of 63.4%.This study confirms that F-ICG-guided lymphangiography correctly staged almost 98% of patients. The high per-patient NPV suggested that avoiding ePLND is safe for most patients when F-ICG stained nodes were pN0. Thus, more conservative approaches might minimise perioperative morbidity during LNMs diagnosis in selected patients.

Purpose To systematically review the relevant literature that evaluates the LN topographical distribution and propose a uniform template. Methods A bibliographic search of PubMed/Medline, Embase and SCOPUS was performed for studies reporting data of LN imaging and/or nodal resection. Results 101 and 26 articles met the inclusion criteria for PCa and BCa, respectively. In PCa, the most common locations of positive LNs for surgical and imaging studies were external iliac (both 38 studies), followed by obturator (38 and 37, respectively). Similarly, in BCa, the most common location of positive nodes for surgical and imaging studies were external iliac (19 and 4, respectively), followed by obturator (15 and 3 studies, respectively). In PCa, median percentages of positive external iliac nodes/patient were 12.2% and 11.6% for surgical and imaging studies, respectively while corresponding rates for BCa were 3.9% and 17.6%. There were high risks of bias across studies as well as high heterogeneity in the definition of the anatomic boundaries of lymphadenectomy templates. ConclusionsThis review highlights the lack of detailed information on exact LN templates and metastases location, which in turn hinders generation of high-quality evidence on optimal lymphadenectomy templates. Our proposed template is applicable for both imaging and surgical description and could facilitate the translation of anatomical location from imaging to surgical resection.

INTRODUCTION AND OBJECTIVE: Current standard imaging procedures have limited ability to predict lymph node (LN) involvement in clinically localized prostate cancer (PCa) and extended pelvic lymph node dissection (ePLND) during radical prostatectomy (RP) remains the most accurate staging procedure. However, meticulous ePLND is time-consuming and associated with an increased risk of morbidity. In order to improve these aspects, sentinel LN mapping with different guided techniques has been proposed over the years. The primary aim of this study is to evaluate the effectiveness of indocyanine green (ICG)-guided ePLND to assess regional LN status in patients who underwent RP. Secondary objective is to evaluate the potential role of a selective ICG lymph node dissection (LND) in patients with ≤ 2 LN metastasis which according to the literature are those who may more benefit from ePLND. METHODS: Data about 226 consecutive patients underwent laparoscopic RP with ICG-guided ePLND at our Department were prospectively evaluated. A solution of 25 mg ICG in 5 ml sterile water was transperineally injected. PLND started with the ICG stained nodes followed by extended template. Primary outcome measures were sensitivity (S), negative predictive value (NPV) and likelihood ratio of a negative test (LRn) of ICG-guided procedure. To our knowledge this study shows data about the largest cohort of patients underwent ICG-guided ePLND. RESULTS: Overall, median age of patients was 64.8 years with a median PSA of 6.6 ng/ml. Extracapsular disease occurred in 50.9% of patients, Gleason score ≥ 8 was reported in 11.9% cases and positive surgical margins rate was 24.3%. Median number of nodes retrieved was 22 (IQR 16-27) and median number of ICG stained per patient nodes was 6 (IQR 4-9). Overall 4939 nodes were removed and 1599 (32.4%) were fluorescent in vivo. Node-positive disease was found in 58 (25.7%), of which 53 (91.4%) had some of the metastatic LNs stained by ICG, while 5 (8.6%) were false negative. Therefore 97.8% of the sample was properly classified by ICG-guided ePNLD (S: 91.4%, NPV: 97.1% and LRn: 8.6%). Considering 209 (92.5%) patients with 0, 1 or 2 metastatic LNs, 39 (18.7%) had a node-positive disease of which 34 (87.2%) had metastatic ICG stained LNs. Again, 97.6% were properly classified by ICG approach (S: 87.2%, NPV: 97.1% and LRn: 12.8%). These 39 node-positive patients had a total of 48 metastatic LNs and all except 9 (18.8%) were fluorescent in vivo (S: 81.2%). CONCLUSIONS: ICG guidance correctly stage 97% of cases. Furthermore, its high NPV will allow to avoid ePLND as soon as an accurate intraoperative analysis is available. Among those patients in whom the LND may have a potentially curative role, ICG alone would have lost only 9 metastatic LNs. This suggest that maybe there is a place for selective LND in patients with limited LN metastatic burden.

Objective: To compare the outcomes of robotic radical nephrectomy (RRN) to those of laparoscopic radical nephrectomy (LRN) for large renal masses. Methods: This was a retrospective analysis of RRN and LRN cases performed for large (≥ cT2) renal masses from 2004 to 2017 and collected in the multi-institutional international database (ROSULA: RObotic SUrgery for LArge renal masses). Peri-operative, functional, and oncologic outcomes were compared between each approach. Descriptive analyses were performed and presented as medians with interquartile ranges. Inverse probability of treatment weighting-adjusted multivariable analyses were used to identify predictors of peri-operative complications. Kaplan–Meier analysis and Cox regression models were used to assess survival outcomes. Results: A total of 941 patients (RRN = 404, LRN = 537) were identified. There was no difference in terms of gender, age, and clinical tumor size. Over the study period, RRN had an annual increase of 11.75% (95% CI [7.34, 17.01] p < 0.001) and LRN had an annual decline of 5.39% (95% CI [−6.94, −3.86] p < 0.001). Patients undergoing RRN had higher BMI (27.6 [IQR 24.8–31.1] vs. 26.5 [24.1–30.0] kg/m 2 , p < 0.01). Operative duration was longer for RRN (185.0 [150.0–237.2] vs. 126 [90.8–180.0] min, p < 0.001). Length of stay was shorter for RRN (3.0 [2.0–4.0] vs. 5.0 [4.0–7.0] days, p < 0.001). RRN cases presented more advanced disease (higher pathologic staging [pT3–4 52.5 vs. 24.2%, p < 0.001], histologic grade [high grade 49.3 vs. 30.4%, p < 0.001], and rate of nodal disease [pN1 5.4 vs. 1.9%, p < 0.01]). Surgical approach did not represent an independent risk factor for peri-operative complications (OR 1.81 95% CI [0.97–3.39], adjusted p = 0.2). The main study limitation is the retrospective design. Conclusions: This study represents the largest known multi-center comparison between RRN and LRN. The two procedures seem to offer similar peri-operative outcomes. Notably, RRN has been increasingly utilized, especially in the setting of more advanced and surgically challenging disease without increasing the risk of peri-operative complications.

Objective To compare outcomes of laparoscopic radical prostatectomy (LRP) performed in live surgery versus daily routine LRP. Methods From January 2014 to June 2017, data from LRP performed at our Institution in live broadcasting by 3 experienced laparoscopic surgeons during educational events were collected. A 1:2 matching (according to BMI, comorbidities, NCCN risk groups, and operating surgeon) was performed with the routine LRP patients collected in our prospectively-maintained database. Chosen procedures were performed within the same time span by the same surgeons. Data of interest were compared. Results Twenty-three live surgery LRPs were analyzed (Group A). Forty-six matched patients were the controls (Group B). Groups were comparable at baseline. No differences were found in perioperative data (operative time, blood loss, and intraoperative complications, 4.3% in both Groups) and postoperative complications. Particularly, 10 (43.5%) and 22 patients (47.8%) did not report complications (Group A vs B, respectively, P = .54). The majority of complications were Clavien 1-2, with 2 patients per Group requiring blood transfusion. Overall positive surgical margins rate was 26.1%. It was significantly higher in Group A (43.5% vs 17.4%; P = .02), but no differences were found in the number of patients who relapsed, who needed radiotherapy or androgen deprivation therapy within a median follow-up of 25 months in both Groups. No differences were found regarding functional data. Limitations include a low sample size and limited follow-up. Conclusion LRP has similar perioperative outcomes when performed in either live surgery or daily routine setting. We underline the higher positive surgical margins rate after live surgeries that should increase the awareness before embarking on it.