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Background: This study aimed to show the association between tumor location and laterality of positive lymph nodes by evaluating biopsy and magnetic resonance imaging (MRI) findings, and to optimize the extended pelvic lymph node dissection (ePLND) side for prostate cancer. Methods: The study enrolled patients who underwent robot-assisted radical prostatectomy with ePLND. Tumor locations were determined according to International Society of Urological Pathology grade group 4/5 in biopsies and Prostate Imaging–Reporting and Data System category 4/5 in MRI results. The concordance of tumor location lobe and positive lymph node side with the performance of tumor location-guided ePLND for positive lymph node detection was evaluated. Results: For 301 patients who underwent ePLND at Kyushu University Hospital, tumor locations determined by biopsy and MRI findings showed no lesion in 8 (2.7%) patients, unilateral lobe in 223 (74.1%) patients, and bilateral lobe in 70 (23.3%) patients. The accuracies for detection of any and all positive lymph nodes by tumor location-guided unilateral ePLND were 99.6% and 97.3%, respectively. Among the patients at St. Luke's International Hospital, the accuracies for detection of any and all positive lymph nodes by tumor location-guided unilateral ePLND were estimated to be 99.0% and 97.3%, respectively. Conclusions: This study proposed tumor location-guided ePLND according to biopsy and MRI findings. This novel strategy is expected to reduce the burden of bilateral ePLND at the cost of acceptable risk of failing to detect positive lymph nodes. [ABSTRACT FROM AUTHOR]

To compare the difference in perioperative outcomes between standard pelvic lymph node dissection (sPLND) and extended pelvic lymph node dissection (ePLND) in robot-assisted radical cystectomy (RARC) and evaluate the survival outcomes. The clinical data were retrospectively collected from patients who underwent RARC between January 2016 and December 2020 in Nanjing Drum Hospital. The patients were divided into sPLND and ePLND group according to the extent of pelvic lymph node dissection. Finally, 80 pairs of patients obtained for two groups by propensity score matching (PSM) and their perioperative and survival outcomes were analyzed. The median number of dissected lymph nodes (LN) after PSM was 13 in sPLND group and 16 in ePLND group (P = 0.004). Perioperative complications were similar between 2 groups. After PSM, ePLND improved 5-year RFS and OS in all patients (85.74 vs. 61.94%, P = 0.004; 82.80 vs. 67.50%, P = 0.033), patients with ≥ T3 disease (73.66 vs. 23.86%; P = 0.007; 68.20 vs. 36.20%; P = 0.032) and patients with LN metastasis (67.70 vs. 7.33%; P = 0.004; 60.60 vs. 16.67%; P = 0.045) compared to sPLND. Extended PLND significantly increased lymph node yield without increasing complication and improved RFS and OS compared to sPLND. [ABSTRACT FROM AUTHOR]

Purpose: Benefits of docetaxel-based neoadjuvant chemohormonal therapy (NCHT) before radical prostatectomy (RP) remain largely unknown. We explored whether docetaxel-based NCHT would bring pathological benefits and improve biochemical progression-free survival (bPFS) over neoadjuvant hormonal therapy (NHT) in locally advanced prostate cancer. Materials and Methods: A randomized trial was designed recruiting 141 locally advanced, high-risk prostate cancer patients who were randomly assigned at the ratio of 2:1 to the NCHT group (75 mg/m2 body surface area every 3 weeks plus androgen deprivation therapy for 6 cycles) and the NHT group (androgen deprivation therapy for 24 weeks). The primary end point was 3-year bPFS. Secondary end points were pathological response including pathological downstaging and minimal residual disease rates. Results: The NCHT group showed significant benefits in 3-year bPFS compared to the NHT group (29% vs 9.5%, P = .002). At a median follow-up of 53 months, the NCHT group achieved a significantly longer median bPFS time than the NHT group (17 months vs 14 months). No significant differences were found between the 2 groups in pathological downstaging and minimal residual disease rates. Conclusions: NCHT plus RP achieved significant bPFS benefits when compared with NHT plus RP in high-risk, locally advanced prostate cancer. A larger cohort with longer follow-up duration is essential in further investigation. [ABSTRACT FROM AUTHOR]

Objectives: To determine candidates for extended pelvic lymph node dissection using a novel nomogram to assess the risk of lymph node invasion in Japanese prostate cancer patients in the robotic era. Methods: A total of 538 patients who underwent robot‐assisted radical prostatectomy with extended pelvic lymph node dissection in three hospitals were retrospectively analyzed. Medical records were reviewed uniformly and the following data collected: prostate‐specific antigen, age, clinical T stage, primary and secondary Gleason score at prostate biopsy, and percentage of positive core numbers. Finally, data from 434 patients were used for developing the nomogram and data from 104 patients were used for external validation. Results: Lymph node invasion was detected in 47 (11%) and 16 (15%) patients in the development and validation set, respectively. Based on multivariate analysis, prostate‐specific antigen, clinical T stage ≥3, primary Gleason score, grade group 5, and percentage of positive cores were selected as variables to incorporate into the nomogram. The area under the curve values were 0.781 for the internal and 0.908 for the external validation, respectively. Conclusions: The present nomogram can help urologists identify candidates for extended pelvic lymph node dissection concomitant with robot‐assisted radical prostatectomy among patients with prostate cancer. [ABSTRACT FROM AUTHOR]

Sentinel node biopsy (SNB) for prostate cancer (PCa) represents an innovative technique aimed at improving nodal staging accuracy. The routinary adoption of this procedure in patients undergoing radical prostatectomy (RP) might be crucial to identify candidates who could effectively benefit from extensive pelvic lymph nodal dissection (ePLND). Despite some promising results, SNB for PCa is still considered experimental due to the lack of solid evidence and procedural standardization. In this regard, our narrative review aimed to analyze the most recent literature in this field, providing an overview of both the diagnostic accuracy measures and the oncological outcomes of SNB. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the impact of extended pelvic lymph node dissection (ePLND) on urinary incontinence (UI) at early post‐surgery robot‐assisted radical prostatectomy (RARP). Methods: Patients who underwent RARP without cavernous nerve sparing were included between 2014 and 2019. Patient data were obtained prospectively. The associations between ePLND and postoperative urinary continence were defined as a maximum of one daily pad use. International prostate symptom score (IPSS) was examined. Expression of synaptophysin and tyrosine hydroxylase (TH) in perilymph node adipose tissue (PLA) was evaluated by immunohistochemistry. Results: In total, 186 and 163 patients underwent RARP with and without ePLND. Urinary continence rate at 1 month postoperatively among patients with ePLND was lower than those without ePLND (24.1% vs. 35.1%, p < 0.05), however, not significantly different at 3, 6, and 12 months after RARP (57.4 vs. 62.6%, 73.1 vs. 74.2%, and 83.0 vs. 81.2%, respectively). Total and voiding plus postvoiding IPSS scores at 1 month were higher in patients with ePLND than in those without ePLND (14.5 ± 0.5 vs. 13.6 ± 0.6, 7.0 ± 0.3 vs. 6.2 ± 0.4, respectively, p < 0.05). In univariate and multivariate analyses, larger prostate volume and ePLND were factors associated with an increased UI rate. Among patients who underwent ePLND, synaptophysin and TH‐positive nerve fibers were detected in PLA. Conclusions: Detection of synaptophysin and TH‐immunopositive nerves suggested denervation of sympathetic and peripheral nerves caused by ePLND might be associated with a higher UI rate and poor urinary symptoms at an early stage after RARP. [ABSTRACT FROM AUTHOR]

Simple Summary: The indication for ePLND at the time of RP is based on a risk assessment of LNI through validated nomograms such as the MSKCC; Briganti 2012; Briganti 2017 and Briganti 2019. However, in daily practice, a relevant percentage of cases, including those with the high-risk disease, show no LNI at the final histopathological assay pathology (pN0) after ePLND. Furthermore, currently available evidence does not demonstrate the superiority of one nomogram over the others, and there is still lacking data to support the routine use of one predictive model over another, even in more aggressive diseases. Therefore, we evaluated the accuracy of the most used nomograms (MSKCC, Briganti 2012, Briganti 2017, and Briganti 2019) for predicting LNI and compared them in our sub-cohort of high-risk PC patients treated with ePLND. We found that the predictive performance of the four nomograms as well as their ability to avoid unnecessary ePLND, are virtually the same, even in high-risk PC patients. Background: The indication for extended pelvic lymph node dissection (ePLND) at the time of radical prostatectomy (RP) is based on nomograms predicting the risk of lymph node invasion (LNI). However, limited data are available on the comparison of these predictive models in high-risk prostate cancer (PC) patients. Therefore, we compared the accuracy of the most used nomograms (MSKCC, Briganti 2012, 2017, and 2019) in the setting of high-risk PC patients submitted to ePLND. Methods: 150 patients with high-risk PC disease treated from 2019 to 2022 were included. Before RP + ePLND, we assessed the MSKCC, Briganti 2012, 2017, and 2019 nomograms for each patient, and we compared the prediction of LNI with the final histopathological analysis of the ePLND using pathologic results as a reference. Results: LNI was found in 39 patients (26%), and 71.3% were cT2. The percentage of patients with estimated LNI risk above the cut-off was significantly higher in pN+ cases than in pN0 for all Briganti nomograms. The percentage of patients at risk of LNI, according to Briganti Nomogram (2012, 2017, and 2019), was significantly higher in pN+ cases than in pN0 (p < 0.04), while MSKCC prediction didn't vary significantly between pN0 and pN+ groups (p = 0.2). All nomograms showed high sensitivity (Se > 0.90), low specificity (Sp < 0.20), and similar AUC (range: 0.526–0.573) in predicting pN+. Particularly, 74% of cases patients with MSKCC estimated risk > 7% showed pN0 compared to 71% with Briganti 2012 > 5%, 69% with Briganti 2017 > 7%, and 70% with Briganti 2019 > 7%. Conclusions: Despite the high-risk disease, in our patients treated with ePLND emerges a still high number of pN0 cases and a similar low specificity of nomograms in predicting LNI. [ABSTRACT FROM AUTHOR]

Introduction: Although several clinical guidelines for prostate cancer (PC) recommend extended pelvic lymph node dissection (ePLND) during radical prostatectomy for high‐risk cases, there are several issues to consider, including certain technical aspects. A simplified approach to the medial internal iliac region and paravesical arteries has not been established. The uretero‐hypogastric nerve fascia (UHF) envelopes the ureter, hypogastric nerve, and pelvic autonomic nerves. To preserve the UHF, it is possible to approach the medial side of the internal iliac vessels without injuring any important tissue. We analyzed technical feasibility and lymph node (LN) yields. Patients and methods: After obtaining institutional review board approval, 265 high‐risk PC patients with ePLND were identified. A da Vinci S or Xi robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used. We divided the patients into conventional (non‐UHF) method and modified (UHF) groups. The numbers of LNs removed, procedure‐related complications, and surgical outcomes were analyzed. Results: The median number of LNs removed was 19.0 in the non‐UHF group and 22.0 in the UHF group (p = 0.004). Significantly more LNs were removed from the internal iliac region in the UHF group (p = 0.042). There was no difference in overall operative, console, or LN dissection time, or the severe complication rate (Clavien‐Dindo grade ≥ III), between the non‐UHF and UHF groups. Conclusions: Our simplified approach using the UHF development technique is technically feasible, has no major complications, and allows for the removal of significantly more LNs compared with the conventional method. [ABSTRACT FROM AUTHOR]

Objectives: We investigated the diagnostic and therapeutic benefits of limited or extended pelvic lymph node dissection during a robot‐assisted radical prostatectomy for localized prostate cancer. Methods: Diagnostic and therapeutic benefits were assessed according to the rates of pN1 and biochemical recurrence, respectively. The primary outcome was the biochemical recurrence‐free rate, and secondary outcomes included the diagnostic and therapeutic benefits of pelvic lymph node dissection. Results: A total of 534 patients were analyzed. Out of the 534 patients, 207 (38.8%) received limited pelvic lymph node dissection while 134 (25.1%) received extended dissection. There were 297 patients with a Briganti index ≥5%. Extended dissections yielded significantly more resected lymph nodes (p < 0.0001), and 72.2% of cases of pN1 were located outside the obturator. The incidence rate of pN1 was 6.1%, and performance of extended lymph node dissection was an independent predictor for pN1 (odds ratio 9.0, 95% confidence interval 2.5–33.1). The rate of biochemical recurrence was 14.9%, and Cox proportional hazards regression analysis of the propensity score matched population revealed that patients with high or very‐high risk tended to benefit from limited lymph node dissection (hazard ratio 8.4, 95% confidence interval 0.8–82.3) while the therapeutic benefit of extended dissection was unclear by comparison. Conclusions: Extended pelvic lymph node dissection significantly improves diagnostic accuracy; however, the therapeutic benefit of pelvic lymph node dissection was not observed in this study. [ABSTRACT FROM AUTHOR]

A prospective randomized study on a new technique preventing lymphocele formation after radical prostatectomy with extended pelvic lymph node dissection shows promising results. 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. 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. 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. 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. 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. 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). 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. 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. [ABSTRACT FROM AUTHOR]

Abstract Background Patients with very‐high‐risk prostate cancer (VHRPCa) have earlier biochemical recurrences (BCRs) and higher mortality rates. It remains unknown whether extended robot‐assisted laparoscopic prostatectomy (eRALP) without neoadjuvant or adjuvant therapy can improve the outcomes of VHRPCa patients. We aimed to determine the feasibility and efficacy of eRALP as a form of monotherapy for VHRPCa. Methods Data from 76 men who were treated with eRALP without neoadjuvant/adjuvant therapy were analyzed. eRALP was performed using an extrafascial approach. Extended pelvic lymph node (LN) dissection (ePLND) included nodes above the external iliac axis, in the obturator fossa, and around the internal iliac artery up to the ureter. The outcome measures were BCR, treatment failure (defined as when the prostate‐specific antigen level did not decrease to

Sentinel node biopsy (SNB) for prostate cancer (PCa) represents an innovative technique aimed at improving nodal staging accuracy. The routinary adoption of this procedure in patients undergoing radical prostatectomy (RP) might be crucial to identify candidates who could effectively benefit from extensive pelvic lymph nodal dissection (ePLND). Despite some promising results, SNB for PCa is still considered experimental due to the lack of solid evidence and procedural standardization. In this regard, our narrative review aimed to analyze the most recent literature in this field, providing an overview of both the diagnostic accuracy measures and the oncological outcomes of SNB.

Objective: The aim of this study is to evaluate the influence of endogenous testosterone density (ETD) on features of aggressive prostate cancer (PCa) in intermediate-risk disease treated with radical prostatectomy and extended pelvic lymph node dissection. Materials and Methods: Density measurements included the ratio of endogenous testosterone (ET), prostate-specific antigen (PSA), and percentage of biopsy positive cores (BPC) on prostate volume (ETD, PSAD, and BPCD, respectively). The ratio of percentage of cancer invading the gland (tumor load, TL) on prostate weight (TLD) was also calculated. Unfavorable disease (UD) was defined as tumor upgrading (ISUP >3) and/or upstaging (pT >2) and/or lymph node invasion (LNI). Associations of ETD with features of aggressive PCa, including UD and TLD, were evaluated by logistic and linear regression models. Results: Evaluated cases were 338. Subjects with upgrading, upstaging, and LNI were 61/338 (18%), 73/338 (21%), and 25/338 (7.4%), respectively. TLD correlated with UD (Pearson's correlation coefficient, r = 0.204; p < 0.0001), PSAD (r = 0.342; p < 0.0001), BPCD (r = 0.364; p < 0.0001), and ETD (r = 0.214; p < 0.0001), which also correlated with BMI (r = −0.223; p < 0.0001), PSAD (r = 0.391; p < 0.0001), and BPCD (r = 0.407; p < 0.0001). TLD was the strongest independent predictor of UD (OR = 2.244; 95% CI = 1.146–4.395; p = 0.018). In the multivariate linear regression model predicting BPCD, ETD was an independent predictor (linear regression coefficient, b = 0.026; 95% CI: 0.016–0.036; p < 0.0001) together with PSAD (b = 1.599; 95% CI: 0.863–2.334; p < 0.0001) and TLD (b = 0.489; 95% CI: 0.274–0.706; p < 0.0001). According to models, TLD increased as ETD increased accordingly, but mean ET levels were significantly lower for patients with UD. Conclusions: As ETD measurements incremented, the risk of large tumors extending beyond the prostate increased accordingly, and patients with lower ET levels were more likely to occult UD. The influence of ETD on PCa biology should be addressed by prospective studies. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the influence of endogenous testosterone density (ETD) on pelvic lymph node invasion (PLNI) in high risk (HR) prostate cancer (PCa) treated with radical prostatectomy (RP) and staged with extended pelvic lymph node dissection (ePLND). Materials and methods: ETD was evaluated as the ratio of endogenous testosterone (ET) on prostate volume (PV). HR-PCa was assessed according to the European Association of Urology (EAU) system. The association of ETD and other routinely clinical factors (BPC: percentage of biopsy positive cores; PSA: prostate specific antigen; ISUP: tumor grade system according to the International Society of Urologic Pathology; cT: tumor clinical stage) with the risk of PLNI was assessed by the logistic regression model. Results: Overall, 201 out of 805 patients (24.9%) were classified HR and PLNI occurred in 42 subjects (20.9%). On multivariate analysis, PLNI was independently predicted by BPC (OR 1.020; 95% CI 1.006–1.035; p = 0.019), ISUP > 3 (OR 2.621; 95% CI 1.170–5.869; p = 0.019) and ETD (OR 0.932; 95% CI 0.870–0.999; p = 0.045). After categorizing continuous clinical predictors, the risk of PLNI was independently increased by ETD up to the median (OR 2.379; 95% CI 1.134–4.991; p = 0.022), BPC > 50% (OR 3.125; 95% CI 1.520–6.425; p = 0.002) as well as by ISUP > 3 (OR 2.219; 95% CI 1.031–4.776; p = 0.042). Conclusions: As ETD measurements decreased, patients were more likely to have PLNI. In HR disease with PLNI, the influence of PCa on ETD should be addressed by higher level studies. [ABSTRACT FROM AUTHOR]

Background: Patients with very‐high‐risk prostate cancer (VHRPCa) have earlier biochemical recurrences (BCRs) and higher mortality rates. It remains unknown whether extended robot‐assisted laparoscopic prostatectomy (eRALP) without neoadjuvant or adjuvant therapy can improve the outcomes of VHRPCa patients. We aimed to determine the feasibility and efficacy of eRALP as a form of monotherapy for VHRPCa. Methods: Data from 76 men who were treated with eRALP without neoadjuvant/adjuvant therapy were analyzed. eRALP was performed using an extrafascial approach. Extended pelvic lymph node (LN) dissection (ePLND) included nodes above the external iliac axis, in the obturator fossa, and around the internal iliac artery up to the ureter. The outcome measures were BCR, treatment failure (defined as when the prostate‐specific antigen level did not decrease to <0.1 ng/ml postoperatively), and urinary continence (UC). Kaplan–Meier, logistic regression, and Cox proportional‐hazards model were used to analyze the data. Results: The median operative time was 246 min, and median blood loss was 50 ml. Twenty‐one patients experienced postoperative complications. Median follow‐up was 25.2 months; 19.7% of patients had treatment failure. Three‐year, BCR‐free survival rate was 62.0%. Castration‐resistant prostate cancer‐free survival rate was 86.1%. Overall survival was 100%. In 55 patients who had complete postoperative UC data, 47 patients (85.5%) recovered from their UC within 12 months. Clinical stage cT3b was an independent preoperative treatment failure predictor (p = 0.035), and node positivity was an independent BCR predictor (p = 0.037). The small sample size and retrospective nature limited the study. Conclusions: This approach was safe and produced acceptable UC‐recovery rates. Preoperative seminal vesicle invasion is associated with treatment failure, and pathological LN metastases are associated with BCR. Therefore, our results may help informed decisions about neoadjuvant or adjuvant therapies in VHRPCa cases. Precis: Extended robot‐assisted laparoscopic prostatectomy and extended pelvic lymph node dissection without adjuvant therapy is safe and effective for some patients with very‐high‐risk prostate cancer. The clinical stage and node positivity status predicted monotherapy failure, which may indicate good adjuvant therapy candidate. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the impact of using clinical stage assessed by multiparametric magnetic resonance imaging (mpMRI) on the performance of two established nomograms for the prediction of pelvic lymph node involvement (LNI) in patients with prostate cancer. Patients and Methods: Patients undergoing robot‐assisted extended pelvic lymph node dissection (ePLND) from 2015 to 2019 at three teaching hospitals were retrospectively evaluated. Risk of LNI was calculated four times for each patient, using clinical tumour stage (T‐stage) assessed by digital rectal examination (DRE) and by mpMRI, in the Memorial Sloan Kettering Cancer Centre (MSKCC; 2018) and Briganti (2012) nomograms. Discrimination (area under the curve [AUC]), calibration, and the net benefit of these four strategies were assessed and compared. Results: A total of 1062 patients were included, of whom 301 (28%) had histologically proven LNI. Using DRE T‐stage resulted in AUCs of 0.71 (95% confidence interval [CI] 0.70–0.72) for the MSKCC and 0.73 (95% CI 0.72–0.74) for the Briganti nomogram. Using mpMRI T‐stage, the AUCs were 0.72 (95% CI 0.71–0.73) for the MSKCC and 0.75 (95% CI 0.74–0.76) for the Briganti nomogram. mpMRI T‐stage resulted in equivalent calibration compared with DRE T‐stage. Combined use of mpMRI T‐stage and the Briganti 2012 nomogram was shown to be superior in terms of AUC, calibration, and net benefit. Use of mpMRI T‐stage led to increased sensitivity for the detection of LNI for all risk thresholds in both models, countered by a decreased specificity, compared with DRE T‐stage. Conclusion: T‐stage as assessed by mpMRI is an appropriate alternative for T‐stage assessed by DRE to determine nomogram‐based risk of LNI in patients with prostate cancer, and was associated with improved model performance of both the MSKCC 2018 and Briganti 2012 nomograms. [ABSTRACT FROM AUTHOR]

Abstract Background Formation of an internal hernia beneath a skeletonized pelvic vessel after pelvic lymph node dissection is extremely rare. We report a case of an internal hernia formation beneath the left external iliac artery after a robotic-assisted laparoscopic prostatectomy with extended pelvic lymph node dissection. Case presentation A 72-year-old man visited our hospital complaining of severe lower abdominal pain. On physical examinations, his abdomen was distended and tympanitic with rebound tenderness and muscular defense. Abdominal non-enhanced computed tomography showed a small bowel obstruction with marked ascites. A coronal non-enhanced computed tomography image revealed thickened loops of small bowel with surrounding mesenteric edema in the left lower quadrant. Enhanced computed tomography was not performed because we decided to perform urgent surgery with a diagnosis of strangulated small bowel obstruction based on physical examination and the computed tomography findings. The patient underwent urgent laparotomy at which time bloody ascites was seen in the peritoneal cavity. The ileum, which was approximately 60 cm proximal to the ileocecal junction, formed a closed loop beneath the left external iliac artery. The incarcerated ileum, 120 cm in length, appeared non-viable with a color change of the ileum to black. We therefore resected the strangulated ileum for a length of 120 cm and performed a functional end-to-end anastomosis. The orifice beneath the left external iliac artery was about 4 cm in diameter. We did not close the orifice because of the risk of injuring the left iliac artery. The postoperative course was uneventful, and the patient was discharged from our hospital 10 days after surgery. Presently, the patient is doing well 5 months after surgery without recurrent disease. Conclusion We report an extremely rare case of internal hernia formation beneath the left external iliac artery after a robotic-assisted laparoscopic prostatectomy with extended pelvic lymphadenectomy. Awareness of such complication and early surgical treatment are important when treating patients with this rare occurrence.

Objective: In patients with intermediate- and high-risk localized prostate cancer (PCa), improving the detection of occult lymph node metastases could play a pivotal role for therapeutic counseling and planning. The recent literature shows that several clinical factors may be related to PCa aggressiveness. The aim of this study is to investigate the potential associations between clinical factors and the risk of multiple lymph node invasion (LNI) in patients with intermediate- and high-risk localized PCa (cT1/2, cN0, and ISUP grading group >2 and/or prostate-specific antigen (PSA) >10 ng/mL) who underwent radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND). Materials and Methods: In a period ranging from January 2014 to December 2018, 880 consecutive patients underwent RP with ePLND for PCa. Among these, 481 met the inclusion criteria and were selected. Data were prospectively collected within an institutional dataset and retrospectively analyzed. Age (years), body mass index (BMI; kg/m2), PSA (ng/mL), prostate volume (mL), and biopsy positive cores (BPC; %) were recorded for each case. BMI and BPC were considered continuous and categorical variables, respectively. The logistic regression models evaluated the association of clinical factors with the risk of nodal metastases. Results: LNI was detected in 73/418 patients (15.2%) of whom 40/418 (8.3%) harbored multiple LNI (median 2, IQR: 3–4). On multivariate analysis, BMI was independently associated with the risk of multiple LNI in the pathological specimen when compared with patients without LNI (OR = 1.147; p = 0.018), as well as the percentage of biopsy positive cores (OR = 1.028; p < 0.0001) and European Association of Urology high-risk class (OR = 5.486; p < 0.0001). BMI was the only predictor of multiple LNI when compared with patients with 1 positive node (OR = 1.189, p = 0.027). Conclusions: In intermediate- and high-risk localized PCa, BMI was an independent predictor of the risk of multiple lymph node metastases. The inclusion of BMI within LNI risk calculators could be helpful, and a detailed counseling in obese patients should be required. [ABSTRACT FROM AUTHOR]

Purpose: Benefits of docetaxel-based neoadjuvant chemohormonal therapy (NCHT) before radical prostatectomy (RP) remain largely unknown. We explored whether docetaxel-based NCHT would bring pathological benefits and improve biochemical progression-free survival (bPFS) over neoadjuvant hormonal therapy (NHT) in locally advanced prostate cancer., Materials and Methods: A randomized trial was designed recruiting 141 locally advanced, high-risk prostate cancer patients who were randomly assigned at the ratio of 2:1 to the NCHT group (75 mg/m 2 body surface area every 3 weeks plus androgen deprivation therapy for 6 cycles) and the NHT group (androgen deprivation therapy for 24 weeks). The primary end point was 3-year bPFS. Secondary end points were pathological response including pathological downstaging and minimal residual disease rates., Results: The NCHT group showed significant benefits in 3-year bPFS compared to the NHT group (29% vs 9.5%, P = .002). At a median follow-up of 53 months, the NCHT group achieved a significantly longer median bPFS time than the NHT group (17 months vs 14 months). No significant differences were found between the 2 groups in pathological downstaging and minimal residual disease rates., Conclusions: NCHT plus RP achieved significant bPFS benefits when compared with NHT plus RP in high-risk, locally advanced prostate cancer. A larger cohort with longer follow-up duration is essential in further investigation.

Objectives: To evaluate the effectiveness of indocyanine green‐guided extended pelvic lymph node dissection during robot‐assisted radical prostatectomy for intermediate‐ to high‐risk prostate cancer. Materials and methods: After institutional review board approval, between July 2017 and December 2018, we carried out 100 indocyanine green‐guided extended pelvic lymph node dissections in patients with localized intermediate‐ and high‐risk prostate cancer, using the Firefly (Novadaq Technologies, Mississauga, ON, Canada) and da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Indocyanine green was injected transrectally using ultrasound sonography before each surgery. Then, lymphatic drainage patterns and pathological findings were recorded. Results: Lymphatic drainage routes were successfully determined in 91 right‐sided and 90 left‐sided cases. Five main lymphatic pathways and sites were identified: (i) an internal route (57%); (ii) a lateral route (50%); (iii) a presacral route (20%); (iv) a paravesical artery site (20%); and (v) a pre‐prostatic site (5%). Lymph node metastasis was positive in 15 patients, with 44 pathologically confirmed metastatic lymph nodes. Metastatic fluorescent lymph nodes were found in 15 out of 44 lymph nodes (34.1%). For sentinel lymph node identification, the 34% sensitivity and 64.8% specificity rates were detected in regard to identification of lymph node metastasis. Conclusions: Lymphatic drainage patterns from the prostate can be identified and classified using indocyanine green‐guided extended pelvic lymph node dissections. Although the direct role of fluorescent lymph nodes in sentinel lymph node identification appears to be limited, the identification of lymphatic pathways could contribute to high‐quality extended pelvic lymph node dissection during robot‐assisted radical prostatectomy. [ABSTRACT FROM AUTHOR]

Introduction: Many publications detail the level and number of lymphadenectomies, whereas the timing of pelvic lymph node dissection (PLND) is infrequently discussed in the robot-assisted radical cystectomy (RARC) series. Aim: To determine the effects of performing PLND before or after cystectomy in totally intracorporeal RARC on operative outcomes. Material and methods: A total of 15 patients included in the study underwent RARC and intracorporeal orthotopic neobladder. Of these, 8 patients underwent PLND before cystectomy (group 1), whereas 7 underwent PLND after cystectomy (group 2). Demographic information, intraoperative data, and post-operative outcomes were recorded for each patient. Results: The mean ± SD age was 61.87 ±6.76 years. Overall mean operation time (OT) was 537.33 ±63.07 min. The mean EBL and hospitalization time were 322.33 ±69.92 ml and 13.87 ±5.2 days. The number of LN removed was 23.75 ±3.454 for group 1 and 13.71 ±6.873 for group 2 (p = 0.007). The postoperative pathological stages were: pT2(5), pT3(2), pT4(1) for group 1, pT2(4), pT3(2), pT4(1) for group 2. Surgical margins were negative in all patient. Overall complications occurred in 7 (46.6%) patients. Only the number of LN removed was statistically significant in favor of group 1 (p = 0.007). Mean follow-up was 15.87 months. Conclusions: Our initial experience with performing extended PLND (ePLND) before or after cystectomy in totally intracorporeal RARC appears to be favorable, with similar oncological results and acceptable complication rates. However, although the number of cases is too low for statistical evaluation, it seems to be advantageous to perform ePLND before cystectomy in terms of LN number and operation time. [ABSTRACT FROM AUTHOR]

The 2019 Briganti nomogram was developed to calculate the risk of lymph node invasion (LNI) and identify prostate cancer (PCa) patients diagnosed with magnetic resonance imaging (MRI)-targeted biopsy who should be considered for an extended pelvic lymph node dissection (ePLND). Since its implementation is still limited by lack of a formal external validation, we aimed to validate this tool in a large contemporary cohort. We identified 487 patients diagnosed using MRI-targeted with concomitant systematic biopsy who underwent radical prostatectomy (RP) and an anatomically defined ePLND at six centers. The external validity of the 2019 Briganti nomogram for estimating LNI risk was assessed via calibration, discrimination, and decision curve analyses (DCAs). A total of 38 (8%) patients had LNI at final pathology. The median number of nodes removed was 18 (interquartile range 14–24). On external validation, the 2019 Briganti nomogram had an area under the receiver operating characteristic curve (AUC) of 79%. Although there was some miscalibration, this was at predicted probabilities >35% and therefore outside the clinically relevant range. DCA demonstrated that the 2019 Briganti nomogram improved clinical risk prediction against LNI threshold probabilities of ≤30%. For a 7% cutoff, 273 (56%) ePLNDs would be spared and only 2.6% LNIs would be missed. The 2019 Briganti nomogram was characterized by higher AUC compared to the 2012 and 2017 Briganti nomograms and the Memorial Sloan Kettering Cancer Center risk calculator (79% vs 75% vs 65% vs 74%) and demonstrated the highest net benefit on DCA. This first multi-institutional validation of the 2019 Briganti nomogram in predicting LNI in PCa patients diagnosed with MRI-targeted biopsy confirms the highest AUC, better calibration and the highest net benefit compared with available tools and should be adopted to identify candidates for ePLND among men diagnosed with MRI-targeted biopsy. We performed the first multi-institutional validation of the first nomogram predicting lymph node invasion specifically developed using data from prostate cancer patients diagnosed with magnetic resonance imaging (MRI)-targeted biopsy. This nomogram exhibited excellent characteristics on external validation compared with available tools and should be adopted to identify candidates for extended pelvic lymph node dissection among men diagnosed with MRI-targeted biopsy. The 2019 Briganti nomogram should be used to identify candidates for extended pelvic lymph node dissection among men with prostate cancer diagnosed via magnetic resonance imaging–targeted biopsy who are being considered for radical prostatectomy. [ABSTRACT FROM AUTHOR]

• Using clinical nomograms with low threshold values may lead to unnecessary lymph node dissections. • In patients with prostate cancer, preoperative PSMA PET-CT may fail to detect lymph node metastases. • Sensitivity of PSMA PET-CT to detect lymph node metastases can be improved by utilizing clinical nomograms with higher threshold values. • To reduce the high cost, justified use of PSMA PET-CT could be limited to patients in the D'Amico high-risk group or higher nomogram scores. The aim was to ensure efficient utilization of PSMA PET-CT by examining the correlation of pathological lymph node metastasis with nomogram scores and risk classifications. Robot-assisted radical prostatectomy and bilateral pelvic lymph node dissections for pelvic lymph nodes were performed using the same template. Bilaterally pelvic lymph nodes were removed within the boundaries of genitofemoral nerves, psoas muscle and lateral pelvic wall laterally, ureteric crossing of the iliac vessels superiorly, lateral bladder wall medially, Cooper ligaments distally, and endopelvic fascia, neurovascular bundles and internal iliac arteries posteriorly. Clinical nomograms were used to calculate the probability of lymph node metastasis preoperatively. Using receiver operating characteristics analysis, discriminatory cut-offs were calculated. The diagnostic performance of PSMA PET-CT was determined for detecting lymph node metastasis. For 81 patients, the median age was 64 years. The median PSA was 6.8 ng/ml. Most patients were in the D'Amico intermediate (56.8%) and high (37%) risk groups. Median Briganti 2017, MSKCC, and Partin scores were 35 (4–99), 37 (8–90), and 12 (2–38), respectively, in pN1 patients. The area under the curve for Briganti 2017, MSKCC, Partin nomograms and PSMA PET-CT scans were 0.852, 0.871, 0.862, and 0.588. Sensitivity, specificity, positive predictive value and negative predictive value for Ga-68 PSMA PET-CT for lymph node metastasis detection were 21.4%, 94%, 42.9%, and 85.1%, respectively, for the whole group. By using higher threshold values for clinical nomograms (Briganti 2017 >32, MSKCC >12, Partin >5), PSMA PET-CT had higher sensitivity (42.9, 30, 27.2) in detecting lymph node metastasis. Patients in the D'Amico high-risk group and those with high nomogram scores are the best candidates who will benefit from preoperative PSMA PET-CT staging to estimate lymph node metastasis. [ABSTRACT FROM AUTHOR]

Objective: Docetaxel has been shown to be an effective chemotherapy agent when combined with androgen deprivation therapy for hormone sensitive metastatic prostate cancer (CaP). Since very high risk CaP has a high rate of occult metastatic disease and early recurrence, we hypothesize that patients with very high risk locally advanced CaP may benefit from docetaxel-based neoadjuvant chemohormonal therapy (NCHT). Thus, we conducted a retrospective study to identify the outcome of these patients treated with NCHT followed by radical prostatectomy (RP).Patients and Methods: We retrospectively analyzed data from 177 consecutive patients who had very high risk locally advanced CaP between March 2014 and July 2017. Patients received 3 different therapies: (i) 60 men in NCHT group, (ii) 73 men in neoadjuvant hormonal therapy (NHT) group, and (iii) 44 men received immediate RP without neoadjuvant therapy (No-NT group). Surgical outcomes were analyzed and survival differences were compared by the Kaplan-Meier method.Results: The NCHT group had statistically significant higher preoperative Prostate-Specific Antigen (PSA) (P < 0.002), higher Gleason score (P < 0.002), and more advanced clinical stage (P < 0.001) than other groups. After RP, 81% (42/52) of patients in NCHT group, 73% (51/70) of patients in NHT group, and 48% (21/44) of patients in No-NT group achieved an undetectable PSA (P < 0.001). A total of 14% (6/42) patients achieving a postoperative undetectable PSA experienced biochemical recurrence in the NCHT group, with median biochemical progression-free survival (bPFS) time of 19 months; 47% (24/51) experienced biochemical recurrence in the NHT group, with median bPFS time of 13 months; 81% (17/21) experienced biochemical recurrence in the No-NT group, with median bPFS time of 9 months (P < 0.001). The median follow-up time of 3 groups was 12.5 months in the NCHT group, 18.3 months in the NHT group, and 22.8 months in the No-NT group (P = 0.01).Conclusion: Despite having poorer prognostic factors, the NCHT group had better bPFS time after surgery compared to NHT and No-NT groups. Randomized controlled investigations are needed to validate these results and further follow-up is required for survival endpoints. [ABSTRACT FROM AUTHOR]

Introduction: To assess the incidence of malignancy involvement of lymph nodes (LNs) in Marcille's fossa in patients undergoing robot assisted radical prostatectomy (RARP) and extended pelvic lymph nodes dissection (ePLND) for prostate cancer (PCa). Design, Setting, and Participants: Between January 2014 and December 2017, details of patients who underwent RARP and ePLND were prospectively analysed. All the nodal packets were dissected separately, grouped into left and right nodes and submitted in separate packages to dedicated pathologist. Results and Limitations: Two hundred and twenty-one patients underwent ePLND and RARP in the study period. In aggregate, Marcille's LNs involvement was found in 5 (2.3%) of patients, 2 on the left side and 3 on the right side. Per cent of positive cores and Gleason at biopsy are clinical predictors of LNs invasion; moreover, in the surgical specimen, seminal vesicle invasion and high-grade cancer were factors related to loco-regional metastases. Conclusions: Marcille's nodes involvement is associated to contemporarily multiple LN metastases in other template locations in high-risk PCa patients. The Marcille's lymphadenectomy would be recommended when planning an ePLND in high-risk PCa. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic or robotic-assisted laparoscopic radical prostatectomy (RALP) is a frequently used approach for localized carcinoma prostate. For intermediate and high-risk cancers, extended pelvic lymph node dissection (e-PLND), is often performed. Conventional e-PLND involves piecemeal retrieval of lymphatic tissue. We describe a novel technique of laparoscopic e-PLND, which involves en-masse removal of pelvic lymph nodes from each side, based on an overlying peritoneal scaffold. Materials and Methods: Fifteen cases of intermediate and high-risk carcinoma prostate underwent laparoscopic radical prostatectomy (LRP) with peritoneal scaffold based e-PLND within a period of 1 year. We describe the surgical techqniue and outcomes in terms of operative time and lymph nodes retrieved. Results: The mean operating times for "peritoneal scaffold" lymphatic dissection was 48 min (38-64). The total number of lymph nodes retrieved was 18 (14-22). There were no cases with postoperative lymph collection or hematoma. Conclusion: The "peritoneal scaffold" technique of e-PLND is a novel technique, which involves having a peritoneal scaffold to bind and hold all the lymphatic tissues together in its anatomical orientation during dissection. This enables complete retrieval of specimen during LRP and RALP.

Introduction: Radical cystectomy and extended pelvic lymph node dissection (ePLND) are the gold standard treatment for muscle-invasive bladder cancer and BCG unresponsive nonmuscle-invasive bladder cancer. In this article, we review the rationale for ePLND in the treatment of bladder cancer and the evidence supporting the equipoise between robot-assisted (RA) and open ePLND. A step-by-step guide of robot-assisted ePLND (RA ePLND) is provided to illustrate the techniques currently employed at our institution. Materials and Methods: Medline and PubMed electronic databases were queried for English language articles on bladder cancer, ePLND, and RA ePLND. In addition, a step-by-step video of RA ePLND was assembled with narration and accompanying explanations of each step to illustrate our current techniques. Key images from the video were selected for illustration of the relevant anatomical landmarks. Results: ePLND with a minimum nodal yield of 10 to 14 is tantamount in the treatment of bladder cancer. The number of lymph nodes resected influenced survival in both pathologically node positive and negative patients. In addition, RA ePLND was found to have equipoise as open ePLND by several groups. In our surgical atlas video, we illustrate key surgical steps, including port placement and exposure. Also, anatomic landmarks of dissection for the internal iliac, external iliac/obturator, and higher nodal packets are described in detail. Conclusions: We illustrate the techniques for a thorough RA ePLND, with the intention to help the robotic surgeon to meet the 10 to 14 nodal yield mandated by the Bladder Cancer Collaborative Group. [ABSTRACT FROM AUTHOR]

Introduction: Fluorescence imaging with indocyanine green is used in urology for the detection of sentinel lymph nodes and identification of prostate margins in radical prostatectomy for delineation of resection zone and selective clamping of vessels in partial nephrectomy; for identification and evaluation of length of ureteral strictures; for assessment of perfusion and viability of anastomoses during reconstructive stage of cystectomy. Safety of this technique is proven, while its diagnostic value and usefulness is still controversial. Methods: This pilot study of using the SPY Elite Fluorescence Imaging System for diagnostics was performed in the I.M. Sechenov First Moscow State Medical University. Ten patients were enrolled: four patients underwent retropubic RP and lymph node dissection, five patients underwent partial nephrectomy, and one patient underwent ureteroplasty. Fluorophore was injected transrectally with TRUS guidance during RP in order to assess the lymph nodes. During partial nephrectomy, the compound was injected intravenously to differentiate the tumor from parenchyma by its blood supply. During ureteroplasty, the indocyanine green solution was injected into the renal pelvis to dye the ureter and locate the stricture. Results: Sensitivity of this technique for visualization of sentinel lymph nodes was 100%, and specificity was 73.3%. In patients who underwent partial nephrectomy, all lesions were malignant and hypofluorescent when compared with healthy parenchyma. SPY allowed us to determine the location and extension of the stricture during ureteroplasty. No hypersensitivity reactions or complications were observed during injection of the compound. [ABSTRACT FROM AUTHOR]

Background: Postoperative management of prostate cancer with lymph node involvement (LNI) is controversial. Retrospective evidence supports the selective use of radiotherapy (RT) after extended pelvic lymph node dissection. It is unclear whether this is generalizable to practice in the United States, where extended dissection is uncommon. The authors identified patients with LNI who potentially could derive a survival benefit with adjuvant RT plus androgen-deprivation therapy (ADT).Methods: Patients with N1M0 prostate adenocarcinoma who underwent radical prostatectomy (RP) and subsequently received ADT from 2003 through 2011 were identified from the National Cancer Database. Kaplan-Meier analyses, log-rank tests, and multivariable Cox proportional hazards regression were performed using overall survival (OS) as the primary outcome.Results: In total, 906 of 2569 eligible patients (35.3%) received RT, and RT was more frequently received by patients who were diagnosed in later years, had fewer positive lymph nodes, had involved surgical margins, and were aged <65 years (all P < .05). The 5-year OS rate was 87% versus 82% in those who received RT versus those who did not (P = .007). After propensity score matching, 826 patients remained in each cohort. RT retained an association with OS (5-year OS: 88% vs 81%; P = .009; hazard ratio, 1.43; 95% confidence interval, 1.10-1.86; P = .008). No interaction was identified between the effect of RT on OS across tested strata of total lymph nodes examined, lymph node ratio, total number of positive lymph nodes, margin status, Gleason score, and prostate-specific antigen.Conclusions: RT plus ADT was associated with improved OS after RP in patients with LNI. These results may help guide therapy in the absence of randomized evidence. Cancer 2017;123:512-520. © 2016 American Cancer Society. [ABSTRACT FROM AUTHOR]

Background Limited data are available on the role of robot-assisted radical prostatectomy (RARP) in patients with locally advanced prostate cancer (PCa). Objective To describe our surgical technique of extrafascial RARP and extended pelvic lymph node dissection (ePLND) in locally advanced PCa. Design, setting, and participants Ninety-four patients with clinical stage ≥T3 undergoing RARP with ePLND at three European centers between 2011 and 2015 were retrospectively evaluated. Surgical procedure Surgery was performed using the DaVinci Si system. The anatomically defined ePLND included nodes overlying the external iliac axis, those in the obturator fossa, and around the internal iliac artery up to the ureter. RARP was performed using an extrafascial approach where the Denonvillers’ fascia was dissected free and left on the posterior surface of the seminal vesicles. Measurements Perioperative outcomes consisted of operative time, blood loss, length of hospital stay, and complications occurred within 30 d after surgery. Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values ≥0.2 ng/ml. Kaplan-Meier analyses assessed time to BCR and clinical recurrence. Multivariable Cox regression analyses assessed predictors of BCR. Results and limitations Median operative time, blood loss, and length of hospital stay were 230 min, 200 ml, and 6 d. Overall, 12 (12.7%) patients experienced complications and five (5.3%), four (4.3%), and three (3.2%) patients had Clavien I, II, and III/IV complications. Overall, 72 (76.6%), 35 (37.2%), and 30 (32.3%) patients had pT3/4, pN1, and positive margins. The median number of nodes removed was 16. Overall, 19 (20.2%) and 21 (22.3%) patients received adjuvant radiotherapy and hormonal therapy. The median follow-up was 23.5 mo. At 3-yr follow-up, the BCR- and clinical recurrence-free survival rates were 63.3% and 95.8%. Pathologic stage, Gleason score, and positive margins represented predictors of BCR (all p ≤ 0.03). Our study is limited by its retrospective nature and by the follow-up duration. Conclusions RARP represents a well-standardized, safe, and oncological effective option in patients with locally advanced PCa. Pathologic stage, Gleason score, and positive margins should be considered to select patients for multimodal approaches. Patient summary Robot-assisted surgery represents a well-standardized, safe, and oncological effective option in men with locally advanced prostate cancer. Two out of three patients treated with this approach are free from recurrence at 3-yr follow-up. Pathologic stage, Gleason score, and positive surgical margins represent predictors of BCR and should be considered to select patients for multimodal approaches. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic or robotic-assisted laparoscopic radical prostatectomy (RALP) is a frequently used approach for localized carcinoma prostate. For intermediate and high-risk cancers, extended pelvic lymph node dissection (e-PLND), is often performed. Conventional e-PLND involves piecemeal retrieval of lymphatic tissue. We describe a novel technique of laparoscopic e-PLND, which involves en-masse removal of pelvic lymph nodes from each side, based on an overlying peritoneal scaffold. Materials and Methods: Fifteen cases of intermediate and high-risk carcinoma prostate underwent laparoscopic radical prostatectomy (LRP) with peritoneal scaffold based e‑PLND within a period of 1 year. We describe the surgical techqniue and outcomes in terms of operative time and lymph nodes retrieved. Results: The mean operating times for “peritoneal scaffold” lymphatic dissection was 48 min (38–64). The total number of lymph nodes retrieved was 18 (14–22). There were no cases with postoperative lymph collection or hematoma. Conclusion: The “peritoneal scaffold” technique of e-PLND is a novel technique, which involves having a peritoneal scaffold to bind and hold all the lymphatic tissues together in its anatomical orientation during dissection. This enables complete retrieval of specimen during LRP and RALP. [ABSTRACT FROM AUTHOR]

Introduction and Objectives: 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.Materials and Methods: 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(-)].Results: 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%.Conclusions: 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. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the effect of previous prostate surgery performed for lower urinary tract symptoms ( LUTS) on the ability to predict lymph node invasion ( LNI) in patients subsequently diagnosed with prostate cancer, testing two widely used LNI predictive models. Patients and Methods From 1990 to 2012, we collected data on 4734 patients with prostate cancer treated with radical prostatectomy and extended pelvic LN dissection ( ePLND). Of these, 4453 (94%) had no prior prostate surgery ('naïve patients'), while 286 (6%) had previously undergone surgery for LUTS. Two LNI prediction models based on patients treated with ePLND were evaluated using the receiver operating characteristic-derived area under the curve ( AUC), the calibration plot method, and decision-curve analyses. Results The rate of LNI was 12%, while the median number of LNs removed was 15 in both groups ( P = 0.9). The two tested nomograms provided more accurate prediction in naïve patients than for those previously treated with prostate surgery for LUTS ( AUC: 82% and 81% vs 68% and 71%, P = 0.01 and P = 0.04, respectively). In naïve patients the surgeon would have missed one LNI for every 53 and 34 avoided ePLND using the Briganti and Godoy nomograms, respectively; in patients previously treated with surgery for LUTS, a LNI would have been missed in 13 and 21 patients not undergoing ePLND. Conclusion The accuracy and the clinical net-benefit of LNI prediction tools decrease significantly in patients with prior prostate surgery for LUTS. These models should be avoided in such patients, who should undergo routine ePLND. [ABSTRACT FROM AUTHOR]

Introduction The role of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) for prostate cancer (PCa) is controversial. Despite extensive research in both patterns of lymphatic drainage and the clinical effect of lymph node involvement, the exact role of PLND in PCa is yet to be defined. Methods A systematic search of the MEDLINE database was performed, and all relevant articles were reviewed in depth. Results We included 84 relevant articles in our review and subdivided the information into the following categories: preoperative patient evaluation, procedure/extent of dissection, complications, and robotic surgery era. Most authors agree that the greatest benefit is seen in patients with high-risk PCa undergoing RP. Multiple imaging modalities have been evaluated for assistance in patient selection, but the use of preoperative nomograms appears to be the most helpful selection tool. The role of limited PLND vs. extended PLND (e-PLND) is yet to be defined, though many authors agree that e-PLND is preferred in the setting of high-risk PCa. Although PLND is associated with a higher incidence of complications, especially lymphocele formation, it is unclear whether e-PLND leads to more complications than limited PLND. The introduction of minimally invasive surgery may have had a negative effect on implementation of PLND in the appropriate patients undergoing RP. Conclusion Despite a lack of prospective, randomized trials evaluating PLND in RP, there does appear to be a consistent benefit in patients with high-risk disease. [ABSTRACT FROM AUTHOR]

Background The technique of robot-assisted radical cystectomy (RARC) has evolved significantly since its inception >10 yr ago. Several high-volume centers have reported standardized techniques with refinements and subsequent outcomes. Objective To review all existing literature on RARC and urinary diversion techniques and summarize key points that may affect oncologic, surgical, and functional outcomes. Design, setting, and participants The Pasadena Consensus Panel on RARC and urinary reconstruction convened May 3–4, 2014, to review the existing peer-reviewed literature and create recommendations for best practice. The panel consisted of experts in open radical cystectomy and RARC. No commercial support was received. Surgical procedure The consensus panel extensively reviewed the surgical technique of RARC in men and women, extended pelvic lymph node dissection, extracorporeal urinary diversion, and intracorporeal urinary diversion. Critical aspects of the technique are described. Outcome measurements and statistical analysis Preoperative, operative, and postoperative parameters from the largest and most contemporary RARC series, stratified by urinary diversion technique, are presented. Results and limitations Preoperative, operative, and postoperative measures of RARC technique adhere closely to the standards established in open surgery. Conclusions Refinement of techniques for RARC and urinary diversion over the past 10 yr has made it safe, reproducible, and oncologically sound. Patient summary We summarize the critical aspects of surgical techniques reviewed at the Pasadena international consensus meeting on RARC and urinary reconstruction. Preoperative, operative, and postoperative measures of RARC technique adhere closely to the standards established in open surgery. [ABSTRACT FROM AUTHOR]

Background: To determine the anatomic extent of pelvic lymph node dissection (PLND) in prostate cancer (PCa) patients at the time of radical prostatectomy (RP), knowledge about the topography of lymph node (LN) metastases is required. Objective: Because small-volume LN metastases may be missed by standard histopathologic examination, we performed an anatomic mapping study combining molecular and histopathologic LN examination in PCa patients treated with RP and extended PLND (ePLND). Design, setting, and participants: A total of 52 patients with intermediate- (n = 15) and high-risk (n = 37) PCa underwent RP and ePLND without neoadjuvant treatment. ePLND included dissection of the obturator fossa and the external, internal, and common iliac vessels. Outcome measurements and statistical analysis: LNs ≥3 mm in diameter were analysed by quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) for prostate-specific antigen (PSA) expression and by standard histopathology. Topography of positive LNs was determined descriptively. Results and limitations: Of 1469 dissected LNs (median: 27 LNs per patient), 1186 LNs were ≥3 mm. Molecular LN analysis was positive in 127 LNs of 27 patients (52%) including 32 LNs of 12 patients (23%) with histopathologic positive LNs. Molecular examination was negative in 3 of 35 histopathologic positive LNs (9%). Combining both molecular and histopathologic findings, positive LNs were located in the standard PLND field defined by obturator fossa and external iliac vessels in 71%, along the internal iliac vessels in 16%, and along the common iliac vessels in 13%. Of LN-positive patients, 63% had LN metastases outside the standard PLND field. The internal iliac field was involved in 48% and the common iliac field in 37% of node-positive patients. Notably, internal and common iliac vessels were the only positive regions in 7% and 11% of node-positive patients, respectively. A limitation is the small number of patients included. Conclusions: These findings underline the enhanced sensitivity of qRT-PCR in comparison with standard histopathology for detection of small-volume LN metastases in PCa patients. Our results support an ePLND including the common iliac vessels, at least up to the ureteral crossing, to optimise nodal staging and to remove LNs potentially harbouring metastases. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to prospectively compare diffusion-weighted magnetic resonance imaging (DWI) and [C]choline positron emission tomography/computed tomography (PET/CT) with computed tomography (CT) for preoperative lymph node (LN) staging in prostate cancer (PCa) patients. Methods: Between June 2010 and May 2012, CT, DWI and [C]choline PET/CT were performed preoperatively in 33 intermediate- and high-risk PCa patients undergoing radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND) including obturator fossa and internal, external and common iliac fields. Patient- and field-based performance characteristics for all three imaging techniques based on histopathological results are reported. Imaging techniques were compared by means of the area under the curve (AUC). Results: LN metastases were detected in 92 of 1,012 (9 %) LNs from 14 of 33 (42 %) patients. On patient-based analysis, sensitivity, specificity and accuracy for CT were 57, 68 and 64 %, respectively, for DWI were 57, 79 and 70 %, respectively, and for [C]choline PET/CT were 57, 90 and 76 %, respectively. On field-based analysis, these numbers for CT were 47, 94 and 88 %, respectively, for DWI were 56, 97 and 92 %, respectively, and for [C]choline PET/CT were 62, 96 and 92 %, respectively. Neither DWI nor [C]choline PET/CT performed significantly better than CT on pairwise comparison of patient- and field-based results. Conclusion: All three imaging techniques exhibit a rather low sensitivity with less than two thirds of LN metastases being detected on patient- and field-based analysis. Overall diagnostic efficacy did not differ significantly between imaging techniques, whereas distinct performance characteristics, esp. patient-based specificity, were best for [C]choline PET/CT followed by DWI and CT. [ABSTRACT FROM AUTHOR]

Our aim was to validate Briganti's nomograms predicting the probability of lymph node involvement (LNI) in prostate cancer (PCa). Clinicopathological data of 256 PCa patients who underwent extended pelvic lymph node dissection (ePLND) and radical prostatectomy (RP) were obtained from two Bulgarian institutions. Predicted probabilities of LNI were assessed using Briganti's nomograms based on ePLND. In addition to the established basic LNI predictors, Briganti's nomograms included the number of lymph nodes removed (version 2006) and the number and percentage of positive biopsy cores (versions 2007 and 2012). The accuracy of these nomograms was compared with the updated Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram (version 2011). Receiver-operating characteristics analysis was done to assess the discriminative ability of each of the nomograms applied.All of Briganti's nomograms showed a higher predictive accuracy as compared with the updated MSKCC nomogram. The respective AUC values were calculated as 0.847, 0.837, 0.858 and 0.875 for the four Briganti nomograms, and 0.770 for the updated MSKCC nomogram, respectively. Despite the potential for heterogeneity in patient selection and management, all predictions demonstrated high concordance with actual observations. Compared with other similar prognostic tools the updated Briganti nomogram (version 2012) showed the highest predictive accuracy and should therefore be preferred. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]