title: Robot-assisted extended pelvic lymph node dissection (PLND) at the time of radical prostatectomy (RP): a video-based illustration of technique, results, and unmet patient selection needs.
abstract: OBJECTIVE
  • To describe the differences in technique and results between standard vs extended template pelvic lymph node dissection (PLND) at the time of radical prostatectomy (RP) using a robot-assisted (RA) technique.
  
  
  METHODS
  • Using extended templates illustrated for the open surgical technique, a RA technique was developed to solve obstacles related to surgical exposure, identification of key landmarks, proper sequencing of operative steps, and prevention of complicationsshown in the accompanying video. • From May 2006 to October 2007, 261 patients underwent a standard PLND, and from November 2007 to November 2010, 670 underwent an extended PLND (E-PLND) by one surgeon.
  
  
  RESULTS
  • The lymph node (LN) yield increased from a median(interquartile range) of 8 (5-11) to 16 (11-21) with the extended technique (P < 0.001). • The ratio of positive LNs increased from 7% to 18%. Among E-PLND cases by risk group, positive LNs were found in 39%, 9%, and 3% of high-, intermediate-, and low-risk cases, and the later two groups strongly associated with upgrading and/or upstaging. • Extensive clipping appears necessary to avoid postoperative lymphoceles, and peritoneal fenestration for the extraperitoneal technique. • The median operative duration for E-PLND was 42 min, roughly double that of a standard PLND.
  
  
  CONCLUSIONS
  • E-PLND is feasible with a RA technique, and increases the LN yield and positive LN ratio;the latter especially in high-risk disease. • The procedure takes twice as long and requires several updates in technique shown in the video.
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA. Johndavis@mdanderson.org
authors.forename: John W
authors.initials: JW
authors.lastname: Davis
authors.forename: Jay B
authors.initials: JB
authors.lastname: Shah
authors.forename: Mary
authors.initials: M
authors.lastname: Achim
mesh_terms: D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control; D008197:Lymph Node Excision / Q000009:adverse effects / Q000379:methods*; D008297:Male; D018579:Patient Selection; D010388:Pelvis / Q000601:surgery; D011183:Postoperative Complications / Q000517:prevention & control; D011446:Prospective Studies; D011468:Prostatectomy / Q000009:adverse effects / Q000379:methods*; D011471:Prostatic Neoplasms / Q000601:surgery*; D012371:Robotics; D025321:Surgery, Computer-Assisted / Q000009:adverse effects / Q000379:methods; D016896:Treatment Outcome; D014741:Video Recording