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Comparative Evaluation of Concomitant Lymphadenectomy in Robot-Assisted Radical Prostatectomy: Extraperitoneal versus Transperitoneal Approach Preliminary Analysis of Outcomes
Satya Allaparthi, MRCS,MD, Thomas Hoang, MD, Nadeem N. Dhanani, MD, MPH, Ingolf A. Tuerk, MD,PhD.
Caritas St Elizabeth Hospital, Boston, MA, USA.

BACKGROUND:
Lymph-node sampling is an important staging tool for patients with prostate cancer, as it can influence adjuvant treatment and prognosis. However, lymphadenectomy adds to the operating time and potential for complications. Herein, we compared the approach chosen, in patients undergoing Extra peritoneal (EP ) vs Transperitoneal (TP) robot-assisted radical prostatectomy (RARP) and effects of concomitant lymphadenectomy on intraoperative and pathological outcomes.
METHODS:
With institutional review board approval, we retrospectively reviewed our database on 181 consecutive RARPs both EP and TP, done in between November 2008 and January 2010,at our institution by a single surgeon (IT). We stratified patients into group- I (EP RARP) and group II (TP RARP) based on approach chosen.In this analysis, we assessed and compared variables that included age, prostate volume,BMI, PSA, pathological stage, margin status, operative time, blood loss, length of stay and rehospitalization rate. The boundaries of pelvic lymphadenectomy were consistent in both surgical approaches, including the obturator fossa and nodal tissue surrounding the external iliac vessels proximally to the vascular bifuraction. Lymph node yields and positivity for both approaches were examined and compared. Comparative analysis was done with Student t-test, (P < 0.05) for continuous variables, Chi-square and Fisher’s exact tests for categorical variables.
RESULTS:
Of the 181 patients, 150 had EP-RARP and 31 TP-RARP. The mean ± SD for age(yrs) ,prostate volume(ml) and PSA (ng/ml) in EP and TP groups were 60.6±6.6, 58±7.5 (p=0.06); 48.2±16.6, 50.6±18.8 (p=0.49) and 6.5±4.6, 7.9±8.5(p=0.181) respectively. However, a statistically significant difference was noted in BMI(kg/m²) 27.5± 3.3 vs. 35.2± 4.2 (p=0.001) between two groups. There were no statistically significant differences in operative time(min) 131.6± 19.6, 133.1±20.9 (p= 0.7) and length of stay (days)1.22 ± 1.2,1.032 ± 0.18(p=0.39). We noticed that, patients in EP group has significantly greater blood loss than TP group, EBL(ml) 213.03±162.01 vs. 144.3±90.8.(p=0.002).The mean number of lymph nodes removed per patient in either group were 8.3± 3.8 and 8.5± 5.3 (p=0.9). Lymph node metastases were detected in nine (6%) and three (2%) patients of respective groups. Pathological staging distribution was T2c in 58.3% vs. 60.45% and T3a 29.3% vs. 21.4% respectively. In both groups surgical margin rates when stratified to T2c and T3a pathological stages were 6% vs. 7.8% and 10% vs. 16.7% respectively. Based on Clavien -Dindo Classification there were 4 grade I, 6 grade II, 1 grade III a ,6 grade III b and 1 grade IV a complications in EP-RARP and 1 grade II, 1 grade III a and 1 grade III b in TP-RARP respectively.However, we noticed 10 lymphoceles and no DVT in EP and 1 lymphocele and 1 DVT in TP group respectively. No significant difference in hospital readmission rates were noticed in both groups.
CONCLUSIONS:
In conclusion, we found that concomitant lymphadenectomy did not adversely impact outcomes in patients undergoing RARP, nor did surgical approach influence ultimate nodal yield. However,patients in EP group had more EBL and lymphocels than TP. While, EP approach is technically demanding working in limited space, it is an acceptable option for experienced surgeons.


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