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Lymph Node Yields With Pelvic Lymphadenectomy During Robotic-Assisted Laparoscopic Radical Prostatectomy - Extra Peritoneal (EP) Vs Transperitoneal (TP ) Does The Approach Matter?
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:
In prostate cancer patients, pelvic lymph node dissection is considered the most accurate method of assessing lymph node metastases. It has both diagnostic and therapeutic implications for the surgical management of prostate cancer.As robotic-assisted laparoscopic radical prostatectomy (RALP) rapidly becomes the dominant technique in the surgical management of prostate cancer, it is imperative that we ensure oncologic outcomes are comparable to those of traditional open radical retropubic prostatectomy (RRP). Furthermore, there must be equity between the various approaches used to accomplish RALP. Some have suggested that EP-RALP my not allow an adequate surgical field in which to accomplish a thorough pelvic lymph node dissection. We compared the lymph node yields after pelvic lymphadenectomy for EP-RALP (extra-peritoneal) and TP- RALP(trans peritoneal).
METHODS:
We examined our departmental, IRB approved, retrospective database of radical prostatectomy procedures performed by single surgeon from October 2008 to February 2010. During this period, 351 patients underwent RALP; of this 181 had undergone pelvic lymphadenectomy that were included for analysis, including 150 EP-RALP and 31 TP-RALP. The boundaries of pelvic lymphadenectomy were standard for each surgical approach, including the template commonly referred to as the obturator lymph node, external iliac artery and vein packets upto the bifurcation. The pathologic processing technique was standard over this period. We examined and compared the lymph node yields and lymph node involvement for each surgical approach .
RESULTS:
Of the 181 patients, 150 had EP-RALP and 31 TP-RALP. The mean ± SD of age ,prostate weight and PSA 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 27.5± 3.3 and 35.2± 4.2 (p=0.001) between two groups. There were no statistically significant differences in operative time 131.6± 19.6, 133.1±20.9 (p= 0.7), and length of stay 1.22 ± 1.2,1.032 ± 0.18(p=0.39). Pathological staging distribution was T2c in 58.3% vs. 60.45% and T3a 29.3% vs. 21.4% respectively. In both groups .Positive surgical margin rates when stratified to T2c and T3a pathological stages were 6% vs. 7.8% and 10% vs. 16.7% respectively.The mean lymph node yields for EP-RALP and TP-RALP were 8.3 (median 8.0, range 1-25) and 8.5 (median 6.0, range 4-28), (p=0.07) respectively. The percentage of patients with lymph node involvement was 6% for EP-RALP and 2.2% for TP-RALP, respectively .
CONCLUSIONS:
Despite of the criticism of the EP approach to RALP poses technical challenges,limits surgical working space and can hinder the adequacy of pelvic lymphadenectomy, our study demonstrates comparable nodal yield between both the EP and TP techniques. This single institution series suggests that with adequate surgeon experience, approach does not impact outcome, and the EP RALP can offer excellent results.


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