european urology 52 (2007) 384 388 available at www.sciencedirect.com journal homepage: www.europeanurology.com Surgery in Motion Radical Perineal Prostatectomy and Simultaneous Extended Pelvic Lymph Node Dissection via the Same Incision Hansjörg Keller *, Joachim Lehmann 1,Jörn Beier Clinic of Urology and Paediatric Urology, Sana Klinikum Hof, 1 Institute of Pathology, Hof, Germany Article info Article history: Accepted September 25, 2006 Published online ahead of print on October 20, 2006 Keywords: Perineal pelvic lymph node excision Prostate cancer Radical prostatectomy Urinary continence Abstract Objectives: Assess the feasibility of extended bilateral pelvic lymph node dissection (eplnd) in radical perineal prostatectomy (RPP) via the same incision under direct vision. Methods: In 90 consecutive patients with prostate cancer and a prostatespecific antigen level >10 ng/ml or a Gleason score >5 or more than two positive biopsies, RPP and eplnd via the same incision were performed in a prospective trial. After removing the prostate, the endopelvic fascia was opened with scissors and the bladder pushed medially. We performed an extended dissection along the obturator nerve, the external iliac vessels up to the ureter and along the internal iliac artery. Complications, number of nodes removed, and number of patients with tumour-positive nodes were recorded. Recovery of urinary continence and erectile function were assessed by a patientreported questionnaire and the International Index of Erectile Function 5 questionnaire, respectively, administered preoperatively and at 1, 3, 6, and 12 mo. Results: We removed a mean and median number of 19 and 18.7 lymph nodes, respectively. Twelve patients had lymph node metastasis. Mean operation time was 149 min, including the complete learning curves of three surgeons. Seven lymphoceles but no major complications occurred. After 1, 3, 6, and 12 mo, 32 (36%), 50 (56%), 74 (82%), and 84 (93%) patients were completely dry, using no pads. Conclusion: eplnd and RPP under direct vision via the same incision are feasible, efficient, and associated with a fast recovery of urinary continence and a low complication rate. Because lymphadenectomy needs no second access, the major disadvantage of RPP is resolved. # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Clinic of Urology and Paediatric Urology, Sana Klinikum Hof, Academic Hospital University of Erlangen, Eppenreuther Str. 9, D-95032 Hof, Germany. Tel. + 49 9281 982378; Fax: +49 9281 982454. E-mail address: urologie@klinikumhof.de (H. Keller). 1 Pathology Hof. 0302-2838/$ see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2006.09.045
european urology 52 (2007) 384 388 385 1. Introduction The incidence of nodal metastases in patients with clinically localised prostate cancer has decreased to 4 25% [1 3], depending on patient selection and technique of lymph node dissection. In radical perineal prostatectomy (RPP), a second laparoscopic access is necessary in these patients. This increases the operative time and requires a change in the patient s position. Saito [4] first described a limited lymphadenectomy during RPP via the same incision, using retractors and laparoscopy for better viewing. He removed a mean of eight lymph nodes (range: 4 12). A limited lymph node dissection is not a reliable staging procedure because it misses >50% of the positive nodes compared to an extended dissection [5 8]. Furthermore, the limited value of a lymph node dissection as a staging procedure only without any therapeutic benefit is currently increasingly challenged [9]. To our knowledge, no evaluation has been done to determine whether an extended pelvic lymph node dissection (eplnd) combined with RPP via the same incision is feasible and efficient. We modified the technique so that we could perform an extended lymph node dissection under direct vision via the same perineal incision, thus avoiding a second laparoscopic access and resolving the major disadvantage of RPP. Fig. 1 Dissection internal artery, external artery (blue loop), ureter (medially). Image taken by the help of laparoscopic optics. 2. Patients and methods From May 2004 to August 2005, 90 consecutive patients, including three after laparoscopic repair of inguinal hernia with Prolene mesh, with either prostate-specific antigen (PSA) >10 ng/ml or a Gleason score >5 or more than two positive biopsies underwent RPP and eplnd simultaneously via the same perineal incision. The patient s age, PSA, Gleason score, pathologic stage, and positive surgical margins were recorded (Table 1). The procedure was performed using a self-retainingsystem (Omnitract 1 ). After the prostate was removed, the endopelvic fascia was incised and the bladder was pushed Table 1 Patient characteristics Mean patient age, yr (range) 67 (53 73) Mean PSA ng/ml (range) 12.1 (1.2 103) Mean Gleason score (range) 7 (5 9) Pathologic stage (positive surgical margins) pt2 4 (20%; 18/90) pt2a-c (%) [R1] 37 (41%) [3 (8.6%)] pt3b (%) [R1] 25 (28%) [6 (24%)] pt3a (%) [R1] 24 (27%) [6 (25%)] pt4 (%) [R1] 4 (4%) [3 (75%)] PSA = prostate-specific antigen. Fig. 2 Complete extended dissection, with lymphatic tissue removed. medially; the iliac vessels and the obturator nerve were all developed by blunt dissection. The bladder was retracted medially and kept in place by the self-retaining system. Under direct vision the node dissection started along the external iliac vessels up to the crossing of the ureter, the internal iliac artery (Fig. 1), and then along the obturator nerve, using haemo-clips for the lymphatic vessels and Allis clamps to pull the tissue slightly (Figs. 2 and 3). A 10F silicon drain was inserted along the site of the iliac vessels on each side and kept in place for 3 5 d or until secretion stopped. After completing eplnd on both sides, the operation procedure was continued as described in our video [10]. In addition to all complications, the number of nodes removed and the number of patients with tumour-positive nodes were recorded. Recovery of urinary continence and erectile function (EF) was investigated by a patient-reported questionnaire and the International Index of Erectile Function 5 (IIEF-5) questionnaire [11] administered preoperatively and at months 1, 3, 6,
386 european urology 52 (2007) 384 388 Table 2 Results: lymph node dissection, complications, and urinary continence No. nodes removed total (mean, median) 1710 (19, 18.7) No. patients with lymph node metastasis 12 (13.3%) Mean operative time, min (range) 149 (75 180) Mean estimated blood loss, ml (range) 330 (100 900) Transfusion rate 0 Rectal lesions 0 Wound infection 2.3% Lymphoceles (treatment necessary) 7.8% (7) [4.4%, (4)] Urinary continence (no pad past 4 wk) No. of patients (%) at 1, 3, 6, 12 mo 32 (36), 50 (56), 74 (82), 84 (93) Fig. 3 Voiding cystogram. Haemo-clips after extended pelvic lymph node dissection via perineal access. the patients needed more than one or two pads after 1 yr. Three of the four patients undergoing bilateral nerve-sparing surgery reported an EF domain score of 20, without phosphodiesterase type 5 (PDE5) inhibitors 12 mo after the operation. The single patient in whom unilateral nerve-sparing surgery was performed reported an EF domain score of 19 with the use of PDE5 inhibitors after 12 mo. and 12, asking for the use of pads during the previous 4 wk and the recovery of EF. Because most of these patients presented with either advanced disease (59% pt3 4) or erectile dysfunction (mean EF domain score = 12 of 25), bilaterally and unilaterally nerve-sparing RPP was performed in only four patients and one patient, respectively, presenting with a PSA 10 ng/ml, a Gleason score 7, unilateral positive biopsies, and an EF domain score 18. 3. Results In all patients, including three with a history of laparoscopic bilateral hernia repair with Prolene mesh, the procedure was possible without problems. The mean and median operation times were 149 and 150 min (range: 75 180 min), respectively, including the complete learning curves of three surgeons. Lymphoceles developed in seven patients, of whom four were treated; two lymphoceles between 50 to 100 ml were punctured and two >100 ml were laparoscopically resected. No rectal injury and no major complications occurred. Mean blood loss was 330 ml (range: 100 900 ml) and no transfusion was necessary during or after the procedure. By meticulous node dissection we removed a total of 1710 nodes, with a mean and median of 19 (range: 8 37) and 18.7 nodes, respectively. Twelve patients (13.3%) showed lymph node metastasis (Table 2). After 1, 3, 6, and 12 mo, 32 (36%), 50 (56%), 74 (82%), and 84 (93%) patients were completely dry and had used no pads at all during the previous 4 wk; none of 4. Discussion Radical prostatectomy is still the gold standard for treating localised prostate cancer. Beside the oncologic outcome, low perioperative morbidity and fast regaining of function are of paramount concern. The desire for lower morbidity, short hospital stay, and decreased costs has resulted in a renaissance of RPP. By using a self-retaining system as described by us for the extended field resection in 2001 and for the nerve-sparing procedure in 2002 [10,12,13], the operation is minimally invasive and can be done in a very short operation time of <80 min, as long as lymphadenectomy is not necessary. The need for lymph node dissection can be estimated preoperatively based on clinical stage, PSA level, and Gleason score and is necessary in 4 25% of patients [1 3], depending on patient selection and technique of lymph node dissection [14 18]. In these patients, to date, lymphadenectomy was performed laparoscopically, which was time-consuming and required a second access. Saito et al. [4] showed in 20 consecutive patients that using several retractors and laparoscopy for viewing, lymphadenectomy via a perineal approach during RPP is possible. He performed a limited dissection, removing eight nodes (range: 4 12) along the obturator nerve and the external iliac vessels. We performed RRP and eplnd in patients presenting with either PSA >10 ng/ml or a Gleason score >5 or more than two positive biopsies and
european urology 52 (2007) 384 388 387 probably missed just <3% of all tumour-positive nodes [3,5,6]. By our patient selection criteria we performed lymphadenectomy in about 35% of all our patients presenting with localised prostate cancer. Looking at the mean operating time of 149 minutes in this study, it seems to be quite long but one has to bear in mind that we had to develop the technique of the extended lymph node dissection via this approach and that it also includes the complete learning curves of three surgeons. Now the total operation time after >150 procedures is about 125 min. As shown, more than twice as many tumourpositive nodes can be found by an extended lymph node dissection compared to a limited dissection technique [5 8]. In contrast to Saito, we therefore modified the technique by removing the prostate in a first step and continued with an extended meticulous lymph node dissection taking out all tissue along the obturator nerve, the external iliac vessels up to the ureter and internal iliac artery. For the first time we performed this procedure under direct vision [4]. In an extended dissection 18 21 lymph nodes were removed [10], compared to 8 10 nodes in a modified technique [3,4,6,7]. We dissected a mean and a median number of 19 and 18.7 nodes (range: 8 37), respectively, and found metastases in 12 (13.3%) of our patients. This compares favourably to the number of lymph node metastases found by others performing an extended field node dissection [3,6 8]. We observed no problems during the procedure and lymphadenectomy could always be performed as an extended field dissection. The lymphatic vessels were meticulously closed by haemo-clips; however, lymphoceles occurred in seven patients (7.8%) and made intervention necessary in four (3.3%) patients. When the prostate is removed first, there is much more space to do the node dissection by pushing the bladder medially using a self-retaining system. The transsection of the urethra before pushing the bladder medially avoids pulling and thus damaging of the sphincter muscles, leading to a fast and excellent recovery of urinary continence. After 1, 3, 6, and 12 mo, 32 (36%), 50 (56%), 74 (82%), and 84 (93%) patients were completely dry using no pads and none of the patients needed more than one to two pads. Potency is the most difficult part to examine and must be interpreted with caution because most of the patients presented in this cohort had either advanced disease or very little EF with a mean EF domain score of only 12, so that only five nerve-paring procedures were performed. Four of these five patients reported an EF domain score after 12 mo of 20 with or without PDE5 inhibitors, so we might assume that nerve sparing is feasible. 5. Conclusions The eplnd under direct vision during RPP via the same incision is feasible and efficient. It is not associated with an increase of morbidity and perioperative complications. Thus, the major disadvantage of a second access for lymph node dissection during RPP is resolved. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/ j.eururo.2006.09.045 and via www.europeanurology. com. Subscribers to the printed journal will find the supplementary data attached (DVD). References [1] Petros JA, Catalona WJ. Lower incidence of unsuspected lymph node metastases in 521 consecutive patients with clinically localized prostate cancer. J Urol 1992;147:1574 92. [2] Han MH, Partin AW, Pound CR, Epstein JI, Walsh PC. Longterm biochemical disease-free and cancer-specific survival following anatomical radical retropubic prostatectomy: the 25-year Johns Hopkins experience. Urol Clin North Am 2001;28:555 65. [3] Bader P, Burkhard FC, Marlwalder R, Studer UE. Disease progression and survival of patients with positive lymph nodes after radical prostatectomy. Is there a chance of cure? J Urol 2003;169:849 54. [4] Saito S, Murakami G. Radical perineal prostatectomy: a novel approach for lymphadenectomy from perineal incision. J Urol 2003;170:1298 300. [5] Wawroschek F, Vogt H, Weckermann D, Wagner T, Hamm M, Harzmann R. Radioisotope guided lymph node dissection for prostate cancer. J Urol 2001;166:1715 9. [6] Heidenreich A, Varga Z, von Knobloch R. Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis. J Urol 2002;167:1681 4. [7] Stone NN, Stock RG, Unger P. Laparoscopic pelvic lymph node dissection for prostate cancer: comparison to the extended and modified techniques. J Urol 1997;158: 1891 4. [8] Briganti A, Chun FK-H, Salonia A, et al. Validation of a nomogram predicting the probability of lymph node
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