Outcomes

Although laparoscopic radical cystectomy has been the discussion of several reports, little attention has been given to the yield and extent of lymphadenectomy. We recently reviewed our technique and results with laparoscopic extended pelvic lymph node dissection (41). Initially, the bifurcation of the common iliac arteries constituted our proximal border (Group I). Commencing August 2002, our dissection included tissue overlying the proximal common iliac artery to the aortic bifurcation (Group II). The extended dissection required an additional 1 to 1.5 hours of operative time. Median number of nodes removed was 3 and 21 for Groups I and II, respectively (p = 0.001). Three patients in each group had pN+ disease. During extended pelvic lymph node dissection, an injury to a deep pelvic vein, managed with intracorporeal suturing, resulted in a 200 mL blood loss. Two other patients in this group developed deep venous thrombosis. There were no port site recurrences over a mean follow-up of 11 months (range, 2-43).

SUMMARY: PELVIC LYMPH NODE DISSECTION FOR BLADDER CANCER

■ All patients undergoing radical cystectomy with curative intent should have a pelvic lymph node dissection.

■ A minimum of 10 to 14 lymph nodes should be removed and microscopically examined.

■ Although the proximal border of the lymphadenectomy is trending to migrate cephalad, with documented evidence of improved survival as more lymph nodes are removed, the true benefit of an extended dissection has not been demonstrated with well-designed prospective trials.

■ For the time being, albeit a limited experience, laparoscopic extended pelvic lymphadenectomy is feasible and results in nodal yields that are commensurate with current recommendations from conventional open surgical series.

■ Ours is only the initial experience and corroborating data from other centers are necessary before laparoscopic extended pelvic lymph node dissection can be considered to be adequate.

PORT-SITE TUMOR SEEDING AND LOCAL RECURRENCE

Issues of tumor spillage and port site seeding have been raised as concerns regarding the oncologic safety of laparoscopic surgery. Specifically, after pelvic lymphadenectomy, there have been four reported cases of tumor recurrence at a port site (42). Three of the cases occurred after staging lymphadenectomy for bladder cancer (43) and the other after pelvic lymph node dissection for prostate cancer (44). In the cases associated with bladder cancer, the specimens were directly extracted through a port rather than placed in impermeable sacs. Furthermore, the cases were high grade invasive transitional cell carcinoma and associated with other predisposing events such as concomitant transurethral resection of bladder tumor, concomitant bladder dome biopsy, and insertion of a suprapubic tube because of hemorrhage during transurethral resection of bladder tumor and ruptured tumor bearing lymph nodes (43).

Care should be taken to avoid incision into tumor-bearing nodes, especially in the setting of high-grade disease. Also, all lymphatic tissue should be immediately placed in an impermeable sac.

SUMMARY

■ Currently, limited laparoscopic pelvic lymphadenectomy can be performed with comparable efficiency to open surgery. In the management of prostate cancer there is a vast experience with laparoscopic pelvic lymph node dissection. However, laparoscopic extended pelvic lymph node dissection for bladder cancer is a relatively recent development and further experience will be required to better define its role.

■ In general, surgical times for limited laparoscopic lymphadenectomy are equivalent or longer depending on the procedure and the experience of the surgeon.

■ Pelvic lymph node dissection for staging and prognosis, as is usually the case for prostate cancer, is not as technically demanding as a lymphadenectomy with therapeutic potential. As such, during radical cystectomy with curative intent, an honest effort must be made to perform as meticulous and rigorous an anatomic lymphadenectomy as is carried out with open surgery.

■ We believe that with growing experience and instrument development, laparoscopic extended pelvic lymph node dissection will be performed with equal efficacy to the open procedure.

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