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28.12.2014
Brachytherapy is a further evolution in radiation therapy for the treatment of localised prostate cancer. Brachytherapy involves the insertion of radioactive seeds placed within the prostate near the tumour itself to allow a localised by high dose radiation to eradicate the tumour.
Prostate brachytherapy can be further divided into temporary brachytherapy which involves placing radioactive wires within the prostate gland for a few minutes before being removed.
Prostate brachytherapy is generally not used for advanced prostate cancers due to the higher risk of recurrence but also the subsequent inability to surgically remove the prostate in the event of tumour recurrence.
The procedure will be completed as a day case and you will be allowed to go home the same day. In high dose brachytherapy higher doses of radiation are usually used using wires which will stay in your body for several minutes at a time.
Brachytherapy is an excellent alternative for patients who are particularly interested in minimising the risk to the erections, however the longer term studies do suggest a gradual decline in erectile function. To date, there is still a paucity of data in the literature on robotic-assisted laparoscopic extended pelvic lymph node dissection (RALEPLND) in patients with prostate cancer. From April 2006 to March 2008, we performed RALEPLND in 99 patients prior to robotic-assisted laparoscopic radical prostatectomy. The total lymph node yield, the frequency of lymph node metastases, and the complication rate. In our experience, robotic-assisted laparoscopic extended pelvic lymph node dissection (PLND) is feasible, and its lymph node yield is well in the range of respected open series. Keywords: Complications, Laparoscopy, Lymph node excision, Prostatic neoplasms, Surgical procedures.
Robotic-assisted laparoscopic radical prostatectomy is an increasingly popular procedure throughout Europe and the United States. From April 2006 to March 2008, 234 men underwent robotic-assisted laparoscopic radical prostatectomy in our department.
Pathologic work-up to detect lymph nodes as well as lymph node metastases included direct visualization and palpation and standard hematoxylin-eosin staining, respectively.
Clinical information and pathological data were evaluated retrospectively with descriptive statistics. We use the boundaries of the lymph node dissection according to Bader et al and their recent modification by Mattei et al, proposing to include the common iliac region up to the ureteric crossing [5], [9], [13], [16], and [17].
After mobilizing the right ascending and left descending as well as sigmoid colon, if indicated, the lymphadenectomy is initiated. Identification of the right ureter and internal iliac artery, thus defining the proximal dissection boundary (right side). The dissection of the external iliac packet starts distally with the division of the adventitia overlying the external iliac vein (Fig.
Starting point for the dissection of the lymphatics overlying the external iliac vein by dividing the adventitia overlying the external iliac vein (right side).
Starting point for the dissection of the obturator lymphatic packet at the angle between the pubic bone and external iliac vein (right side). Identification of the obturator nerve at its proximal course after separating the external iliac artery and vein (right side). The lymph node dissection is completed only after a careful inspection for bleeding and thoroughness of the dissection has been carried out. Gleason score not available for four patients, in two patients because no prostatectomy was performed and in two patients because the patients received neoadjuvant androgen deprivation therapy by referring urologists.
Percentage based on all 99 patients undergoing robotic-assisted laparoscopic extended pelvic lymph node dissection. With respect to our results, with a median lymph node yield of 19 and the applied dissection template and surgical technique, we were able to demonstrate the feasibility of a sound RALEPLND. The frequency of the detected lymph node metastasis is not only related to the dissection template but also to the study population. Typically, lymphocele formation is the most frequent complication associated with lymph node dissection [23]. In our experience, RALEPLND is feasible, and its lymph node yield is well in the range of respected open series.
Acknowledgement statement: We would like to thank Damina Balmer for her assistance in the preparation of the manuscript.
Permanent prostate brachytherapy involves permanent radioactive seeds which slowly release radiation over a period of time. All patients for brachytherapy are carefully assessed regarding the size of the prostate and any potential obstruction as this can be a problem in larger prostates or in patients with pre-existing obstruction to their flow.
The lower levels of radiation in the seeds are not generally harmful to others but as a precaution you will be asked to avoid close contact with children and pregnant women for a short time. The subsequent follow up will require long term PSA levels to monitor for trends to assess for treatment success. In order to gain optimal access to the common iliac bifurcation, the five trocars were placed in a more cephalad position than in patients undergoing radical prostatectomy without RALEPLND. The robotic-assisted laparoscopic approach in itself does not seem to limit a surgeon's ability to perform a complete extended pelvic lymph node dissection. The robotic-assisted laparoscopic approach does not seem to preclude a complete extended PLND.
This is reflected by a rapidly increasing number of publications reporting various refinements of technique as well as functional outcomes and early oncologic results [1], [2], and [3]. In 99 of these patients, we performed RALEPLND prior to robotic-assisted laparoscopic radical prostatectomy (RALRP). Patients with a clinical T3 tumor who opted for radical prostatectomy were included as well.
The transperitoneal route was chosen in all patients undergoing RALEPLND on account of excellent working space. The 8-mm robotic trocars are placed pararectal on the right side and in a more lateral position on the left side (b, c). Therefore, in the manuscript and especially in the DVD, we highlight the specific landmarks that should be identified during the course of the dissection. Special attention is paid to the careful dissection of the tissue medially to the internal iliac artery. Of major importance is the identification of several important landmarks, namely, the median and medial umbilical folds and the pulsation of the external iliac artery. At the latest, the bifurcation of the common iliac artery should be visible after the completion of the dissection of the external packet.
The lymph node packets from each region are removed and sent to the pathologist separately.


Much has been written about dissection templates, indications, and oncologic outcome for extended and limited lymph node dissection in patients with prostate cancer [5], [6], [7], [9], [12], and [18]. The robotic-assisted dissection of lymphatic tissue at the proximal course of the obturator nerve is difficult due to impaired vision during retrograde dissection.
An important caveat is not using a specimen bag to retrieve the lymph node packets, as this could pose a risk for port site recurrence. The robotic-assisted laparoscopic approach in and of itself does not seem to preclude a complete extended pelvic lymph node dissection.
Strebel had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. We are deeply grateful to Stefan Schwyter for his excellent preparation of the illustrations and to René Senn for the ease in the postproduction of the DVD. Professor Appu is one of a handful of urologists to have completed a formal brachytherapy fellowship with the international pioneer brachytherapy Dr.
The initial potency rates are also better but longer term studies suggest that the curves equalise to surgical outcome. The thin tubes are inserted through the skin into your prostate at precise locations after MRI planning. Brachytherapy is an excellent treatment option in carefully selected patients with the appropriate low risk prostate cancer and prostate anatomy. After identification of important landmarks, the lymphatics covering the external iliac vein, the obturator lymphatic packet, and the lymphatics overlying the internal iliac artery were removed on both sides. Yet ever since the initial reports by Guilloneau et al, robotic lymph node dissection in patients undergoing radical prostatectomy has not received much attention in the robotic urological community [4]. In two patients referred to our department for staging purposes only, we performed only RALEPLND without RALRP; the reasons were that in one case, the bulky lymph node packets subsequently tested positive in the frozen section analysis, while the second patient refused radical prostatectomy and opted for radiotherapy. Using a three-arm Da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA), we routinely placed five trocars. One assistant trocar (12mm) is placed in a medial and cranial position to the anterior superior iliac spine (d).
Alternatively, following the medial umbilical ligament down to the pelvic floor will lead to the internal iliac artery.
Only packets that are too big to be removed through the 12-mm trocar are retrieved within a specimen bag. The lack of standardization in the terminology and the definitions of anatomic dissection boundaries make a comparison among published data difficult [6]. Unfortunately, several authors use the terms low, intermediate, and high risk in different ways, which, again, makes comparison among results difficult [5], [13], and [15]. Separation of the external iliac vessels allows for antegrade dissection and proper clearance of this region (Fig. Although a port site recurrence after laparoscopic radical prostatectomy in general is exceedingly rare in patients with intermediate- and high-risk features, it might be increased [26] and [27]. You will need to undergo scans including MRI and 3D reconstructions to accurately characterise the size and anatomy of your prostate.
These tubes are connected to a machine that will feed radioactive energy into the prostate and is left in place for a certain amount of time.
This is in contrast to the ongoing debate concerning the extent of and the indication for a lymph node dissection in patients undergoing radical prostatectomy for prostate cancer [5], [6], [7], [8], and [9]. All of these trocars were placed in a more cephalad position than in patients undergoing RALRP without RALEPLND in order to gain better access to the common iliac bifurcation. This trocar setup provides additional working space for the second assistant trocar (5mm) between the camera and right robotic trocar (e). After identification of these landmarks, the incision of the peritoneum starts laterally to the medial umbilical fold longitudinally along the external iliac vessels (Fig.
The fibrofatty tissue containing the lymphatics overlying the internal iliac artery and its obturator and especially the medial vesical branches is completely removed (Fig.
We chose a dissection template that was well defined by others not only in order to facilitate comparison of the results but also because good evidence is provided in the literature to support this dissection template [9] and [16]. Basically, we chose to perform an extended lymph node dissection in intermediate- and high-risk patients according to the definition of D’Amico et al [21]. It is of note that the frequency of these complications was similar to other reports, although we placed no drains [5], [9], [13], and [15]. The radioactive seeds will then be inserted under anaesthesia so you are not aware of the procedure and will fee no discomfort. This usually requires an overnight stay and the treatment is often repeated for high risk prostate cancer.
There is much confusion among different authors and centers concerning the terminology and the boundaries of the lymph node dissection [10] and [11]. The trocar for the robotic camera was placed in the midline sub- or supraumbilical depending on how tall the patient was. The lymphatic packet is grasped and retracted in a cephalad and medial direction, which allows for blunt and sharp dissection of the packet from the underlying vein. The dissection is initiated at the angle between the external iliac vein and the pubic bone. One important advantage of this dissection template is the preservation of the lymphatics overlying the external iliac artery, thus decreasing the risk of lymphedema of the lower extremities [5] and [15]. Therefore, based on our results, we question the need to place two drains in patients undergoing extended lymph node dissection, at least when choosing a robotic-assisted transperitoneal approach.
Outside of study protocols, a single retrieval bag might suffice, as an assessment of lymph node metastases by different sites is not indicated. Randomized prospective evaluation of extended versus limited lymph node dissection in patients with clinically localized prostate cancer. Laparoscopic pelvic lymph node dissection for prostate cancer: comparison of the extended and modified techniques. The template of the primary lymphatic landing sites of the prostate should be revisited: results of a multimodality mapping study. Impact of surgical volume on the rate of lymph node metastases in patients undergoing radical prostatectomy and extended pelvic lymph node dissection for clinically localized prostate cancer. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer.
Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy in prostate cancer: high incidence of lymph node metastases. An ultrasound probe is inserted through your rectum and will recreate pictures of your prostate. This treatment carries a higher risk of erectile dysfunction and is generally used less than seed brachytherapy.


Two 8-mm pararectus trocars for the robotic working instruments were placed on the left and right side slightly lower than the camera trocar. Distally, the incision and dissection is carried out until the pubic bone is clearly identified (Fig. Only after clear identification of the obturator nerve, the distal end of the packet is secured with hemolock clips and divided. In this perspective, a median lymph node yield of 19 is well in the range of the published data of the respected open series [5], [9], [12], and [19]. This frequency of detected metastases is similar to other recently reported results [13] and [19]. Pelvic drain placement has been discussed not only to prevent lymphocele formation but also to prevent urinoma formation and postoperative hematoma.
Complications of pelvic lymphadenectomy in 1,380 patients undergoing radical retropubic prostatectomy between 1993 and 2006. The needles will be inserted through the skin using a long fine needle to implant the radioactive seeds. Likewise, recent data suggest renouncing a lymph node excision in low-risk patients [5], [6], and [12]. We placed two additional trocars that were used by a single assistant, usually one 5-mm trocar between the camera and right working trocar and a 12-mm trocar medial and cranial to the right anterior superior crest.
The packet is dissected beneath the external iliac vein and proceeds to the pelvic side wall, which is the lateral boundary of the dissection. Additionally, this yield is in line with the frequently quoted study by Weingärtner et al on cadavers considering a lymph node yield of 20 to be an accurate staging procedure [20].
Of note, 25% of all metastatic lymph nodes were detected in the area around the internal iliac artery.
Two recently published articles addressed the issue of pelvic drainage after prostatectomy, concluding that pelvic drainage can be omitted in up to 90% of robotic-assisted prostatectomies [24] and [25].
Tension to the medial umbilical ligament is of importance to dissect the lymphatic tissue in the hypogastric region. All four console surgeons are familiar either with open extended pelvic lymph node dissection or laparoscopic lymph node dissection in patients with prostate cancer. Good outcome for patients with few lymph node metastases after radical retropubic prostatectomy.
A pelvic drain can often be avoided after radical retropubic prostatectomy—an update in 552 cases. Pathologically confirmed port site metastasis after laparoscopic radical prostatectomy: case report and literature review.
Each seed is about the size of a grain of rice and will slowly emit radiation within the prostate. Data on conventional laparoscopic pelvic lymph node dissection in patients with prostate cancer are widely available [13], [14], and [15].
In patients with a narrow pelvis, we placed the trocar for the robotic camera 3–4cm to the left of the umbilicus in order to gain additional space for the assistant trocars (Fig. Proximally, the peritoneal incision proceeds up to the crossing of the ureter over the common iliac artery (Fig.
The proximal attachments of the packet are dissected using a combination of sharp and blunt dissection, always paying close attention to avoid any sharp, blunt, or thermal injury to the nerve. The number of metastatic lymph nodes with regard to pathologic Gleason score and pathologic T stage are shown in Table 2 and Table 3. Although this frequency is lower than in other reports, these findings support the idea of including the area around the internal iliac artery into the dissection template for extended pelvic lymph node dissection, as pointed out by other authors [9] and [22]. In accordance with these two recently published articles, we assessed the integrity of the vesicourethral anastomosis intraoperatively in all patients of our series with a bladder filling with 50–100ml saline. However, two out of four surgeons were robotic novices and thus had no experience in robotic lymph node dissection. Robotic-assisted laparoscopic prostatectomy: functional and pathologic outcomes with interfascial nerve preservation. Laparoscopic extended pelvic lymph node dissection for prostate cancer: description of the surgical technique and initial results. Anatomical basis for pelvic lymphadenectomy in prostate cancer: results of an autopsy study and implications for the clinic. Yet none of the recently published studies included experience with robotic-assisted laparoscopic pelvic lymph node dissection. Alternatively, it is possible to identify the obturator nerve early in the course of the obturator dissection.
This is possibly reflected in the median lymph node yield of the first 50 patients being 16 compared to the second 49 patients, for whom median node yield was 21. Thus, to date, there is still a paucity of data in the literature on robotic-assisted laparoscopic extended pelvic lymph node dissection (RALEPLND) in patients with prostate cancer. When separating the external iliac artery and vein just distal to the bifurcation of the common iliac artery, the obturator nerve becomes visible in its proximal course (Fig. The aim of this study was to assess the technical feasibility and to analyze our experience with RALEPLND. However, the main purpose of this analysis was to assess the technical feasibility and the nodal yield of the intervention, not to redefine indications and the extent of pelvic lymph node dissection in patients with prostate cancer. In addition, our surgical technique of RALEPLND is presented in detail in the complementary video. After these steps, the cephalad and caudal boundaries of the lymph node dissection are defined.
However, we perform this maneuver in any case at the end of the dissection of the obturator fossa to ascertain that all lymphatic tissue has been cleared out of this region.
Lymphedema was observed in two patients: In one patient, a bilateral lymphedema of the lower leg resolved after physical therapy with supportive lymphatic drainage. The overall median blood loss for RALRP, including the extended lymph node dissection, was 500ml, and two patients received blood transfusions (2 units per patient).
However, the transfusions were not related to (excessive) bleeding associated with RALEPLND but rather to bleeding during RALRP.



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