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Lymph node dissection for intermediate and high risk prostate cancer


Medical editor Bjørn Brennhovd
Urologist
Oslo University Hospital
Norway

General

Studies show that an extended lymph node dissection including the area around the internal and external iliac arteries, as well as the traditional obturator area, may be therapeutic in certain patients having few lymph node metastases. A correlation exists between the number of removed lymph nodes and the time to progression, and certain patients do not have PSA recurrence after 10 years without adjuvant therapy. However, an extensive lymph node dissection causes increased morbidity with lymphocele and lymphedema. Therefore, the benefit of the procedure must outweigh the risk.

At Oslo University Hospital, routine robot-assisted laparoscopic lymph node dissections are performed during the same surgery as the prostatectomy. This procedure is rarely performed alone.  

Indications

  • Staging of intermediary and high risk cancer

Goal

  • To diagnose microscopic tumor spreading
  • Possible curative effect if performed with radical prostatectomy

Preparation

  • Enema
  • Thrombosis prophylaxis
  • Antibiotic prophylaxis
  • Foley catheter

Implementation

During open surgery, a low midline incision is made from the symphysis to the umbilicus. The entire procedure is extraperitoneal.

  • During laparoscopy, the procedure is performed transperitoneally.
  • Remove fatty tissue and lymph nodes in one area limited to the urethral crossing over the common iliac artery, laterally to the external iliac artery and medially to the internal iliac artery. 
  • Identify the obturatorial nerve and obturatorial artery
  • Dissect the fatty tissue off the nerve and vein.
  • Ligate distal lymph vessels.
  • Check the hemostasis.

If staging is completed to assess curative radiation treatment, the nodes are put in formalin.


Follow-up

Observations

  • Bleeding
  • Anastomotic dehiscence
  • Urinary tract infection
  • Blood clot/lung embolism

The patient will have a Foley catheter. He will be trained to clean the catheter and use a leg bag before returning home. The patient should also be informed about erection and continence exercises. After a lymph node dissection with robot-assisted radical prostatectomy, the patient is normally discharged after the second postoperative day.

The Foley catheter is removed at the outpatient clinic 10 days postoperatively. A urine sample is taken for bacterial testing.

The patient will then have an outpatient follow-up check with an urologist 6 weeks after the operation.

The pathology report may take 2 to 3 weeks. This diagnostic test is very resource-demanding for a pathology laboratory.

Delayed effects

  • Incontinence
  • Impotence

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