Standardized and Simplified Extended Pelvic Lymph Node Dissection During Robot-assisted Radical Prostatectomy: The Monoblock Technique

OBJECTIVE To describe a simplified technique of extended pelvic lymph node dissection (ePLND) for prostate cancer treated by robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS The technique uses a standardized 10-step procedure to obtain a single tissue monoblock from each side that contains all lymph nodes within the ePLND template. We performed a prospective study of all patients with prostate cancer (n = 134) with a preoperative Gleason score of >= 7 and/or prostate-specific antigen level >10 ng/mL undergoing ePLND before RARP using trans-peritoneal access at our institute from July 2008 to August 2011. The standardized procedure consisted of 10 distinct surgical steps. Dissection obtained all lymph nodes and surrounding fatty tissue in a single monoblock applying the following ePLND template: cranially, the ureter crossing the common iliac artery; caudally, the femoral canal; laterally, the medial border of the external iliac artery; and medially, the medial border of the hypogastric artery. The number of resected lymph nodes and postoperative ePLND-related complications according to the modified Clavien classification were documented. RESULTS The median number of resected lymph nodes was 14 (interquartile range 11-19). Complications related to ePLND were seen in 8 patients (5.9%). CONCLUSION The robot-assisted monoblock ePLND technique is simple to perform, offers a good overview of the operative field during the entire procedure, permits complete and radical removal of the lymphatic tissue contained in the ePLND template, and avoids spreading of fatty and lymphatic tissue within the abdominal cavity. UROLOGY 81: 446-450, 2013. (C) 2013 Elsevier Inc.