eMedicine Specialties > Urology > Surgery

Laparoscopic Pelvic Lymph Node Dissection

Author: Jay T Bishoff, MD, Director, Section of Endourology, Department of Urology, Urology San Antonio
Coauthor(s): William J Harmon, MD, Director of Minimally Invasive Urologic Surgery, Urology San Antonio, PA, Associate Clinical Professor, Division of Urology, UTHSC, San Antonio, TX; Robert G Moore, MD, Director of Endourology and Minimally Invasive Surgery, Director of Endourology Fellowship, Associate Professor, Department of Surgery, Division of Urology, Saint Louis University
Contributor Information and Disclosures

Updated: Jan 29, 2007

Introduction

History of the Procedure

The introduction of prostate-specific antigen (PSA) as a screening test for prostate cancer created a dramatic shift or stage migration, which led to the diagnosis of prostate cancer in earlier stages of the disease. As a result, more patients are now undergoing treatment for prostate cancer, exercising many different treatment options, which include radical prostatectomy (open, laparoscopic, robotic), brachytherapy, external beam radiation therapy, intensity-modulated radiation therapy (IMRT), cryosurgery, microwave thermotherapy, and high-frequency ultrasound therapy.

Despite refinements in surgical technique of all the treatment options, radical prostatectomy remains an operative procedure that is associated with significant morbidity. Complications that result from these different treatment options, including urinary incontinence, impotence, and fecal incontinence, dictate a conservative approach in patients shown to have metastatic disease. In addition, decisions concerning nonsurgical treatment of prostate cancer using external beam radiation, brachytherapy, or adjuvant hormonal therapy may be altered in cases with microscopic metastatic disease. Thus, the goal of laparoscopic pelvic lymph node dissection (LPLND) is to exclude high-risk patients from noncurative therapy.

Since the establishment of LPLND as a staging procedure in patients with prostate cancer, indications have been expanded to include the staging of bladder, penile, and urethral malignancies. In these other types of genitourinary cancers, the presence of metastatic disease also has a tremendous impact on therapeutic choices.

Indications

Noninvasive imaging technologies including computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) scan can be useful in the diagnosis of metastatic disease in a number of malignancies. However, these imaging modalities are inadequate to reliably diagnose pelvic lymph node involvement in most patients with prostate cancer and can have false-positive findings due to infection or inflammation of the prostate after biopsy.

The utility of capromab pendetide (ProstaScint) imaging in the management and staging of prostate cancer continues to be explored but has not yet been fully determined. The appropriate techniques for obtaining images, the clinical indications, and its use in clinical staging of pelvic spread of prostate cancer still are being optimized. Once additional information is gathered through careful clinical trials, capromab pendetide scans may be a complementary diagnostic tool to PSA, Gleason score determined by prostate biopsy findings, and digital rectal examination.

Pelvic lymphadenectomy remains the criterion standard for detecting metastatic spread to the pelvic lymph nodes. The indications for staging pelvic lymphadenectomy prior to prostatectomy include (1) prebiopsy serum PSA greater than 20; (2) Gleason sum greater than or equal to 8; (3) 5 or more positive systematic sextant biopsies or total linear involvement of 28% or more; (4) palpably advanced local disease, clinical stages T3 and T4; (5) positive seminal vesicle biopsy; and (6) enlargement of pelvic lymph nodes as seen by pelvic imaging. Using standard nomograms, such as the Partin tables below, we can predict that 24-51% of patients with PSA greater than 20 and a Gleason sum of 8-10 will have nodal disease and would not be candidates for curative resection.

Table 1. Multivariate Logistic Regression Analysis for Prediction of Pathologic Stage Using Prostate-Specific Antigen, Gleason Score, and Clinical Stage (TNM): Prediction of Organ-Confined Disease (percent)

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Table 2. Multivariate Logistic Regression Analysis for Prediction of Pathologic Stage Using Prostate-Specific Antigen, Gleason Score, and Clinical Stage (TNM): Prediction of Lymph Nodal Status (percent)

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Numbers represent the percent predictive probability (95% confidence interval) of the patient having a given final pathological stage based on a multinomial log-liner regression of all 3 variables (Partin, 1997).

Other genitourinary malignancies requiring pelvic lymphadenectomy often need a more extensive nodal dissection that includes removing the common iliac, external iliac, and obturator lymph nodes. Transitional cell carcinoma of the bladder with lymphatic spread often has an aggressive clinical course. Like prostate cancer, noninvasive techniques to determine nodal status are inadequate, and pelvic lymphadenectomy is the most accurate way to definitively establish the presence of metastatic disease in the lymph nodes.

Given the poor survival rate of patients with aggressive bladder cancer, those with enlarged lymph nodes on pelvic imaging studies may be candidates for laparoscopic staging prior to radical cystoprostatectomy. Patients who choose bladder-sparing treatment with chemotherapy, radiation therapy, or partial cystectomy and those who desire orthotopic neobladder construction also may benefit from staging laparoscopic pelvic lymph node dissection (LPLND).

Carcinoma of the penis has a characteristic pattern of nodal spread depending on the location and depth of the primary lesion. Laparoscopic extended pelvic lymphadenectomy may be used in the initial staging of penile cancer.

Laparoscopic pelvic lymph node dissection in the staging of urethral cancer has been recommended for patients meeting the following criteria: (1) radiologic evidence of pelvic lymphadenopathy not accessible to fine-needle aspiration biopsy, (2) preceding exenterative surgery in tumors of the proximal urethra, and (3) patients with locally invasive distal urethral lesions. The use of laparoscopic pelvic node dissection for bladder cancer, urethral cancer, and penile cancer continues to develop, and further study is necessary to establish definitive indications.

Contraindications

Contraindications for laparoscopic pelvic lymph node dissection (LPLND) include severe cardiopulmonary disease, bowel obstruction, active infection, and uncorrected coagulopathy. Morbid obesity, prior abdominal surgery, hiatal hernia, history of pelvic fractures, hip replacement, or large pelvic or intra-abdominal masses may be considered as relative contraindications. Relative contraindications are related to the surgeon's experience with laparoscopic surgery and LPLND.

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