eMedicine Specialties > Urology > Surgery

Lymph Node Dissection, Pelvic: Treatment

Author: Frank Papanikolaou, MD, Clinical Fellow, The Hospital for Sick Children, Department of Surgery, Division of Urology, University of Toronto, Canada
Contributor Information and Disclosures

Updated: Jun 13, 2008

Treatment

Preoperative Details

Staging with pelvic CT scanning for bladder cancer can provide information about the bladder tumor and the presence of pelvic or paraaortic lymphadenopathy. However, the presence of lymphadenopathy does not necessarily indicate metastatic disease. Moreover, CT scanning can fail to reveal nodal metastases in up to 40% of cases.

The staging information that is useful for pelvic lymph node dissection (PLND) in prostate cancer includes T stage, prostate-specific antigen level, and Gleason score. Currently, imaging studies have no role in the evaluation of the pelvic lymph nodes.

Intraoperative Details

Bladder cancer

The limits of PLND in bladder cancer are as follows: The cephalad limit is 2 cm above the bifurcation of the common iliac artery, the caudad limit is the endopelvic fascia, the medial limit is the bladder, and the lateral limit is the genitofemoral nerve.

A PLND for bladder cancer is usually performed in conjunction with a radical cystectomy. A modified dissection, leaving the nodes along the external iliac artery intact, may be appropriate in low-risk patients because skeletonization of the external iliac artery is associated with an increased risk of lymphedema.

The procedure is as follows:

  1. Position the patient supine in the dorsal lithotomy position.
  2. Make a midline lower-abdominal incision. For a PLND in conjunction with a radical cystectomy, the incision should extend from the pubic symphysis to above the umbilicus. Incise the fascia and peritoneum at the level of the umbilicus.
  3. Explore the abdominal and pelvic viscera and paraaortic nodes for evidence of metastatic spread.
  4. Dissect the peritoneum off the posterior rectus sheath.
  5. Develop a flap of peritoneum in the shape of a V, with its apex at the umbilicus and its ends directed toward the internal inguinal rings. Grasp the apex and pull it caudad.
  6. Incise the peritoneum and investing tissue covering the external iliac vessels to the bifurcation of the common iliac artery. Isolate the ureters as they pass in front of the common iliac arteries.
  7. Dissect free the psoas and iliopsoas muscles.
  8. Skeletonize the external iliac artery from the inguinal ligament to 2 cm above the bifurcation of the common iliac artery. Identify and preserve the circumflex iliac, inferior epigastric vessels, and the genitofemoral nerve.
  9. Divide the nodal package anteromedially over the external iliac artery. Roll the tissue posteriorly off the artery, and then dissect it off the external iliac vein.
  10. Dissect the fat overlying the fascia of the psoas and iliopsoas muscles. Identify the obturator fossa by retracting the bladder medially, and ligate and divide the obturator vessels. Carry the dissection of fat and nodes medially and superiorly along the obturator vessels. At the junction of the obturator vessels with the internal iliac vessels, ligate and divide the obturator vessels, if necessary.
  11. Remove the pelvic lymph node packet, and send it for histologic evaluation.
  12. Repeat the procedure on the opposite side.

Prostate cancer

PLND in prostate cancer can be performed as either an open or a laparoscopic procedure. In addition, the open procedure can be performed as part of a radical prostatectomy or as a minilaparotomy. The minilaparotomy and laparoscopic approaches can be used when a perineal approach is being considered.

The discussion that follows applies to both the open and laparoscopic approach, with procedural information specific to each and then information common to both. However, the technical aspects of laparoscopy are not addressed in this article.

The limits of node dissection for PLND in prostate cancer are as follows: The cephalad limit is the bifurcation of the common iliac artery, the caudad limit is the node of Cloquet, the medial limit is the obturator vessels, and the lateral limit is the pelvic sidewall.

The procedure specifically for open PLND is as follows:

  1. Proceed to make a midline lower-abdominal incision. For a PLND in a patient with prostate cancer, the incision should extend from the pubic symphysis to just below the umbilicus. Incise the anterior rectus fascia at the decussation of the fibers along the length of the skin incision.
  2. Incise the transversalis fascia beneath the rectus muscle. This allows mobilization of the peritoneum medially and cephalad.
  3. Isolate, divide, and ligate the vas deferens.
  4. Gain exposure with a Bookwalter retractor. To retract the bladder, place a malleable retractor blade on one side of the nodes and a straight blade on the opposite side. Place a Jackson retractor on top of the external iliac vein.

The procedure specifically for laparoscopic PLND is to create a pneumoperitoneum and obtain laparoscopic access using 3 operating ports. Incise the peritoneum midway between the internal ring and the obliterated umbilical artery to expose the external iliac vein.

The procedure common to both the open and laparoscopic techniques is as follows:

  1. Skeletonize the external iliac vein. Clean down to the pelvic sidewall alongside the external iliac vein, and insert a vein retractor.
  2. Push the fatty tissue along the Cooper ligament, laterally towards the distal margin of the nodal packet. Tease the node of Cloquet from the femoral canal. Clip and divide.
  3. Identify and preserve the obturator nerve and vessels.
  4. Remove the pelvic lymph node packet, and send it for histologic evaluation.
  5. Repeat the procedure on the opposite side.

Complications

Complications of pelvic lymph node dissection (PLND) that are common to both bladder and prostate cancer include the following:

  • During dissection of the lymph nodes, acute bleeding may result from injury to the iliac vessels. Treatment entails repair of the vascular injury using an open surgical technique.
  • Postoperative development of a deep vein thrombosis, with the possibility of a resultant pulmonary embolism, remains a significant problem with PLND. Postoperative prophylaxis with subcutaneous heparin can decrease this risk.
  • Obturator nerve injury with resultant loss of adduction of the thigh is rare.
  • Development of a symptomatic lymphocele is also rare. Treatment includes conservative management, percutaneous drainage, or marsupialization.
  • Lymphedema of the extremities can result in significant morbidity. Sparing of the lymphatics lateral to the iliac vessels can decrease the rate of this complication.

More on Lymph Node Dissection, Pelvic

Overview: Lymph Node Dissection, Pelvic
Workup: Lymph Node Dissection, Pelvic
Treatment: Lymph Node Dissection, Pelvic
Follow-up: Lymph Node Dissection, Pelvic
References
[ CLOSE WINDOW ]

References

  1. Skinner DG. Management of invasive bladder cancer: a meticulous pelvic node dissection can make a difference. J Urol. Jul 1982;128(1):34-6. [Medline].

  2. Vieweg J, Whitmore WF Jr, Herr HW, Sogani PC, Russo P, Sheinfeld J, et al. The role of pelvic lymphadenectomy and radical cystectomy for lymph node positive bladder cancer. The Memorial Sloan-Kettering Cancer Center experience. Cancer. Jun 15 1994;73(12):3020-8. [Medline].

  3. Paik ML, Scolieri MJ, Brown SL, et al. Limitations of computerized tomography in staging invasive bladder cancer before radical cystectomy. J Urol. Jun 2000;163(6):1693-6. [Medline].

  4. Messing EM, Manola J, Sarosdy M, Wilding G, Crawford ED, Trump D. Immediate hormonal therapy compared with observation after radical prostatectomy and pelvic lymphadenectomy in men with node-positive prostate cancer. N Engl J Med. Dec 9 1999;341(24):1781-8. [Medline].

  5. Pilepich MV, Krall JM, al-Sarraf M, John MJ, Doggett RL, Sause WT, et al. Androgen deprivation with radiation therapy compared with radiation therapy alone for locally advanced prostatic carcinoma: a randomized comparative trial of the Radiation Therapy Oncology Group. Urology. Apr 1995;45(4):616-23. [Medline].

  6. Abeloff MD, Armitage JO, Lichter AS, Niederhuber JE, eds. Urethral Carcinoma. In: Clinical Oncology. 2nd ed. St Louis, Mo: Churchill Livingstone; 2000.

  7. Bolla M, Gonzalez D, Warde P, Dubois JB, Mirimanoff RO, Storme G, et al. Improved survival in patients with locally advanced prostate cancer treated with radiotherapy and goserelin. N Engl J Med. Jul 31 1997;337(5):295-300. [Medline].

  8. Carter H, Partin AW. Diagnosis and Staging of Prostate Cancer. In: Walsh PC, Retik AB, Vaughn ED, Wein AJ, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998:2519-37.

  9. Granfors T, Modig H, Damber JE, Tomic R. Combined orchiectomy and external radiotherapy versus radiotherapy alone for nonmetastatic prostate cancer with or without pelvic lymph node involvement: a prospective randomized study. J Urol. Jun 1998;159(6):2030-4. [Medline].

  10. Hinman F. Pelvic Lymphadenectomy. In: Hinman F, ed. Atlas of Urologic Surgery. 2nd ed. Philadelphia, Pa: WB Saunders; 1998:517-24.

  11. Hinman F. Modified Pelvic Lymph Node Dissection, Laparoscopic and Minilaparotomy Pelvic Lymph Node Dissection. In: Hinman F, ed. Atlas of Urologic Surgery. 2nd ed. Philadelphia, Pa: WB Saunders; 1998:465-75.

  12. Janetschek G. Pelvic lymph node dissection in prostate cancer: editorial review. Curr Opin Urol. Mar 2005;15(2):65-7. [Medline].

  13. Koppie TM, Vickers AJ, Vora K, Dalbagni G, Bochner BH. Standardization of pelvic lymphadenectomy performed at radical cystectomy: can we establish a minimum number of lymph nodes that should be removed?. Cancer. Nov 15 2006;107(10):2368-74. [Medline].

  14. Messing EM, Catalona W. Urothelial Tumors of the Urinary Tract. In: Walsh PC, Retik AB, Vaughn ED, Wein AJ, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998:2327-2410.

  15. Mills RD, Fleischmann A, Studer UE. Radical cystectomy with an extended pelvic lymphadenectomy: rationale and results. Surg Oncol Clin N Am. Jan 2007;16(1):233-45. [Medline].

  16. Partin AW, Kattan MW, Subong EN, Walsh PC, Wojno KJ, Oesterling JE, et al. Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update. JAMA. May 14 1997;277(18):1445-51. [Medline].

  17. Stein JP. The role of lymphadenectomy in patients undergoing radical cystectomy for bladder cancer. Curr Oncol Rep. May 2007;9(3):213-21. [Medline].

  18. Stein JP, Penson DF, Cai J, Miranda G, Skinner EC, Dunn MA, et al. Radical cystectomy with extended lymphadenectomy: evaluating separate package versus en bloc submission for node positive bladder cancer. J Urol. Mar 2007;177(3):876-81; discussion 881-2. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

pelvic lymphadenectomy, lymph node dissection, pelvic lymph node dissection, PLND, bladder cancer, prostate cancer, urethral cancer, penile cancer, genitourinary cancer

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Frank Papanikolaou, MD, Clinical Fellow, The Hospital for Sick Children, Department of Surgery, Division of Urology, University of Toronto, Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Dan Theodorescu, MD, PhD, Paul Mellon Professor of Urologic Oncology, Department of Urology, University of Virginia Health Sciences Center
Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center
J Stuart Wolf, Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Bradley Fields Schwartz, DO, FACS, Associate Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.