Sequencing Robot-Assisted Extended Pelvic Lymph Node Dissection Prior to Radical Prostatectomy: A Step by Step Guide to Exposure and Efficiency

To describe a novel, step-by-step approach to robot-assisted extended pelvic lymph node dissection (EPLND) at the time of robot-assisted radical prostatectomy (RARP) for intermediate to high risk prostate cancer.

The sequence of EPLND is at the beginning of the operation to take advantage of greater visibility of the deeper, hypogastric planes. The urachus is left intact for an exposure/retraction point. The anatomy is described in terms of lymph nodes that are easily retrieved, versus those that require additional manipulation of the anatomy, and a determined surgeon. A representative cohort of 167 RARP's was queried for representative metrics that distinguish the EPLND: 146 primary cases and 21 with neoadjuvant systemic therapy.

The median (Inner Quartile Range, IQR) lymph node yield was 22 (16-28) for primary surgeries and 21 (16-23) for neoadjuvant cases. The percentage of cases with positive nodes (pN1) was 16.4% for primary and 29% for neoadjuvant. The hypogastric lymph nodes were involved in 75% of pN1 primary cases-uniquely positive in 33%. Each side of EPLND took the attending a median 16 minutes (13-20) and trainees 25 (24-38).

Robotic extended pelvic lymph node dissection prior to robotic prostatectomy provides anatomical approach to surgical extirpation mimicking the open approach. We believe this sequence offers efficiency and efficacy advantages in high risk and select intermediate risk prostate cancer patients undergoing robotic prostatectomy. This article is protected by copyright. All rights reserved.

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