Laparoscopic extraperitoneal and transperitoneal pelvic lymphadenectomies for prostate cancer

The description of the laparoscopic extraperitoneal and transperitoneal pelvic lymphadenectomies for prostate cancer covers all aspects of the surgical procedure used for the management of prostate cancer. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, external limit, internal limit, inferior limit, posterior limit, superior limit, extraction, left lymphadenectomy, end of procedure. Consequently, this operating technique is well standardized for the management of this condition.

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Laparoscopic   extraperitoneal   and   transperitoneal   pelvic   lymphadenectomies   for   prostate   cancer

Authors
C Saussine, H Lang
Abstract
The description of the laparoscopic extraperitoneal and transperitoneal pelvic lymphadenectomies for prostate cancer covers all aspects of the surgical procedure used for the management of prostate cancer.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, external limit, internal limit, inferior limit, posterior limit, superior limit, extraction, left lymphadenectomy, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.
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2002-08
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WeBSurg.com, Aug 2002;2(08).
URL: http://www.websurg.com/doi-ot02en292.htm

Laparoscopic   extraperitoneal   and   transperitoneal   pelvic   lymphadenectomies   for   prostate   cancer

1. Introduction
Pelvic lymphadenectomy is performed to evaluate the extent of lymph node involvement for the staging of prostatic adenocarcinoma. It is often the first operative step of a radical retropubic prostatectomy, although it may also be performed separately. Since 1991, it has become feasible via laparoscopy (Schuessler et al., 1991).
Only the pelvic lymph node chains are removed. The higher the number of pelvic lymph node chains removed, the greater the opportunity to find lymph node invasion. Morbidity also increases with the number of lymph node chains removed.
Most surgeons perform a limited pelvic lymph node dissection with removal of the majority of the internal iliac nodes, including the obturator nodes. Limited lymphadenectomy offers a combination of efficacy and lower morbidity. The findings are used to determine the subsequent course of treatment.
A transperitoneal or an extraperitoneal approach to the pelvic lymph nodes may be used.
2. Anatomy
• Lymph node network
The prostate lymph node network originates from gland acini and forms nodes that are increasingly spread out towards the periphery. These nodes make up the subcapsular periprostatic tissue network that continues as lymphatics that accompany prostate-supplying vessels. There are large anastomoses that are connected to the lymphatics of the seminal vesicles, the gallbladder, and the rectum (Weingartner et al., 1996).
The lymphatic ducts form 4 distinct pedicles:
1. External iliac pedicle
2. Internal iliac pedicle
3. Posterior pedicle
4. Inferior pedicle
• Lymphatic ducts
• External iliac pedicle
1. Femoral ring
2. Deep inguinal ring
3. Inguinal ligament
4. External iliac chain
5. External iliac node
The external iliac pedicle terminates at the external iliac lymph node chain.
The lymph nodes of the external iliac pedicle are also involved in the lymphatic drainage of the lower limbs and the scrotum.
• Internal iliac pedicle
1. Obturator foramen
2. Obturator nodes
3. Inferior vesical artery
4. Obturator nerve
5. Internal iliac node
The internal iliac pedicle includes the obturator nodes and terminates at the internal iliac nodes.
• Posterior pedicle
1. Sacral nodes
2. Promontory nodes
3. Common iliac nodes
4. Preaortic nodes
The posterior pedicle drains towards the promontory and sacral nodes.
• Inferior pedicle
1. Inferior pedicle
2. Pudendal artery
3. Sectioned pelvic floor muscles
4. Middle rectal artery
5. Internal iliac lymph node
Adjacent to the pudendal artery, the inferior pedicle drains towards the internal iliac lymph node chain.
• Lymph node metastases
1. Internal iliac nodes
2. Obturator nodes
3. Sacral nodes
4. External iliac nodes
Eighty five percent of lymph node metastases involve the internal iliac nodes first. Metastases then reach the lymph nodes of the external iliac chain or of the sacral chain. Common iliac nodes and preaortic nodes are rarely invaded.
External iliac lymph node invasion or sacral lymph node invasion is always accompanied by the invasion of internal iliac lymph nodes.
3. Pelvic lymphadenectomies
• Pelvic lymph nodes
1. Common iliac nodes
2. Promontory nodes
3. Presacral and presciatic nodes
4. Internal iliac nodes
5. External iliac nodes
6. Obturator nodes
• Types of dissections
• Classic lymphadenectomy
Various pelvic lymphadenectomies can be performed (Stone et al., 1997).
Classic lymphadenectomy consists of removing internal iliac, external iliac and common iliac lymph nodes.
• Extended lymphadenectomy
The sacral lymph nodes are removed in addition to those removed in classic lymphadenectomy.
• Modified lymphadenectomy
Modified pelvic lymphadenectomy is performed to remove internal iliac nodes, including the obturator nodes.
• Obturator lymphadenectomy
Only the obturator nodes are removed.
In prostate cancer, pelvic lymphadenectomies are either modified or obturator, in order
to establish a diagnosis while causing minimal side effects.
• Limits of node dissection
The anatomical limits of modified pelvic lymphadenectomy are as follows:
- anteriorly, the posterior surface of the external iliac vein;
- posteriorly, the obturator nerve;
- cephalad, the confluence of the of the external iliac vein and the internal iliac vein;
- caudad, the iliopubic branch of the pelvis with the pectineal ligament;
- medially, the umbilical artery;
- laterally, muscles of the pelvic sidewall.
4. Indications
Pelvic lymphadenectomy offers no diagnostic or therapeutic benefit in cases of metastatic cancer.

Indications
Pelvic lymphadenectomy is part of the evaluation of the extent of prostate adenocarcinoma.

Localized prostate cancer:
Pelvic lymphadenectomy is indicated in cases of localized prostate cancer.
Certain authors no longer recommend lymphadenectomy in cases of localized prostate cancer with prostate-specific antigen (PSA) <10ng/mL and a Gleason score <7 before curative therapy (Fergany et al., 2000). This attitude is controversial, as positive lymph nodes have been found during lymphadenectomies for cancers fulfilling these criteria.

T3 prostate cancer:
The risk of lymph node invasion is more considerable and averages 10% in T3 prostate cancer involving tumor extension through the prostate capsule or invasion of the seminal vesicles (Kava et al., 1998). Studies have shown that laparoscopy does not have a negative effect on tumor behavior and clinical outcome when there is lymph node malignancy (Caddedu et al., 1997). When lymph nodes are invaded, the patient is considered metastatic. Castration is therefore necessary.
When lymph nodes are not invaded, external beam radiation therapy centered on the prostate and seminal vesicles limits the side effects of pelvic irradiation.

Cancer treated by radiation therapy:
For recurrence following radiation therapy, laparoscopic lymphadenectomy has been suggested (Lund et al., 1997).

Contraindications
Contraindications to laparoscopic lymphadenectomy are mainly related to anesthesia.

Anesthesia:
Contraindications are as follows: any patient with a contraindication to general anesthesia; patients with acute respiratory failure who tolerate pneumoperitoneum poorly.

Coagulation anomalies:
Blood coagulation tests should be normal before performing pelvic lymph node dissection.

Previous abdominal surgery:
Transperitoneal lymphadenectomy can be performed despite previous history of abdominal surgery.
It is necessary to free peritoneal adhesions. In these cases, however, it is easier to use an extraperitoneal approach. The first trocar is introduced using minilaparotomy. In some cases, the freeing of adhesions may not be completely possible and a unilateral lymphadenectomy is performed.
5. Preop period
Depending on the stage of the cancer, pelvic lymphadenectomy has different implications.

Cancer localized in the prostate
Lymphadenectomy is often performed as the first step of a prostatectomy (retropubic or laparoscopic). It can also be performed prior to a perineal prostatectomy, prostate localized radiation therapy or prostate curietherapy. These treatment modalities are applied if the lymphadenectomy does not indicate lymph node metastasis. If positive lymph nodes are found, androgen suppression is proposed.

T3 prostate cancer
Lymphadenectomy is often performed prior to radiation therapy localized to the prostate gland and the seminal vesicles, which may be proposed if no positive lymph nodes are found.
Evaluation of the extent of the disease before lymphadenectomy is often limited to a bone scan. Some authors do not perform bone scans in cases of early cancer with prostate-specific antigen (PSA) <10ng/mL and a Gleason score <7.
If the bone scan shows metastatic invasion, lymphadenectomy is no longer indicated.
In some cases, ultrasonography, CT scan or magnetic resonance imaging point to the likelihood of lymph node invasion.

Anesthetic workup
The preoperative workup focuses on the respiratory and cardiac functions of the patient. Blood coagulation tests should be normal and urine should be sterile prior to operating. The patient is informed of the risks of laparoscopic pelvic lymph node dissection as well as the possibility of required conversion to open surgery. Prior history of laparotomy or surgical inguinal hernia repair with properitoneal meshes increases the risk of conversion due to adhesions.
Bowel preparation is not done routinely. It may consist of enemas performed the evening before and the morning of surgery.
Skin preparation is the same as for conventional surgical lymph node dissection, with shaving of the patient’s hair from the costal margin to mid-thigh area.
6. Operating room set-up
• Patient
- general anesthesia;
- 30° Trendelenburg;
- dorsal decubitus;
- both legs fixed to the table with adhesive tapes (to prevent the patient from slipping because of the Trendelenburg position, especially when the patient is obese);
- both arms placed alongside the body;
- urinary catheter to ensure an empty bladder in order to decrease the risks of bladder perforation, even though the surgeon is not hindered by a full bladder.
• Team
a. Right lymphadenectomy
1. Surgeon
2. Assistant
3. Scrub nurse
The surgeon stands on the patient’s left for a right lymphadenectomy and on the patient’s right for a left lymphadenectomy.
The assistant stands on the patient’s right for a right lymphadenectomy and on the patient’s left for a left lymphadenectomy.
The scrub nurse stands on the patient’s left, next to the surgeon or the assistant.
• Equipment
The laparoscopic unit and the monitor are placed at the patient’s feet. They may be placed more laterally, opposite the surgeon and the assistant, if there is a second monitor.
7. Trocar placement
• Landmarks
- the umbilicus;
- the pubis;
- the right anterior and superior iliac spine;
- the left anterior and superior iliac spine.
• Transperitoneal approach
1. Anterior fascia of the rectus abdominis muscles
2. Posterior fascia of the rectus abdominis muscles
3. Arcuate line
4. Peritoneum
For the transperitoneal approach, the umbilical trocar is placed using a minilaparotomy. This first trocar can be introduced after creating the pneumoperitoneum with a Veress needle. The other trocars are introduced under the visual guidance of the laparoscope.
• Extraperitoneal approach
• Open trocar placement
1. Umbilicus
2. Exposure of the anterior fascia of the rectus abdominis muscles
3. Opening of the anterior fascia of the rectus abdominis muscles
4. Rectus abdominis muscle
5. Anterior fascia of the rectus abdominis muscles
6. Penetration of the preperitoneal retropubic space
For the extraperitoneal approach, the umbilical trocar is placed with an open technique, but without opening the peritoneum. To do this, the anterior fascia of the rectus abdominis muscles is incised transversally. Using scissors, and remaining posterior to the muscles, the surgeon sweeps aside the connective tissue to penetrate the preperitoneal retropubic space.
• Trocars A and B
1. Opening of the anterior fascia of the rectus abdominis muscles
2. Posterior fascia of the rectus abdominis muscles
3. Arcuate line
4. Peritoneum
The space that is created is enlarged laterally to allow for the insertion of trocar A. Insufflation is performed through this trocar and, combined with gentle lateral movements of the laparoscope, the space is made large enough for trocar B.
• Variation
A balloon dilator may be used to create the preperitoneal retropubic space.
• Trocars C and D
1. Epigastric vessels
2. Rectus abdominis muscles
3. Bladder
4. Peritoneum after clearing of attachments
Scissors introduced through trocar B help clear away the attachments between the peritoneum and the posterior surface of the rectus muscles until trocars C and D can be inserted. The peritoneum is dissected free until the epigastric vessels can be seen.
8. Instruments
• Instruments
The instruments required for lymphadenectomy are standard:
1. 0° laparoscope
2. Monopolar scissors
3. Grasper
4. Clip applier
5. Bipolar grasper (optional)
• Instruments in trocars
Positioning the instruments in trocars depends on the side of the lymphadenectomy.
For a right lymphadenectomy, the surgeon uses trocars B and D and the assistant uses trocars A and C.
For a left lymphadenectomy, the surgeon uses trocars B and C and the assistant uses trocars A and D.
9. Exposure
• Transperitoneal approach
The Trendelenburg position causes the intestinal loops to move up towards the upper half of the abdominal cavity. This frees the peritoneum covering the lymph node dissection area. In some cases, a slight rotation improves the exposure. The surgeon may sometimes use a grasper to lift the loops up.
In obese patients, identification of the ductus deferens is difficult. Traction on the spermatic cord makes it possible to mobilize the ductus deferens and distinguish it from the ureter.
Exposure varies between transperitoneal and extraperitoneal approaches.
For the transperitoneal approach, the landmarks are as follows:
1. Sigmoid colon
2. Right deep inguinal ring
3. Ductus deferens
4. Cecum
5. Ileum
6. Promontory
• Extraperitoneal approach
The insufflation of CO2 pushes the peritoneum and its contents cephalad. The Trendelenburg position is usually not required, except in cases of violation of the peritoneum.
10. Exposure/group
• Landmarks
1. Umbilical artery
2. Deep inguinal ring
3. Spermatic vessels
4. Ductus deferens
5. External iliac artery
6. External iliac vein
We usually begin pelvic lymph node dissection on the right side. Depending on the biopsy and imaging data, the surgeon may start on the opposite side.
• Transperitoneal approach
• Peritoneal incision
1. Epigastric vessels
2. Ductus deferens
3. Medial border of the external iliac vein
The lymph node group is approached as the peritoneum is opened. The incision is made parallel and medial to the external iliac artery, whose pulse can be sensed through the peritoneum. The larger the incision, the easier it is to free the superior part of the lymph node group. The ureter constitutes the cephalad limit of the peritoneal incision.
• Ductus deferens
1. Distal segment of the ductus deferens
2. Internal iliac lymph node group
3. External iliac lymph nodes
4. External iliac vein
Division and medial retraction of the ductus deferens favor access to the obturator fossa.
The ductus deferens is dissected in the anterior part of the peritoneal incision. It is clipped and divided. The surgeon holds its internal or distal segment with a grasper. Traction exerted from within opens the pelvic lymph node dissection area. The external iliac vein often appears during this traction; if not, it must be searched for.
• Extraperitoneal approach
1. External iliac vein
2. Ductus deferens
The surgeon searches for the pulse of the external iliac artery. Dissection of the fatty tissue medial to this pulse reveals the external iliac vein. Division of the ductus deferens is not required with the extraperitoneal approach. The ductus deferens, adherent to the peritoneum, is retracted cephalad.
11. External limit
1. Lymph node group
2. Inferior surface
3. External surface
4. Superior surface
5. Posterior surface
6. Internal surface
The principle of the dissection is to gradually circumscribe the limits of the lymph node group.
The internal border of the external iliac vein and the underlying muscles of the pelvic wall are dissected. The surgeon should look for the following landmarks: the pectineal ligament caudally and the obturator nerve posteriorly.
The vein must be dissected cautiously. Any injury to the vein will cause bleeding, which should be controlled by tamponade. The vein should be sutured either directly, or after conversion.
7. Pectineal ligament
8. Pelvic floor
9. Obturator nerve
10. External iliac vein
12. Internal limit
• Transperitoneal approach
Caudally, the protrusions of the umbilical artery and the pectineal ligament delimit the internal boundary for the pelvic lymph node dissection.
1. Internal limit
2. Pectineal ligament
3. Umbilical artery
4. Internal surface of lymph nodes
• Extraperitoneal approach
1. Pectineal ligament
2. Umbilical artery
3. External iliac vein
The umbilical artery is pushed up cephalad, along with the peritoneum, which will then define the medial boundary of the dissection.
13. Inferior limit
1. Pectineal ligament
2. Obturator foramen
3. Obturator nerve
4. Obturator vein
Once the lymph nodes have been dissected, the lymphatics are clipped and divided close to the pectineal ligament. The presence of obturator vessels may interfere with this dissection. Non-controlled division of these vessels can cause bleeding, which should be controlled by tamponade and clip application.
14. Posterior limit
1. Obturator nerve
2. Obturator artery
The obturator nerve delimits the posterior boundary. It must not be mistaken for the obturator artery. Its electrical stimulation induces a contraction of the adductor muscles of the thigh.
15. Superior limit
1. Confluence
2. Internal iliac chain
3. Obturator nodes
4. External iliac nodes
This is probably the least regulated and most variable step of the lymphadenectomy.
To perform a complete modified lymphadenectomy, the confluence between the external iliac vein and the internal iliac vein must be exposed. This exposure is not always easy, and it is sometimes necessary to complete the dissection with the obturator nodes. Division is performed using clips.
16. Extraction
a. Transperitoneal approach
1. Lymphadenectomy space
2. Extraction bag
For a transperitoneal approach, the lymph node group is temporarily placed in the right iliac fossa. For an extraperitoneal approach, the lymph node group is temporarily placed in the retropubic space. Hemostasis is performed as necessary with a bipolar grasper. Extraction is done at the end of the procedure. Left and right lymph node groups are introduced into an extraction bag, which is then removed through the umbilical opening. A hemostatic material is left in the space where the dissection was performed. The peritoneum is left open to limit the risk of postoperative lymphocele (Freid et al., 1998). A drain is not required.
17. Left lymphadenectomy
• Transperitoneal approach
1. Adhesions
These steps may be superimposed, but they are usually preceded by the freeing of the peritoneum from the sigmoid colon in order to expose the pelvic lymph node dissection area.
Blind or excessive coagulation of the sigmoid colon can lead to secondary perforation in areas of coagulative necrosis.
• Extraperitoneal approach
These steps may be superimposed. The sigmoid colon does not interfere, because it is pushed away from the dissection plane along with the peritoneum by the gas from the insufflation.
18. End of procedure
Once hemostasis has been checked at the level of the 2 nodal cavities:
- the trocars are removed under visual control to ensure the absence of bleeding;
- the optical trocar is removed last;
- the muscle aponeurosis is approximated using absorbable sutures at the level of trocar opening sites greater than 5 mm;
- staples are used to close the skin at all trocar sites;
- the skin is then washed and an antiseptic solution is applied. Small adhesive bandages are placed on each trocar wound.
19. Postop period
The urinary catheter is removed on POD 1.
Light food intake is allowed on POD 1.
The patient is discharged on POD 1 or POD 2 depending on return of bowel function and on the preoperative general state of the patient.
To prevent phlebitis, administration of low-molecular-weight heparin for 10 days is recommended.
The main complication is lymphocele formation. Preventive measures include wide peritoneal incisions and lymphostasis using clips.
20. Advantages/disadvantages
The advantages of the transperitoneal approach are:
- preexisting working space,
- easy trocar placement.

The advantages of the extraperitoneal approach are:
- lack of interference from intraperitoneal organs;
- minimal risk of bowel injury;
- easy to perform in case of intraperitoneal adhesions from a previous operation.

The disadvantages of the transperitoneal approach are:
- interference from intraperitoneal organs;
- risk of bowel injury;
- difficulties in case of intraperitoneal adhesions.

The disadvantages of the extraperitoneal approach are:
- need to create a working space,
- greater risk of lymphocele.

21. Reference
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1997;50:391-4.
Fergany A, Kupelian PA, Levin HS, Zippe CD, Reddy C, Klein EA. No difference in biochemical failure
rates with or without pelvic lymph node dissection during radical prostatectomy in low-risk patients.
Urology 2000;56:92-5.
Freid RM, Siegel D, Smith AD, Weiss GH. Lymphoceles after laparoscopic pelvic node dissection.
Urology 1998;51:131-4.
Kava BR, Dalbagni G, Conlon KC, Russo P. Results of laparoscopic pelvic lymphadenectomy in
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Lund GO, Winfield HN, Donovan JF, See WA, Loening SA, Williams RD. Laparoscopic pelvic lymph
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