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Comparison Of Extraperitoneal And Transperitoneal Pelvic Lymph Node Dissection During Minimally Invasive Radical Prostatectomy
Jeffrey K Mullins, M. Eric Hyndman, Lynda Z Mettee, Christian P Pavlovich
Johns Hopkins Medical Institutions, Baltimore, MD

Introduction:
Pelvic lymph node dissection (PLND) during radical prostatectomy (RP) has prognostic and possible therapeutic benefits. We assessed whether an extraperitoneal minimally-invasive RP (MiRP) allows for standard-template PLND comparable to transperitoneal MiRP+PLND.
Materials and Methods:
A retrospective clinicopathologic study of 914 consecutive patients who underwent MiRP (laparoscopic or Da VinciTM robot-assisted laparoscopic) with bilateral PLND by one surgeon (CPP) from 2001- 2010 was performed. Low-risk patients generally received a limited dissection (external iliac nodes) when PLND was performed. Those with intermediate and high-risk disease generally received a standard PLND (external iliac and obturator nodes). Patients were stratified into groups based on operative approach (extraperitoneal vs. transperitoneal) for most analyses.
Results:
Overall, 192 patients had transperitoneal MiRP+PLND, and 377 had extraperitoneal MiRP+PLND. The extraperitoneal group had higher BMI (p=0.03), a higher percentage of low-risk (p=0.003) and a lower percentage of intermediate-risk disease (p=0.006).
Lymph node yield (LNY) was higher with extraperitoneal PLND overall (6.5 vs. 5.3, p=0.003). When stratified by risk category, LNY was greater in the extraperitoneal group for patients with low-risk disease only (6.6 vs. 4.9, p=0.008). There was no difference in nodal yield in intermediate/high-risk patients receiving standard PLND by either transperitoneal or extraperitoneal approach (6.0 vs. 5.5, p=0.36 and 8.0 vs. 5.8, p=0.14, respectively). Lymph node involvement was rare overall. Estimated blood loss and complication rates were comparable between operative approaches.
Conclusions:

The extraperitoneal MiRP approach does not compromise the oncologic efficacy or safety of routine PLND.


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