The Use of Peritoneal Interposition Flap for the Prevention of Lymphocele Formation After Pelvic Lymph Node Dissection During Robotic-Assisted Laparoscopic Radical Prostatectomy: A Systematic Review and Meta-analysis
Angela Estevez, MD1, Utsav Bansal, MD1, Joseph Wagner, MD2, Sumedh Kaul, M.S1, Aaron Fleishman, MPH1, Tatum Williamson, MD1, Paul Bain, PhD3, Peter Chang, MD, MPH1, Andrew Wagner, MD1, Boris Gershman, MD1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Hartford Healthcare Medical Group, Hartford, CT, USA, 3Countway Library, Harvard Medical School, Boston, MA, USA.
Introduction: Lymphocele formation is a well-known complication after pelvic lymph node dissection (PLND) in robotic-assisted laparoscopic radical prostatectomy (RARP) and can be associated with high morbidity. Consequently, multiple strategies have been proposed to reduce the rate of lymphocele formation. One of the most promising such techniques is the use of a peritoneal interposition flap (PIF). Herein, we conducted a systematic review and meta-analysis to evaluate the association of PIF with lymphocele formation and postoperative complications after RARP.
Methods: We conducted a systematic search of MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials through January 18, 2023 with a professional librarian. Two investigators independently selected studies for inclusion in the final analysis. A random effects meta-analysis was then performed to evaluate the associations of PIF with the following outcomes: symptomatic/asymptomatic lymphocele and non-lymphocele postoperative complications within 90 days of surgery.
Results: A total of four randomized controlled trials (RCTs) and five retrospective studies, including a total of 2,476 patients, met eligibility criteria and were included in the final analysis. Compared to a standard technique, the use of PIF was associated with a reduced risk of 90-day symptomatic lymphocele formation after RARP when examining only RCTs (pooled OR 0.46, 95% CI 0.23-0.93; I2 = 24%, Figure 1a) or both RCTs and observational studies (OR 0.37, 95% CI 0.18-0.74; I2 = 43%, Figure 1b). Similarly, use of PIF was associated with a reduced risk of 90-day any lymphocele formation (OR 0.46, 95% CI 0.34-0.64, I2=4%; Figure 2). There were no statistically significant differences in postoperative complications between the two groups (OR 0.98; 95% CI 0.73-1.32; I2=11%; Figure 3).
Conclusions: Use of the PIF is associated with an approximately 50% reduced risk of symptomatic and any lymphocele formation within 90-days of surgery, and it is not associated with an increase of postoperative complications. 
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