Laparoscopic Extended Pelvic Lymph Node Dissection During Radical Cystectomy: Technique and Outcomes

Abstract

Introduction:

Laparoscopic radical cystectomy (LRC) is both safe and efficacious. Extending the laparoscopic limit by doing extended pelvic lymph node dissection (PLND) and then doing external diversion by a small Pfannenstiel incision can further decrease the morbidity of the procedure while maintaining oncologic efficacy. We intend to perform and evaluate laparoscopic extended PLND (EPLND) in patients undergoing LRC with ileal diversion by a four-port split-and-roll technique.

Materials and Methods:

The essential steps of the procedure include patient in steep 45° Trendelenburg position with the surgeon and camera assistant on left position, 12 mm supra umbilical port for camera, 12 mm dissection port at the previously marked ileal conduit site, 5 mm retraction, and assistant port in left and right quadrant. Root of bowel mesentery is reflected cranially to expose aortic bifurcation. The packet is longitudinally divided anterior to the artery (iliac and aorta) using the split-and-roll technique. After delivering the packet posterior to the artery, a similar split-and-roll technique is done for the tissue surrounding the external iliac vein. The borders in standard PLND are genitofemoral nerve as lateral limit, bladder wall as medial limit, distally up to the inguinal ligament, midportion of common iliac artery as cranial limit, and pelvic floor as inferior limit. However, in the EPLND, cranial limit of dissection becomes 3 cm proximal to aortic bifurcation, rest remaining the same. The accompanying video highlights our detailed technique.

Results:

We performed this technique in 37 patients. All were completed in a mean LND time of 108±24 minutes, no blood transfusion. One patient had self-limiting right obturator nerve injury (Clavien grade I) and another had left external iliac vein bleeding requiring suture repair (Clavien grade III). The average lymph node yield was 36±8. The pathologic stage was N0 (14), N1 (18), and N2 (5), respectively.

Conclusion:

EPLND during LRC is technically feasible and safe. Nodal yield is comparable to that of open surgery.

The authors declare that no competing financial interests exist.

Runtime of video: 6 mins 3 secs