Laparoscopic and Robotic-Assisted Extended Pelvic Lymph Node Dissection for Invasive Bladder Cancer: A Review

Main Article Content

Weijun Fu
Xu Zhang

Keywords

Bladder cancer, Radical cystectomy, Laparoscopy, Robotics, Pelvic lymph node dissection

Abstract

Minimally invasive surgical techniques, including laparoscopic and robotic-assisted radical cystectomy (RC), are emerging as the preferred treatment options for invasive bladder cancer. Mounting evidence has demonstrated that laparoscopic and robotic-assisted RC with extended pelvic lymph node dissection (PLND) is a viable alternative for managing invasive bladder cancer. In this review, we summarized recent advances and critically assessed the minimally invasive approaches and risk factors associated with extended PLND in patients undergoing laparoscopic or robotic-assisted RC. The findings indicated that laparoscopic and robotic-assisted PLND, employing either a standard or extended approach, is technically feasible and offers benefits such as minimal invasiveness, superior visualization, reduced blood loss, and expedited recovery. The risk factors involved in the laparoscopic extended PLND are minimal. Clinically, laparoscopic and robotic-assisted extended PLND is significantly advantageous in that it sticks to the principles of open surgery and respects anatomical boundaries. Nevertheless, laparoscopic and robotic-assisted extended PLND is technically challenging and necessitate extended operation time. Furthermore, large-scale, prospective, multicenter trials are warranted to validate the long-term efficacy of laparoscopic and robotic-assisted extended PLND in terms of disease-specific survival.

Metrics

Metrics Loading ...
Abstract 138 | PDF Downloads 63 HTML Downloads 26

References

1. Stein JP, Lieskovsky G, Cote R, Groshen S, Feng AC, Boyd S, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol. 2001 Feb;19(3):666–75. https://doi.org/10.1200/JCO.2001.19.3.666 PMID:11157016
2. Brunocilla E, Pernetti R, Martorana G. The role of pelvic lymph node dissection during radical cystectomy for bladder cancer. Anticancer Res. 2011 Jan;31(1):271–5. PMID:21273609
3. Clement KD, Pearce E, Gabr AH, Rai BP, Al-Ansari A, Aboumarzouk OM. Perioperative outcomes and safety of robotic vs open cystectomy: a systematic review and meta-analysis of 12,640 cases. World J Urol. 2021 Jun;39(6):1733–46. https://doi.org/10.1007/s00345-020-03385-8 PMID:32734460
4. Lerner SP. The role and extent of pelvic lymphadenectomy in the management of patients with invasive urothelial carcinoma. Curr Treat Options Oncol. 2009 Aug;10(3-4):267–74. https://doi.org/10.1007/s11864-009-0107-3 PMID:19565335
5. Lisiński J, Kienitz J, Tousty P, Kaczmarek K, Lemiński A, Słojewski M. Comparison of Laparoscopic and Open Radical Cystectomy for Muscle-Invasive Bladder Cancer. Int J Environ Res Public Health. 2022 Nov;19(23):15995. https://doi.org/10.3390/ijerph192315995 PMID:36498068
6. Challacombe BJ, Bochner BH, Dasgupta P, Gill I, Guru K, Herr H, et al. The role of laparoscopic and robotic cystectomy in the management of muscle-invasive bladder cancer with special emphasis on cancer control and complications. Eur Urol. 2011 Oct;60(4):767–75. https://doi.org/10.1016/j.eururo.2011.05.012 PMID:21620562
7. Richards KA, Hemal AK, Kader AK, Pettus JA. Robot assisted laparoscopic pelvic lymphadenectomy at the time of radical cystectomy rivals that of open surgery: single institution report. Urology. 2010 Dec;76(6):1400–4. https://doi.org/10.1016/j.urology.2010.01.019 PMID:20350755
8. Finelli A, Gill IS, Desai MM, Moinzadeh A, Magi-Galluzzi C, Kaouk JH. Laparoscopic extended pelvic lymphadenectomy for bladder cancer: technique and initial outcomes. J Urol. 2004 Nov;172(5 Pt 1):1809–12. https://doi.org/10.1097/01.ju.0000140994.72981.20 PMID:15540725
9. Haber GP, Gill IS. Laparoscopic radical cystectomy for cancer: oncological outcomes at up to 5 years. BJU Int. 2007 July;100: 137-142. https://doi.org/10.1111/j.1464-410X.2007.06865.x PMID: 17552961
10. Hemal AK, Kolla SB, Wadhwa P, Dogra PN, Gupta NP. Laparoscopic radical cystectomy and extracorporeal urinary diversion: a single center experience of 48 cases with three years of follow-up. Urology. 2008 Jan;71:41-46. https://doi.org/10.1016/j.urology.2007.08.056 PMID: 18242362
11. Ghazi A, Zimmermann R, Al-Bodour A, Shefler A, Janetschek G. Optimizing the approach for lymph node dissection during laparoscopic radical cystectomy. Eur Urol. 2010 Jan;57(1):71–8. https://doi.org/10.1016/j.eururo.2009.06.024 PMID:19577355
12. Shao P, Meng X, Li J, Lv Q, Zhang W, Xu Z, et al. Laparoscopic extended pelvic lymph node dissection during radical cystectomy: technique and clinical outcomes. BJU Int. 2011 Jul;108(1):124–8. https://doi.org/10.1111/j.1464-410X.2010.09774.x PMID:20950309
13. Huang J, Lin T, Liu H, Xu K, Zhang C, et al. Laparoscopic radical cystectomy with orthotopic ileal neobladder for bladder cancer: oncologic results of 171 cases with a median 3-year follow-up. Eur Urol. 2010 Sep; 58:442-449. https://doi.org/10.1016/j. eururo.2010.05.046 PMID: 20554372
14. Guru KA, Sternberg K, Wilding GE, Tan W, Butt ZM, Mohler JL, et al. The lymph node yield during robot-assisted radical cystectomy. BJU Int. 2008 Jul;102(2):231–4. https://doi.org/10.1111/j.1464-410X.2008.07589.x PMID:18325058
15. Woods M, Thomas R, Davis R, Andrews PE, Ferrigni RG, Cheng J, et al. Robot-assisted extended pelvic lymphadenectomy. J Endourol. 2008 Jun;22(6):1297–302. https://doi.org/10.1089/end.2008.0075 PMID:18498233
16. Pruthi RS, Wallen EM. Robotic-assisted laparoscopic pelvic lymphadenectomy for bladder cancer: a surgical atlas. J Laparoendosc Adv Surg Tech A. 2009 Feb;19(1):71–4. https://doi.org/10.1089/lap.2008.0207 PMID:19288592
17. Pruthi RS, Nielsen ME, Nix J, Smith A, Schultz H, Wallen EM. Robotic radical cystectomy for bladder cancer: surgical and pathological outcomes in 100 consecutive cases. J Urol. 2010 Feb;183(2):510–4. https://doi.org/10.1016/j.juro.2009.10.027 PMID:20006884
18. Kasraeian A, Barret E, Cathelineau X, Rozet F, Galiano M, et al. Robot-assisted laparoscopic cystoprostatectomy with extended pelvic lymphadenectomy, extracorporeal enterocystoplasty, and intracorporeal enterourethral anastomosis: initial Montsouris experience. J Endourol. 2010 Mar;24(3): 409-13. https://doi.org/10.1089/end.2009.0209 PMID: 20218885
19. Lavery HJ, Martinez-Suarez HJ, Abaza R. Robotic extended pelvic lymphadenectomy for bladder cancer with increased nodal yield. BJU Int. 2011 Jun;107(11):1802–5. https://doi.org/10.1111/j.1464-410X.2010.09789.x PMID:21070571
20. Akbulut Z, Canda AE, Ozcan MF, Atmaca AF, Ozdemir AT, Balbay MD. Robot-assisted laparoscopic nerve-sparing radical cystoprostatectomy with bilateral extended lymph node dissection and intracorporeal studer pouch construction: outcomes of first 12 cases. J Endourol. 2011 Sep;25(9):1469–79. https://doi.org/10.1089/end.2010.0632 PMID:21830910
21. Perera M, McGrath S, Sengupta S, Crozier J, Bolton D, Lawrentschuk N. Pelvic lymph node dissection during radical cystectomy for muscle-invasive bladder cancer. Nat Rev Urol. 2018 Nov;15(11):686–92. https://doi.org/10.1038/s41585-018-0066-1 PMID:30104615
22. Stein JP. Lymphadenectomy in bladder cancer: how high is “high enough”? Urol Oncol. 2006;24(4):349–55. https://doi.org/10.1016/j.urolonc.2005.07.013 PMID:16818190
23. Skinner DG. Management of invasive bladder cancer: a meticulous pelvic node dissection can make a difference. J Urol. 1982 Jul;128(1): 34-6. https://doi.org/10.1016/s0022-5347(17)52740-8 PMID: 7109065
24. Vazina A, Dugi D, Shariat SF, Evans J, Link R, Lerner SP. Stage specific lymph node metastasis mapping in radical cystectomy specimens. J Urol. 2004 May;171(5):1830–4. https://doi.org/10.1097/01.ju.0000121604.58067.95 PMID:15076287
25. Karl A, Carroll PR, Gschwend JE, Knüchel R, Montorsi F, Stief CG, et al. The impact of lymphadenectomy and lymph node metastasis on the outcomes of radical cystectomy for bladder cancer. Eur Urol. 2009 Apr;55(4):826–35. https://doi.org/10.1016/j.eururo.2009.01.004 PMID:19150582
26. Park J, Kim S, Jeong IG, Song C, Hong JH, Kim CS, et al. Does the greater number of lymph nodes removed during standard lymph node dissection predict better patient survival following radical cystectomy? World J Urol. 2011 Aug;29(4):443–9. https://doi.org/10.1007/s00345-011-0644-9 PMID:21240505
27. Dorin RP, Daneshmand S, Eisenberg MS, Chandrasoma S, Cai J, Miranda G, et al. Lymph node dissection technique is more important than lymph node count in identifying nodal metastases in radical cystectomy patients: a comparative mapping study. Eur Urol. 2011 Nov;60(5):946–52. https://doi.org/10.1016/j.eururo.2011.07.012 PMID:21802833
28. Svatek R, Zehnder P. Role and extent of lymphadenectomy during radical cystectomy for invasive bladder cancer. Curr Urol Rep. 2012 Apr;13(2):115–21. https://doi.org/10.1007/s11934-012-0235-3 PMID:22328190
29. Roth B, Wissmeyer MP, Zehnder P, Birkhäuser FD, Thalmann GN, Krause TM, et al. A new multimodality technique accurately maps the primary lymphatic landing sites of the bladder. Eur Urol. 2010 Feb;57(2):205–11. https://doi.org/10.1016/j.eururo.2009.10.026 PMID:19879039
30. Dhar NB, Klein EA, Reuther AM, Thalmann GN, Madersbacher S, Studer UE. Outcome after radical cystectomy with limited or extended pelvic lymph node dissection. J Urol. 2008 Mar;179(3):873–8. https://doi.org/10.1016/j.juro.2007.10.076 PMID:18221953
31. Leissner J, Ghoneim MA, Abol-Enein H, Thüroff JW, Franzaring L, Fisch M, et al. Extended radical lymphadenectomy in patients with urothelial bladder cancer: results of a prospective multicenter study. J Urol. 2004 Jan;171(1):139–44. https://doi.org/10.1097/01.ju.0000102302.26806.fb PMID:14665862
32. Steven K, Poulsen AL. Radical cystectomy and extended pelvic lymphadenectomy: survival of patients with lymph node metastasis above the bifurcation of the common iliac vessels treated with surgery only. J Urol. 2007 Oct;178(4 Pt 1):1218–23. https://doi.org/10.1016/j.juro.2007.05.160 PMID:17698113
33. Desai MM, Berger AK, Brandina RR, Zehnder P, Simmons M, Aron M, et al. Robotic and laparoscopic high extended pelvic lymph node dissection during radical cystectomy: technique and outcomes. Eur Urol. 2012 Feb;61(2):350–5. https://doi.org/10.1016/j.eururo.2011.09.011 PMID:22036642
34. Davis JW, Gaston K, Anderson R, Dinney CP, Grossman HB, et al. Robot assisted extended pelvic lymphadenectomy at radical cystectomy: lymph node yield compared with second look open dissection. J Urol. 2011 Jan;185(1): 79-83. https://doi.org/10.1016/j.juro. 2010.09.031 PMID: 21074799
35. Stein JP, Penson DF, Cai J, Miranda G, Skinner EC, Dunn MA, et al. Radical cystectomy with extended lymphadenectomy: evaluating separate package versus en bloc submission for node positive bladder cancer. J Urol. 2007 Mar;177(3):876–81. https://doi.org/10.1016/j.juro.2006.10.043 PMID:17296365
36. Nix J, Smith A, Kurpad R, Nielsen ME, Wallen EM, Pruthi RS. Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results. Eur Urol. 2010 Feb;57(2):196–201. https://doi.org/10.1016/j.eururo.2009.10.024 PMID:19853987
37. Hellenthal NJ, Hussain A, Andrews PE, Carpentier P, Castle E, Dasgupta P, et al. Lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. BJU Int. 2011 Feb;107(4):642–6. https://doi.org/10.1111/j.1464-410X.2010.09473.x PMID:20575975
38. Arora A, Pugliesi F, Zugail AS, Moschini M, Pazeto C, Macek P, et al. Higher nodal yield with robot-assisted pelvic lymph node dissection for bladder cancer compared to laparoscopic dissection: implications for more accurate staging. Arab J Urol. 2020 Oct;19(1):92–7. https://doi.org/10.1080/2090598X.2020.1824570 PMID:33763254
39. Herr H, Lee C, Chang S, Lerner S, Bladder Cancer Collaborative Group. (2004) Standardization of radical cystectomy and pelvic lymph node dissection for bladder cancer: a collaborative group report. J Urol. 2004 May;171(5):1823-8. https://doi.org/10.1097/01.ju.0000120289.78049.0e PMID: 15076285
40. Tarin TV, Power NE, Ehdaie B, Sfakianos JP, Silberstein JL, Savage CJ, et al. Lymph node-positive bladder cancer treated with radical cystectomy and lymphadenectomy: effect of the level of node positivity. Eur Urol. 2012 May;61(5):1025–30. https://doi.org/10.1016/j.eururo.2012.01.049 PMID:22342773
41. Wang GJ, Barocas DA, Raman JD, Scherr DS. Robotic vs open radical cystectomy: prospective comparison of perioperative outcomes and pathological measures of early oncological efficacy. BJU Int. 2008 Jan;101(1):89-93. https://10.1111/j.1464-410X.2007.07212.x PMID: 17888044
42. Stein JP, Cai J, Groshen S, Skinner DG. Risk factors for patients with pelvic lymph node metastases following radical cystectomy with en bloc pelvic lymphadenectomy: concept of lymph node density. J Urol. 2003 Jul;170(1):35–41. https://doi.org/10.1097/01.ju.0000072422.69286.0e PMID:12796639
43. Kassouf W, Agarwal PK, Herr HW, Munsell MF, Spiess PE, Brown GA, et al. Lymph node density is superior to TNM nodal status in predicting disease-specific survival after radical cystectomy for bladder cancer: analysis of pooled data from MDACC and MSKCC. J Clin Oncol. 2008 Jan;26(1):121–6. https://doi.org/10.1200/JCO.2007.12.9247 PMID:18165646
44. May M, Herrmann E, Bolenz C, Tiemann A, Brookman-May S, Fritsche HM, et al. Lymph node density affects cancer-specific survival in patients with lymph node-positive urothelial bladder cancer following radical cystectomy. Eur Urol. 2011 May;59(5):712–8. https://doi.org/10.1016/j.eururo.2011.01.030 PMID:21296488
45. Osawa T, Abe T, Shinohara N, Harabayashi T, Sazawa A, Kubota K, et al. Role of lymph node density in predicting survival of patients with lymph node metastases after radical cystectomy: a multi-institutional study. Int J Urol. 2009 Mar;16(3):274–8. https://doi.org/10.1111/j.1442-2042.2008.02221.x PMID:19087211
46. Haber GP, Crouzet S, Gill IS. Laparoscopic and robotic assisted radical cystectomy for bladder cancer: a critical analysis. Eur Urol. 2008 Jul;54(1):54–62. https://doi.org/10.1016/j.eururo.2008.03.076 PMID:18403100
47. Chade DC, Laudone VP, Bochner BH, Parra RO. Oncological outcomes after radical cystectomy for bladder cancer: open versus minimally invasive approaches. J Urol. 2010 Mar;183(3):862–9. https://doi.org/10.1016/j.juro.2009.11.019 PMID:20083269
48. Kauffman EC, Ng CK, Lee MM, Otto BJ, Wang GJ, Scherr DS. Early oncological outcomes for bladder urothelial carcinoma patients treated with robotic-assisted radical cystectomy. BJU Int. 2011 Feb;107(4):628–35. https://doi.org/10.1111/j.1464-410X.2010.09577.x PMID:20883479
49. Hwang EC, Sathianathen NJ, Imamura M, Kuntz GM, Risk MC, Dahm P. Extended versus standard lymph node dissection for urothelial carcinoma of the bladder in patients undergoing radical cystectomy. Cochrane Database Syst Rev. 2019 May;5(5):CD013336. https://doi.org/10.1002/14651858.CD013336 PMID:31111956
50. Perera M, McGrath S, Sengupta S, Crozier J, Bolton D, Lawrentschuk N. Pelvic lymph node dissection during radical cystectomy for muscle-invasive bladder cancer. Nat Rev Urol. 2018 Nov;15(11):686–92. https://doi.org/10.1038/s41585-018-0066-1 PMID:30104615
51. Dhar NB, Klein EA, Reuther AM, Thalmann GN, Madersbacher S, Studer UE. Outcome after radical cystectomy with limited or extended pelvic lymph node dissection. J Urol. 2008 Mar;179(3):873–8. https://doi.org/10.1016/j.juro.2007.10.076 PMID:18221953

Most read articles by the same author(s)