Robot-assisted extended pelvic lymph node dissection (PLND) at the time of radical prostatectomy (RP): A video-based illustration of technique, results, and unmet patient selection needs

Objective: To describe the differences in technique and results between standard vs extended template pelvic lymph node dissection (PLND) at the time of radical prostatectomy (RP) using a robot-assisted (RA) technique. Patients and Methods Using extended templates illustrated for the open surgical technique, a RA technique was developed to solve obstacles related to surgical exposure, identification of key landmarks, proper sequencing of operative steps, and prevention of complicationsshown in the accompanying video. From May 2006 to October 2007, 261 patients underwent a standard PLND, and from November 2007 to November 2010, 670 underwent an extended PLND (E-PLND) by one surgeon. RESULTS The lymph node (LN) yield increased from a median(interquartile range) of 8 (5-11) to 16 (11-21) with the extended technique (P < 0.001). The ratio of positive LNs increased from 7% to 18%. Among E-PLND cases by risk group, positive LNs were found in 39%, 9%, and 3% of high-, intermediate-, and low-risk cases, and the later two groups strongly associated with upgrading and/or upstaging. Extensive clipping appears necessary to avoid postoperative lymphoceles, and peritoneal fenestration for the extraperitoneal technique. The median operative duration for E-PLND was 42 min, roughly double that of a standard PLND. CONCLUSIONS E-PLND is feasible with a RA technique, and increases the LN yield and positive LN ratio;the latter especially in high-risk disease. The procedure takes twice as long and requires several updates in technique shown in the video.