European Urology

Abstract

Background

Lymph node dissection (LND) for muscle-invasive bladder cancer is one of the integral steps of radical cystectomy. In addition to staging, adequate LND has been found to alter both the prognosis for and the course of the disease after radical cystectomy.

Objective

To point out several essential steps that provide optimal exposure for LND during laparoscopic radical cystectomy for muscle-invasive bladder cancer.

Design, setting and participants

From August 2006 to September 2008, we performed 10 laparoscopic cystectomies with an extended LND using this approach at our institution. Patient and tumor characteristics, the anatomic extent of the LND, the number of lymph nodes examined, and the postoperative complications encountered were evaluated.

Surgical procedure

Essential steps include (1) a modified five-trocar arrangement; (2) use of a 30° telescope during LND; (3) prior complete mobilization of the sigmoid colon, allowing its retraction using an umbilical tape; (4) accomplishment of most of the bilateral LND from the right side; and (5) performance of LND after removal of the specimen.

Measurements

The primary end points were adequate intraoperative exposure of the template and number of lymph nodes retrieved. The secondary end point was evaluation of postoperative lymph node recurrence as an assessment of a complete LND.

Results and limitations

Mean total operative time was 512.5 min (range: 420–660), with a mean operative time of 143 min (range: 115–165) for the extended LND. Adequate exposure was successful in all 10 patients. The average number of lymph nodes examined was 25.5 (range: 19–32), with 4 nodes positive for metastasis. No patients had pelvic or lymph node metastasis at a mean follow-up of 14.8 mo (range: 4–30). Limitations included an analysis of a small series of patients.

Conclusions

This new approach provides optimal exposure for an adequate laparoscopic LND during radical cystectomy, without any compromise.

Take Home Message

The oncologic outcome of laparoscopic radical cystectomy should not be compromised by an inadequate lymph node dissection (LND). Exposure is essential for adequacy of LND; although indisputably necessary when performing dissection within an extended template, exposure is also fundamental for a limited template.