Surgery in Motion

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

By: Mihir M. Desaia lowast , Andre K. Bergera, Ricardo R. Brandinaa, Pascal Zehndera, Matthew Simmonsb, Monish Arona, Eila C. Skinnera and Inderbir S. Gilla

European Urology, Volume 61 Issue 2, February 2012, Pages 350-355

Published online: 01 February 2012

Keywords: Robotics, Laparoscopy, Pelvic lymph node dissection, Bladder cancer

Abstract Full Text Full Text PDF (477 KB)



With the increasing use of laparoscopic and robotic radical cystectomy (RC), there are perceived concerns about the adequacy of lymph node dissection (LND).


Describe the robotic and laparoscopic technique and the short-term outcomes of high extended pelvic LND (PLND) up to the inferior mesenteric artery (IMA) during RC.

Design, setting, and participants

From January 2007 through September 2009, we performed high extended PLND with proximal extent up to the IMA (n=10) or aortic bifurcation (n=5) in 15 patients undergoing robotic RC (n=4) or laparoscopic RC (n=11) at two institutions.

Surgical procedure

We performed robotic extended PLND with the proximal extent up to the IMA or aortic bifurcation. The LND was performed starting from the right external iliac, obturator, internal iliac, common iliac, preaortic and para-aortic, precaval, and presacral and then proceeding to the left side. The accompanying video highlights our detailed technique.


Median age was 69 yr, body mass index was 26, and American Society of Anesthesiologists class ≥3 was present in 40% of patients. All urinary diversions, including orthotopic neobladder (n=5) and ileal conduit (n=10), were performed extracorporeally.

Results and limitations

All 15 procedures were technically successful without need for conversion to open surgery. Median operative time was 6.7h, estimated blood loss was 500ml, and three patients (21%) required blood transfusion. Median nodal yield in the entire cohort was 31 (range: 15–78). The IMA group had more nodes retrieved (median: 42.5) compared with the aortic bifurcation group (median: 20.5). Histopathology confirmed nodal metastases in four patients (27%), including three patients in the IMA group and one patient in the aortic bifurcation group. Perioperative complications were recorded in six cases (40%). During a median follow-up of 13 mo, no patient developed local or systemic recurrence. Limitations of the study include its retrospective design and small cohort of patients.


High extended PLND during laparoscopic or robotic RC is technically feasible. Longer survival data in a larger cohort of patients are necessary to determine the proper place for robotic and laparoscopic surgery in patients undergoing RC for high-risk bladder cancer.

Take Home Message

High extended pelvic lymph node dissection during laparoscopic or robotic radical cystectomy is technically feasible. Nodal yield is comparable to that of open surgery.

Keywords: Robotics, Laparoscopy, Pelvic lymph node dissection, Bladder cancer.


a USC Institute of Urology, University of Southern California, Los Angeles, CA, USA

b Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

lowast Corresponding author. USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA. Tel. +1 323 865 3700; Fax: +1 323 865 0120.

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