Sequencing robot-assisted extended pelvic lymph node dissection prior to radical prostatectomy: a step-by-step guide...

To describe a novel, step-by-step approach to robot-assisted extended pelvic lymph node dissection (ePLND) at the time of robot-assisted radical prostatectomy (RARP) for intermediate-high risk prostate cancer.

The sequence of ePLND is at the beginning of the operation to take advantage of greater visibility of the deeper hypogastric planes. The urachus is left intact for an exposure/retraction point. The anatomy is described in terms of lymph nodes (LNs) that are easily retrieved vs those that require additional manipulation of the anatomy, and a determined surgeon. A representative cohort of 167 RARPs was queried for representative metrics that distinguish the ePLND: 146 primary cases and 21 with neoadjuvant systemic therapy.

The median (interquartile range, IQR) LN yield was 22 (16-28) for primary surgeries and 21 (16-23) for neoadjuvant cases. The percentage of cases with positive LNs (pN1) was 16.4% for primary and 29% for neoadjuvant. The hypogastric LNs were involved in 75% of pN1 primary cases and uniquely positive in 33%. Each side of ePLND took the attending surgeon a median (IQR) of 16 (13-20) min and trainees 25 (24-38) min.

Robot-assisted ePLND before RARP provides an anatomical approach to surgical extirpation mimicking the open approach. We think this sequence offers efficiency and efficacy advantages in high-risk and select intermediate-risk patients with prostate cancer undergoing RARP.