Free-indocyanine green-guided pelvic lymph node dissection during radical prostatectomy

Area of Science:

• Urology
• Oncology
• Medical Imaging

Background:

• Extended pelvic lymph node dissection (ePLND) is the standard for detecting lymph node metastases (LNMs) in prostate cancer (CaP).
• Accurate staging of nodal status is crucial for treatment decisions in localized CaP.
• There is a need for less invasive methods to assess nodal status accurately.

Purpose of the Study:

• To evaluate the accuracy of free-Indocyanine Green (F-ICG) guided lymphangiography in assessing pathological nodal (pN) status in CaP patients.
• To determine if F-ICG could serve as a replacement for ePLND in real-time lymph node staging.

Main Methods:

• A prospective single-center study included 219 CaP patients undergoing F-ICG-guided PLND, ePLND, and radical prostatectomy.
• Pathological outcomes of F-ICG-guided PLND were compared to confirmatory ePLND.
• Diagnostic test parameters (accuracy, sensitivity, NPV, LR(-)) were calculated for per-patient and per-node analyses.

Main Results:

• F-ICG-guided PLND visualized lymph nodes in all procedures without adverse events.
• The per-patient accuracy was 97.7%, with a sensitivity of 91.4% and a negative predictive value (NPV) of 97.0%.
• On a per-node basis, F-ICG identified 32.1% of removed nodes as fluorescent, with a sensitivity of 63.4% for detecting LNMs.

Conclusions:

• F-ICG-guided lymphangiography accurately stages nodal status in nearly 98% of prostate cancer patients.
• The high per-patient NPV suggests that avoiding ePLND is safe for patients with F-ICG-negative nodes.
• This technique may enable more conservative approaches, minimizing morbidity in selected CaP patients undergoing nodal staging.