In our department, we began our laparoscopic program in the discovery years of minimally invasive surgery. Initially, only a limited dissection of pelvic nodes was performed, as we were building experience and progressively mastering the technique. Then, with growing case load and given the encouraging results of extended dissection, we decided to implement extended PLND templates during our LRP cases, in patients with intermediate and high-risk prostate cancer. After many years of satisfying results, the robotic platform was introduced in our hospital, and inevitably all our prostate cancer cases were shifted to a robotic approach. In the present study we report our results in a limited cohort of patients who underwent laparoscopic or robotic-assisted RP and extended PLND. We found a significant difference (p<0.0001) in node yield across the two techniques: using a robotic approach we are dissecting more nodes (median 18 vs 12 LNs) and clearing better our template.
Nonetheless, this amelioration comes at a cost: longer operating times and increased blood loss. In what way did the robotic approach allow us to retrieve more nodes? The template, the method of extraction and the pathologist being the same, one would expect similar yields with both the techniques. One could also argue that we are taking “more” time to dissect our LNs. This may be a possible answer, as a consequence of the more important value given today to extended PLND in the management of high-risk prostate cancer. The current study does not allow us to draw a straightforward answer: however, we believe that the robot gives us the dexterity to better clear the hypogastric region, area which is in fact most difficult to access in standard laparoscopy.
Written by: Simone Albisinni, MD and Roland van Velthoven, MD PhD