Arenas L F, Füllhase C, Boemans P, Fichtner J
Urologische Klinik, Evangelisches und Johanniter Klinikum Niederrhein, Oberhausen, Germany.
Aktuelle Urol. 2010 Jan;41 Suppl 1:S10-4. doi: 10.1055/s-0029-1224663. Epub 2010 Jan 21.
INTRODUCTION/OBJECTIVE: Pelvic lymphadenectomy is the best method for staging localized prostate cancer. There is no consensus about how the pelvic lymphadenectomy should be performed for patients with cT2, Gleason score 7 or higher, PSA higher than 10 ng/mL. Scintigraphic studies of prostate lymph drainage show that many lymph nodes are not dissected according to the current recommendation of lymphadenectomy which could explain the high rate of cancer recurrence. The objectives of this work are an analysis of the local lymph node metastasis according to the preoperative data (digital examination, PSA and Gleason score) and a comparison between laparoscopic extended and limited pelvic lymphadenectomy, for staging, their technique and complications.
Two groups were created for analysis. The indications for laparoscopic pelvic lymph-adenectomy are the following: preoperative PSA 10 ng/mL or higher, Gleason score 7 or higher and/or digital examination cT2. Patients with suspected distant metastasis were excluded. The first group is composed of the patients who under-went a limited laparoscopic pelvic lymphadenectomy (LLPL) between January 1995 and December 2002. The medical data were analyzed retrospectively. The second group was created with patients who received extended laparoscopic pelvic lymphadenectomy (ELPL). These data were consecutively collected between November 2006 and October 2007. LLPL was the extraction of the external iliac and obturator lymph nodes. ELPL included, additionally, dissection of the internal iliac lymph nodes as well as tissue medial to the genitofemoral nerve. Histopathological findings were compared with serum PSA, histopathological stage and preoperative biopsy. Complications, operating time, and number of extracted lymph nodes were also compared.
There were no significant differences in age, serum PSA or mean biopsy Gleason between two groups. The first group (LPLL) is composed of 381 patients and the second (ELPL), 163. The mean operating time was 72.5 minutes for LLPL and 84.3 for ELPL. The mean number of lymph nodes extracted was 13.8 (LLPL) and 31.1 (ELPL). Metastases were detected in 18.8% (LLPL) and 24.7% (ELPL). In 37.5% of cases, the metastasis occurred in lymph nodes outside from those dissected by LPLL. The rates of complications and conversion rate were not significantly different for the two groups.
For patients with clinically localized prostate cancer, ELPL is associated with a higher rate of detection of lymph node metastasis outside of the field dissected in the LPLL. Pelvic lymphadenectomy, especially extraction of the lymph nodes of the internal iliac is important in patients with preoperative Gleason score 7 or greater and/or serum PSA greater than 10 ng/mL. Laparoscopic lymphadenectomy does not augment the rate of complications and is an excellent technique in prostate cancer staging.
引言/目的：盆腔淋巴结清扫术是对局限性前列腺癌进行分期的最佳方法。对于临床分期为cT2、Gleason评分7分及以上、前列腺特异抗原（PSA）高于10 ng/mL的患者，盆腔淋巴结清扫术应如何实施尚无共识。前列腺淋巴引流的闪烁显像研究表明，按照目前淋巴结清扫术的推荐，许多淋巴结未被清扫，这可能是癌症复发率高的原因。本研究的目的是根据术前数据（直肠指检、PSA和Gleason评分）分析局部淋巴结转移情况，并比较腹腔镜扩大盆腔淋巴结清扫术和局限性盆腔淋巴结清扫术在分期、技术及并发症方面的差异。
为进行分析设立了两组。腹腔镜盆腔淋巴结清扫术的适应证如下：术前PSA 10 ng/mL及以上、Gleason评分7分及以上和/或直肠指检为cT2。排除疑似远处转移的患者。第一组由1995年1月至2002年12月期间接受局限性腹腔镜盆腔淋巴结清扫术（LLPL）的患者组成。对医疗数据进行回顾性分析。第二组由接受扩大腹腔镜盆腔淋巴结清扫术（ELPL）的患者组成。这些数据于2006年11月至2007年10月连续收集。LLPL是清扫髂外和闭孔淋巴结。ELPL还包括清扫髂内淋巴结以及生殖股神经内侧的组织。将组织病理学结果与血清PSA、组织病理学分期和术前活检结果进行比较。还比较了并发症、手术时间和清扫淋巴结的数量。
两组患者在年龄、血清PSA或平均活检Gleason评分方面无显著差异。第一组（LPLL）有381例患者，第二组（ELPL）有163例。LLPL的平均手术时间为72.5分钟，ELPL为84.3分钟。LLPL清扫淋巴结的平均数量为13.8个，ELPL为31.1个。LLPL组转移率为18.8%，ELPL组为24.7%。在37.5%的病例中，转移发生在LLPL未清扫的淋巴结。两组的并发症发生率和中转开腹率无显著差异。
对于临床局限性前列腺癌患者，ELPL发现LLPL清扫范围外淋巴结转移的概率更高。盆腔淋巴结清扫术，尤其是清扫髂内淋巴结，对于术前Gleason评分7分及以上和/或血清PSA大于10 ng/mL的患者很重要。腹腔镜淋巴结清扫术不会增加并发症发生率，是前列腺癌分期的一种优秀技术。
