Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
J Endourol. 2012 Jun;26(6):748-53. doi: 10.1089/end.2011.0266. Epub 2011 Nov 8.
Published outcomes of pelvic lymph node dissection (PLND) during robot-assisted laparoscopic prostatectomy (RALP) demonstrate significant variability. The purpose of the study was to compare PLND outcomes in patients at risk for lymph node involvement (LNI) who were undergoing radical prostatectomy (RP) by different surgeons and surgical approaches.
Institutional policy initiated on January 1, 2010, mandated that all patients undergoing RP receive a standardized PLND with inclusion of the hypogastric region when predicted risk of LNI was ≥ 2%. We analyzed the outcomes of consecutive patients meeting these criteria from January 1 to September 1, 2010 by surgeons and surgical approach. All patients underwent RP; surgical approach (open radical retropubic [ORP], laparoscopic [LRP], RALP) was selected by the consulting surgeon. Differences in lymph node yield (LNY) between surgeons and surgical approaches were compared using multivariable linear regression with adjustment for clinical stage, biopsy Gleason grade, prostate-specific antigen (PSA) level, and age.
Of 330 patients (126 ORP, 78 LRP, 126 RALP), 323 (98%) underwent PLND. There were no significant differences in characteristics between approaches, but the nomogram probability of LNI was slightly greater for ORP than RALP (P=0.04). LNY was high (18 nodes) by all approaches; more nodes were removed by ORP and LRP (median 20, 19, respectively) than RALP (16) after adjusting for stage, grade, PSA level, and age (P=0.015). Rates of LNI were high (14%) with no difference between approaches when adjusted for nomogram probability of LNI (P=0.15). Variation in median LNY among individual surgeons was considerable for all three approaches (11-28) (P=0.005) and was much greater than the variability by approach.
PLND, including hypogastric nodal packet, can be performed by any surgical approach, with slightly different yields but similar pathologic outcomes. Individual surgeon commitment to PLND may be more important than approach.
机器人辅助腹腔镜前列腺切除术（RALP）中盆腔淋巴结清扫术（PLND）的发表结果显示出显著的变异性。本研究的目的是比较不同外科医生和手术方法进行根治性前列腺切除术（RP）时具有淋巴结受累（LNI）风险的患者的 PLND 结果。
机构政策于 2010 年 1 月 1 日启动，规定所有接受 RP 的患者均接受标准化的 PLND，当预测 LNI 风险≥2%时，包括腹下区域。我们分析了 2010 年 1 月 1 日至 9 月 1 日符合这些标准的连续患者的结果，这些患者由外科医生和手术方法进行评估。所有患者均接受 RP；手术方法（开放根治性耻骨后 [ORP]、腹腔镜 [LRP]、RALP）由会诊外科医生选择。通过多变量线性回归比较外科医生和手术方法之间的淋巴结产量（LNY）差异，并调整临床分期、活检 Gleason 分级、前列腺特异性抗原（PSA）水平和年龄。
在 330 例患者（126 例 ORP、78 例 LRP、126 例 RALP）中，323 例（98%）进行了 PLND。方法之间的特征无显著差异，但 ORP 的 nomogram 预测 LNI 的概率略高于 RALP（P=0.04）。所有方法的 LNY 均较高（18 个节点）；在调整分期、分级、PSA 水平和年龄后，ORP 和 LRP 切除的节点更多（中位数分别为 20、19），而 RALP（16）（P=0.015）。调整 nomogram 预测 LNI 后，各方法的 LNI 率均较高（14%），无差异（P=0.15）。在所有三种方法中，个体外科医生的中位数 LNY 变异相当大（11-28）（P=0.005），且变异程度大于方法的变异程度。
PLND，包括腹下淋巴结包块，可通过任何手术方法进行，其产量略有不同，但病理结果相似。外科医生对 PLND 的承诺可能比方法更重要。
