Robotic extended pelvic lymphadenectomy for bladder cancer with increased nodal yield.

STUDY TYPE: Therapy (case series).

LEVEL OF EVIDENCE: 4. What's known on the subject? and What does the study add? The standard of care for invasive bladder cancer is open radical cystectomy with the extent of pelvic lymph node dissection impacting oncological outcomes. Scepticism remains regarding whether an adequate node dissection can be performed in minimally-invasive fashion as previously reported nodal yields of laparoscopic or robotic lymphadenectomy are well below those reported with open surgery. This study demonstrates that extended pelvic lymphadenectomy can be performed robotically with equivalent nodal yields to open series from centres of excellence.

OBJECTIVE: To report our initial experience with robot-assisted extended pelvic lymph node dissection (ePLND) using a standardized open template.

PATIENTS AND METHODS: In total, 15 consecutive patients underwent robotic radical cystectomy at a single center by a single surgeon using a standard dissection template. Operating time, time to perform ePLND, pathological stage, estimated blood loss, length of hospital stay, number of nodes obtained and nodal positivity were assessed. Postoperative complications and re-admissions were reviewed.

RESULTS: The mean (range) age and body mass index was 66 (46-87) years and 29 (22-43) kg/m2, respectively. The mean (range) operating time and ePLND time was 423 (300-506) min and 107 (66-160) min. Mean (range) estimated blood loss was 160 (50-500) mL. The mean (range) and median length of hospital stay were 3.4 (3-7) days and 3 days, respectively. The mean (range) nodal yield was 41.8 (18-67) nodes, with greater than 25 nodes in 13 patients. Three patients were found to have nodal positivity. Of the fifteen patients, four received neoadjuvant chemotherapy. Two patients were re-admitted for postoperative complications within 30 days. There were no complications directly resulting from the ePLND.

CONCLUSIONS: Robot-assisted ePLND at the time of cystectomy can be safely and effectively performed on the robotic platform with comparable nodal yields to open series at centers of excellence for cystectomy. Nodal yields are likely to comprise a factor related to the effort of the surgeon, and not the method by which the lymphadenectomy is performed.