Pelvic Lymph Node Dissection: A Comparison Among Extraperitoneal Single-port and Transperitoneal Multiport Radical Prostatectomy-A Single-center Experience

Abstract

Background and objective: The role of pelvic lymph node dissection (PLND) for prostate cancer is still controversial. This study aims to compare the outcomes of PLND between extraperitoneal single-port (SP eRARP) and transperitoneal multiport (MP tRARP) robotic-assisted radical prostatectomy.

Methods: This was a retrospective analysis from our single-center database for patients who underwent SP eRARP or MP tRARP with PLND between 2015 and 2023. The primary endpoint was to analyze and compare specific data related to PLND between the two populations by the detection of pN+ patients, the total number of lymph nodes removed, and the number of positive lymph nodes removed. The secondary endpoints included comparing major complications, lymphoceles, and biochemical recurrence between the two cohorts of the study.

Key findings and limitations: A total of 293 patients were included, with 85 (29%) undergoing SP eRARP and 208 (71%) undergoing MP tRARP. SP eRARP showed significant differences in PLND extension from MP tRARP, while MP tRARP yielded more lymph nodes (p < 0.001). There were no differences in pN+ patient detection (p = 0.7) or the number of positive lymph nodes retrieved (p = 0.6). The rates of major complications (p = 0.6), lymphoceles (p = 0.2), and biochemical recurrence (p = 0.9) were similar between the two groups. Additionally, SP eRARP had shorter operative time (p = 0.045), hospital stay (p < 0.001), and less postoperative pain at discharge (p = 0.03). Limitations include a retrospective, single-center analysis.

Conclusions and clinical implications: Despite the SP approach in RARP resulting in fewer retrieved lymph nodes, outcomes were comparable with the MP approach regarding the detection of patients with positive lymph nodes and the number of positive nodes. Additionally, the SP approach led to lower pain levels and shorter hospital stays.

Patient summary: With this study, we demonstrate that pelvic lymph node dissection performed via the extraperitoneal approach during robotic-assisted radical prostatectomy with a single-port system provides comparable outcomes with the standard transperitoneal multiport approach in detecting patients with positive lymph nodes and retrieving positive nodes. In addition, it offers significantly reduced pain levels and shorter hospital stays.

Keywords: Extraperitoneal; Lymph node dissection; Prostatectomy; Robotic surgical procedures.

Fig. 1

(A) Graphical representation comparing the rate of detection of patients with positive lymph nodes (pN+) and the ratio of positive lymph nodes to total nodes removed (RPLN/LNY) between extraperitoneal single-port robot-assisted radical prostatectomy and transperitoneal multiport robot-assisted radical prostatectomy. (B) Graphical representation comparing surgical outcomes, including the rates of overall and major postoperative complications, positive surgical margins (PSMs), and the population with intermediate-unfavorable- or high-risk prostate cancer at final histology (ISUP >2), between extraperitoneal single-port robot-assisted radical prostatectomy and transperitoneal multiport robot-assisted radical prostatectomy. (C) Graphical representation comparing oncological outcomes, including the rates of biochemical recurrence (BCR), radiotherapy, and hormone therapy between extraperitoneal single-port robot-assisted radical prostatectomy and transperitoneal multiport robot-assisted radical prostatectomy. ISUP = International Society of Urological Pathology; MP tRARP = transperitoneal multiport robot-assisted radical prostatectomy; PLND = pelvic lymph node dissection; SP eRARP = extraperitoneal single-port robot-assisted radical prostatectomy.