Extraperitoneal single‐site robot‐assisted radical prostatectomy with extended pelvic lymph node dissection: technique and experience

摘要

For patients with locally advanced or high-risk localised prostate cancer who require lymph node dissection (LND), guidelines recommend an extended pelvic LND (ePLND). Such an extensive dissection ensures accurate staging information for most patients [1]. Advancements in surgical instrumentation and optimisation of surgical techniques could potentially empower surgeons to perform an ePLND in a more minimally invasive manner. Extraperitoneal single-site or single-port robot-assisted radical prostatectomy (ESSRARP) has emerged as an intriguing concept. However, data from SSRARP with PLND studies have presented a less promising picture. The median number of lymph nodes (LNs) removed using the ESSRARP approach was only five [2, 3]. Compared with the transperitoneal anterior approach, the main difficulties for ePLND through an extraperitoneal approach are restricted workspace and a high incidence of symptomatic lymphocele [4, 5]. Exploring bridge technique is particularly interesting and appears to serve as good training for transitioning to the use of the single-port platform. Our primary aim in this study was to describe the surgical steps and technique of the ESSRARP with ePLND, along with the preliminary data. Patients eligible for this surgical technique were men with high-risk localised or locally advanced prostate cancer [1] and with a very high risk of LN invasion (LNI) [6]. All patients at the First Affiliated Hospital of Guangzhou Medical University (Guangzhou, China) who underwent this procedure provided informed consent, and the study was approved by the Institutional Review Board (IRB number: ES-2024-102-02). Before surgery, all patients were fully informed about their diagnosis, prognosis, and various treatment options. Written informed consent and video publication consent were obtained from all patients. The da Vinci® Xi robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used for all procedures. The patient was positioned in a modified Trendelenburg position (Fig. 1A). The incision for the extraperitoneal approach was made above the pubic symphysis (Fig. 1B). To ensure removal of the specimen, the transverse incision was ~5 cm. The extraperitoneal space was generated by balloon dilator and inflated with CO2 with a pressure of 12 mmHg (Fig. 1C). A commercially available disposable multi-instrument laparoscopic port (Sunride Biotech Co., Ltd., Changzhou, Jiangsu Province, China) (Fig. 1E) was installed here and the extraperitoneal space was subsequently inflated to a pressure of 12 mmHg (Fig. 1D). The 12-mm camera port was placed caudally and toggled 30° up throughout the operation, leaving the 12-mm cephalad channel as the assistant port (Fig. 1F). Our procedure adheres to the conventional steps of a RP [4]. A PLND is better performed after RP but before the urethrovesical anastomosis, as the retraction of the bladder and peritoneal during PLND may affect the tightness of the anastomosis. The order of PLND is not standardised and is often determined by anatomical variations and the ease of dissection. Superficial tissue was dissected along the external iliac vein to determine the location of the deep circumflex iliac vein (Fig. 2A). The genitofemoral nerve and psoas major muscle were exposed at the lateral limit (Fig. 2B). The external iliac LND was performed first on the lateral side of the vessel, followed by the medial side (Fig. 2D). Following the course of the external iliac artery, the bifurcation of the common iliac artery was identified as the cranial limit (Fig. 2C). The ureter was pushed medially to safeguard it. The umbilical artery served as a reliable landmark when identifying the internal iliac artery proved challenging. This dissection of the lymphatic tissue, including the LNs along the internal iliac vessels, continued distally to the prostate, defining the medial limit of the ePLND (Fig. 2E). We chose to dissect lymphatic tissue from the lateral aspect of the external iliac vessel