Laparoscopic and Robotic Pelvic Lymphadenectomy

Abstract

In 1991, Schuessler et al. first reported the application of laparoscopic pelvic lymph node dissection (L-PLND) for staging of adenocarcinoma of the prostate (1). Subsequently, laparoscopic-limited obturator PLND, and in select cases, extended obturator and iliopsoas node dissection, has become the primary initial application of urologic laparoscopic surgery as a diagnostic and therapeutic technique (2). Follow-up studies on L-PLND clearly indicated that this procedure was comparable in accuracy and significantly less morbid than open PLND (Table 1) (3–6). While early studies showed a longer operative time for L-PLND, they also demonstrated a significant reduction in postoperative pain, hospitalization, and convalescence compared with open PLND (3–5). As expected, L-PLND initially showed an increased overall cost. However, with gradual refinements of technique, reusable equipment, and a reduced need for specialized instrumentation, overall cost is now likely to be equivalent to or less than open PLND (7–9). More recently, robot-assisted L-PLND has been performed in conjunction with robot-assisted laparoscopic radical prostatectomy, both by the transperitoneal and extraperitoneal routes. The cost effectiveness of this procedure is unclear in light of the need for significant capital investment in the robotic device, its maintenance, and the ongoing need for limited reusable accessories.