Extended Pelvic Lymph Node Dissection in Bladder Cancer

Abstract

INTRODUCTION: Radical cystectomy and extended pelvic lymph node dissection (ePLND) are the gold standard treatment for muscle-invasive bladder cancer and BCG unresponsive nonmuscle-invasive bladder cancer. In this article, we review the rationale for ePLND in the treatment of bladder cancer and the evidence supporting the equipoise between robot-assisted (RA) and open ePLND. A step-by-step guide of robot-assisted ePLND (RA ePLND) is provided to illustrate the techniques currently employed at our institution. MATERIALS AND METHODS: Medline and PubMed electronic databases were queried for English language articles on bladder cancer, ePLND, and RA ePLND. In addition, a step-by-step video of RA ePLND was assembled with narration and accompanying explanations of each step to illustrate our current techniques. Key images from the video were selected for illustration of the relevant anatomical landmarks. RESULTS: ePLND with a minimum nodal yield of 10 to 14 is tantamount in the treatment of bladder cancer. The number of lymph nodes resected influenced survival in both pathologically node positive and negative patients. In addition, RA ePLND was found to have equipoise as open ePLND by several groups. In our surgical atlas video, we illustrate key surgical steps, including port placement and exposure. Also, anatomic landmarks of dissection for the internal iliac, external iliac/obturator, and higher nodal packets are described in detail. CONCLUSIONS: We illustrate the techniques for a thorough RA ePLND, with the intention to help the robotic surgeon to meet the 10 to 14 nodal yield mandated by the Bladder Cancer Collaborative Group.