, Maria Chiara Sighinolfi 2, Ibrahim Elsodany 1, George Habib 1, Stefano Puliatti 3,4, Ahmed Zoeir 1, Ahmed Elsherbiny 1, Mohamed Abo-Elenien 1, Ayman Mousa 1, Mohamed Elbendary 1, Mohamed Radwan 1, Giorgia Gaia 5, Abdel Hamid Elbahnasy 1, Slavatore Micali 3, Bernardo Rocco 21 Urology Department, Faculty of Medicine, Tanta University, 31527 Tanta, Egypt
2 Urology Department, ASST Santi Paolo e Carlo, University of Milan, 20142 Milan, Italy
3 Urology Department, University of Modena & Reggio Emilia, 41126 Modena, Italy
4 ORSI Academy, 9090 Melle, Belgium
5 Obstetrics and Gynecology Department, ASST Santi Paolo e Carlo, 20142 Milan, Italy
Abstract
Objectives: Pelvic lymphadenectomy is a crucial step in the management of different pelvic cancers for both prognostic and/or therapeutic goals. Robotic surgeries offered numerous benefits over open and/or laparoscopic surgeries such as better visualization, shorter hospital stay, less pain and better cosmoses. The aim of this narrative review is to evaluate the value and outcomes of robotic pelvic lymph node dissection (PLND). Mechanism: The PubMed database was searched using the following keywords “Robotic” AND “pelvic lymph node dissection” to identify all the relevant articles concerned with the role and outcomes of robotic PLND. We included only English articles published between 2010 and 2022. Data from the retrieved articles were then used to formulate this review that highlight the introduction, the outcomes of robotic pelvic lymph node dissection (PLND), and the mapping of sentinel lymph node (SLN) in cervical, endometrial, prostate, and bladder cancers. Findings in Brief: PLND is an integral part of gynecological and urological oncology for its role in tumor staging and planning of further treatment plan. Furthermore, it may play an important therapeutic role in bladder cancer. Robotic approach to PLND is safe and efficient and can be potentially used for cervical, endometrial, prostate, and bladder cancers. Conclusions: Robotic PLND could be an alternative to open and laparoscopic approaches as it may decrease the associated morbidities without compromising the quality of Lymph node dissection (LND).
Keywords
- pelvic lymph node dissection
- robotic surgery
- bladder cancer
- cervical cancer
- endometrial cancer
- prostate cancer
The core concept of surgical oncology is the radicalness, which includes the resection of the primary tumor, the surrounding tissues, and loco-regional lymph nodes [1]. Loco-regional (20.5%) and distant (12.9%) lymph nodes (LN) represent the most common sites of metastasis, which justify the inclusion of lymph node dissection as an important step in the surgical management of different solid tumors [2]. Pelvic malignancies are not exception, where pelvic lymph node dissection (PLND) is considered an integral part of the management of several pelvic malignancies for prognostic and/or therapeutic purposes including cervical cancer [3], endometrial carcinoma [4], bladder cancer [5], and prostate cancer [6]. Despite the significance of PLND in pelvic oncological surgeries, it may be associated with increased morbidity and cost. Therefore, surgeons are obliged to weigh the potential benefits of PLND against its inherent drawbacks [7].
The advent of robotic technology to the surgical field offered several
advantages to both surgeons and patients in the form of three-dimensional vision,
10
The PubMed database was searched using the following keywords “Robotic” AND “pelvic lymph node dissection” to identify all the relevant articles concerned with the role and outcomes of robotic PLND. Several search filters were applied to limit the search to only English articles published between 2010 and 2022. Data from the retrieved articles were then used for the formalization of the current narrative review.
Cervical cancer is the fourth most commonly diagnosed female cancer accounting for approximately 6.5% and 7.7% of all newly diagnosed female cancers and cancer specific-mortality in 2020, respectively [12]. Radical hysterectomy is the standard treatment option for early-stage cervical cancer (stage IA1-IB2), which was performed in an open approach for more than 100 years until minimally invasive approaches (laparoscopic and robotic-assisted laparoscopic) were adopted in the field of gynecological oncology [13]. However, it should be noted that the rate of minimally invasive radical hysterectomy has dramatically decreased over the last four years [14], following the publication of a phase three randomized controlled trial (RCTs) reporting that minimally invasive approaches to radical hysterectomy may be associated with worse disease-free survival (86.0% vs 96.5%) and overall survival (93.8% vs 99%) compared to open approaches [15]. Yet, it is worth mentioning that this trial was not devoid of limitations and concerns (mainly related to the difference in surgeon’s experience, centers’ volume, and only 15.6% of the patients undergone robotic-assisted approach) that might have affected the outcomes and thus minimally invasive approaches should not be completely abended [13]. Furthermore, a retrospective analysis of patients undergoing robotic-assisted laparoscopic radical hysterectomy (RALRH) for early-stage cervical cancer in Spain showed that centers with higher surgical volume, more participation in clinical trials, greater use of magnetic resonance imaging (MRI) for diagnosis, favorable learning curve, and higher use of sentinel lymph node biopsies usually report lower rates of recurrences and better oncological outcomes, highlighting the impact of surgical practice on the oncological outcomes of RALRH [16].
Radical trachelectomy is another option for the management of selected patients
with small early-stage cervical carcinoma (
Pelvic Lymph node metastasis is not rare in patients with early-stage cervical cancer, where it may range from 2% in patients with stage IA2 tumors to 14–36% in patients with stage IB tumors; while, para-aortic lymph node metastasis is less common (2–5% in patients with stage IB tumors) [19]. Thus, regardless the chosen treatment option (radical hysterectomy or radical trachelectomy), bilateral PLND remains an important step in the management plan of early-stage cervical cancer as the lymph node status is the most crucial prognostic factor and plays an essential role in guiding adjuvant protocols [20].
Generally, minimally invasive approaches appear to be an attractive alternative to open pelvic lymphadenectomy with comparable surgical and oncological outcomes [21, 22]. Despite the controversy regarding the value of nodal yield on the survival of patients with negative lymph nodes, a more extensive lymph node dissection theoretically improves the pathological accuracy of lymph node status as a greater number of retrieved lymph nodes potentially increase the chance of detecting and resecting micro-metastasis [3]. Thus, the number of retrieved pelvic lymph nodes remains a surrogate marker of the extent and quality of surgery [23]. Table 1 (Ref. [15, 18, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38]) shows a summary of nodal yield in the included studies about different approaches to radical hysterectomy. Considering comparative trials, the majority of authors reported a comparable nodal yield among different surgical approaches (16–36 for robotic, 14–27 for laparoscopic, 17–25 for open) [21, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 39]. On the contrary, some studies demonstrated a significantly higher nodal yield for the open approach [36, 37], while others supported the superiority of minimally invasive approaches [22, 38].
| Article | Approach | Patients | Nodal yield | Operative time (min) | Blood loss (mL) | Hospital stay (days) |
|---|---|---|---|---|---|---|
| Salvo et al. [18] | Open-RT | 358 | 17 | 171 | 200 | 6 |
| MIS-RT | 288 | 18 | 262 | 50 | 2 | |
| Gao et al. [24] | RSS-RH | 32 | 21.37 | 223.56 | 217.25 | 7.5 |
| LESS-RH | 35 | 20.71 | 248.61 | 294.74 | 7.17 | |
| Ding et al. [28] | 2D-LRH | 54 | 21.7 | 151.6 | 233.5 | 10.4 |
| 3D-LRH | 85 | 23 | 111.8 | 211.6 | 10.7 | |
| RALRH | 100 | 22.4 | 171.6 | 317.5 | 10.9 | |
| Ramirez et al. [15] | Open-RH | 312 | 21 | NA | NA | 5 |
| MIS-RH | 319 | 20 | NA | NA | 3 | |
| Pellegrino et al. [29] | RALRH | 34 | 35.58 | 227.64 | 67.88 | 2.58 |
| LRH | 18 | 24.23 | 242.87 | 203.33 | 3.27 | |
| Nie et al. [30] | RALRH | 100 | 22.39 | 171.64 | 317.5 | 10.41 |
| LRH | 833 | 22.51 | 192.1 | 322.51 | 11.5 | |
| Wallin et al. [36] | Open-RH | 155 | 28.9 | 197 | 596 | 6.3 |
| RALRH | 149 | 22.7 | 206 | 80.9 | 2.4 | |
| Diver et al. [38] | MIS-RH | 101 | 19.4 | NA | 50 | 1.9 |
| Open-RH | 282 | 16 | NA | 500 | 4.9 | |
| Li et al. [31] | 3D-LRH | 24 | 18.08 | 222 | 325 | 15.54 |
| RALRH | 37 | 16.05 | 215.84 | 309.73 | 15.57 | |
| Corrado et al. [32] | Open-RH | 43 | 25 | 290 | 480 | 8 |
| LRH | 41 | 20 | 220 | 250 | 6 | |
| RALRH | 41 | 23 | 180 | 150 | 4 | |
| Corrado et al. [33] | Mini-LRH | 30 | 17.5 | 180 | 50 | 2 |
| RALRH | 30 | 20 | 185 | 60 | 3 | |
| Yim et al. [34] | RALRH | 60 | 18 | 200.5 | 100 | 11 |
| LRH | 42 | 19.9 | 215.6 | 145 | 10 | |
| Vizza et al. [35] | LRH | 25 | 21 | 188 | 220 | 6 |
| RALRH | 25 | 23 | 190 | 160 | 4 | |
| Tinelli et al. [25] | LRH | 76 | 27.1 | 255 | 95 | 4 |
| RALRH | 23 | 24.7 | 323 | 157 | 3 | |
| Sert et al. [37] | RALRH | 35 | 19.5 | 263.8 | 82.8 | 3.8 |
| LRH | 7 | 15.4 | 364.2 | 164.2 | 8.4 | |
| Open-RH | 26 | 26.1 | 163.4 | 595 | 9.2 | |
| Schreuder et al. [27] | RALRH | 13 | 29 | 434 | 300 | 4 |
| Open-RH | 14 | 26 | 225 | 2000 | 9 | |
| Nam et al. [26] | RALRH | 32 | 20.2 | 218.8 | 220.9 | 11.6 |
| Open-RH | 32 | 24.2 | 209.9 | 531.5 | 16.9 |
MIS, minimally invasive surgery; RH, radical hysterectomy; NA, not available; RT, radical trachelectomy; RSS, robotic single site surgery; LESS, laparoendoscopic single site surgery; LRH, laparoscopic radical hysterectomy; RALRH, robotic-assisted laparoscopic radical hysterectomy; 2D, two-dimensional; 3D, three-dimensional.
Noteworthy, the minimally invasive approaches offer several advantages in the form of less estimated blood loss (50–317.5 mL for robotic [18, 30, 37, 38], 50–325 mL for laparoscopic [31, 33], and 200–2000 mL for open approach [18, 27]) and shorter hospital stay [18, 27, 32, 36, 37, 38, 39]. However, minimally invasive approaches are usually associated with longer operative times [18, 27, 28, 37, 39].
The concept of SLNs was initially described by Gould et al. [40], in
1960 for patients with parotid carcinoma, subsequently this concept was
introduced to different types of solid malignancies. Generally, SLN may provide
the missing balance between the value of PLND and the associated lymphatic
complications [41]. SLN mapping is based on the concept that a negative first
lymph node group receiving lymphatic drainage from a primary tumor indicates a
theoretically negative lymph nodes in the remainder of that basin [42]. In
patients with cervical cancer, SLN may be used as an alternative to
lymphadenectomy only in patients with early-stage cervical carcinoma and tumors
Endometrial cancer (ECa) is the fifth most commonly diagnosed malignancy in women. Unlike other solid tumors, ECa is showing an increasing incidence and mortality in developed and high-income countries [47]. Surgery remains the cornerstone management for patients with ECa. It includes the radical resection of cervix, uterus, fallopian tubes, and ovaries. Lymph node dissection (LND) is a fundamental part of this surgery as it may provide staging information and guide adjuvant therapy [48]. The decision and extent of LND in patients with ECa is still a matter of debate and is dependable on the preoperative findings (tumor grade, size, site, and myometrial invasion) together with the surgeon’s evaluation of all the peritoneal surfaces, pelvic and para-aortic lymph nodes because the lymphatic drainage of the uterus is not limited to the pelvic lymph nodes but it may have a direct lymphatic communication between the fundus of the uterus and the aortic lymph node chains [49]. Generally, this surgery can be performed either through an open, laparoscopic, or robotic approaches. Studies about the minimally invasive approaches (laparoscopic and robotic) in the management of early and advanced ECa supported the advantages of these approaches over laparotomy as regards blood loss, recovery, and hospital stay without compromising the complication rates and oncological outcomes [48]. However, similar to cervical cancer, some concerns were raised regarding the long-term oncological outcomes (recurrence-free survival, overall survival, and disease-specific survival) of robotic surgery compared to laparoscopic surgery [50]. Yet, the robotic approach is still an interesting option for the surgical treatment of patients with ECa.
As previously mentioned, the lymphatic drainage of the uterus includes both
pelvic and para-aortic lymph nodes rendering lymph node metastasis in ECa
patients a challenging situation as it greatly affects patients’ 5-years survival
(94% for patients with negative lymph nodes, 75% for patients with positive
pelvic nodes, and 38% for patients with positive para-aortic nodes) [51]. Pelvic
lymph node metastasis ranges from 3.8–15.2%, 7.3–17.1%, and 6.9–35.3% in
low-grade, intermediate-grade, and high-grade tumors, respectively. Similarly,
aortic lymph node metastasis ranges from 0.8–9.4%, 5.3–20.5%, 0–25% in
low-grade, intermediate-grade, and high-grade tumors, respectively [52]. Overall,
the risk of paraaortic lymph node metastasis is 50% in case of positive pelvic
lymph nodes, while isolated positive aortic lymph nodes are reported in only
2–3% of patients [49]. Tumor size is another predictor of lymph node metastasis
in those patients; however, the cutoff size is controversial in the literature
ranging from 2–5 cm. A recent systematic review and meta-analysis of 40 articles
identified 2 cm as the ideal cutoff size for prediction of lymph node metastasis
(odds ratio (OR) = 4.11, 95% confidence interval (CI) 3.36–4.66, p
Several studies assessed the value of robotic surgery during lymphadenectomy in ECa patients [53, 54]. Generally, compared to open and laparoscopic approaches, robotic surgery was associated with a comparable nodal yield (10.5–13 for open and 11–13 for robotic) [53, 54, 55, 56], even in obese patients (pelvic nodes 18 vs 14, aortic nodes 9 vs 3) [53]. On the contrary, Backes et al. [57] reported that robotic approach may be associated with significantly lower pelvic nodal yield compared to laparotomy (15 vs 18, p = 0.007), while the aortic nodal yield was not statistically different. Interestingly, minimally invasive surgeries were associated with higher rates of pelvic lymphadenectomy compared to open surgery [55, 57].
Robotic single site docking is a feasible option in patients undergoing robotic hysterectomy and lymphadenectomy (pelvic and/or para-aortic) for surgical staging of ECa with few reported complications including early postoperative complications (8%), lower limb lymphedema (14%), and pelvic lymphocysts (8%) [51, 56, 58]. Noteworthy, retrospective cohorts showed that patients with intermediate- or high-risk ECa should undergo combined pelvic and para-aortic lymphadenectomy as it is associated with better survival outcomes compared to pelvic lymphadenectomy only [59]. Table 2 (Ref. [53, 54, 55, 56, 57]) show a summary of included studies about different approaches to the management of endometrial cancer.
| Article | Approach | Patients | Nodal yield | Operative time (min) | Blood loss (mL) | Hospital stay (days) |
|---|---|---|---|---|---|---|
| Bernardini et al. [53] | Open-RH | 41 | 14 | 165 | 300 | 4 |
| RALRH | 45 | 18 | 270 | 200 | 2 | |
| Eklind et al. [54] | RALRH | 40 | 13 | 127 | 76 | 1.8 |
| Open-RH | 48 | 13 | 179 | 317 | 4.8 | |
| Pulman et al. [55] | Open-RH | 69 | 14 | 210 | 300 | 4 |
| LRH | 44 | 17 | 240 | 150 | 1 | |
| RALRH | 63 | 18 | 240 | 150 | 1 | |
| Corrado et al. [56] | RSS-RH | 125 | 13 | 122 | 50 | 2 |
| Backes et al. [57] | Open-RH | 93 | 18 | NA | 300 | 4 |
| RALRH | 89 | 15 | NA | 75 | 1 |
RH, Radical Hysterectomy; NA, not available; RSS, robotic single site surgery; LRH, laparoscopic radical hysterectomy; RALRH, Robotic-assisted Laparoscopic Radical Hysterectomy.
Sentinel lymph node biopsy is proposed as an alternative to lymphadenectomy in
ECa. In this setting, a dye with/without a radiotracer is injected into the
cervical (most common) or uterine stroma, subsequently, it will be accumulated in
the corresponding lymph nodes to aid the recognition of SLNs using the robotic or
laparoscopic camera [60]. In ECa, bilateral pelvic mapping is an integral part of
the procedure of SLN to decrease the rate of pelvic lymphadenectomies without
omitting the mapping of one side of the pelvis [61]. Initially, SLN in ECa was
performed using a combination of
The Fluorescence Imaging for Robotic Endometrial Sentinel lymph node biopsy (FIRES) trial is a prospective, multicenter, cohort study that aims to assess
the value of ICG-SLN biopsy as an alternative to lymphadenectomy in 385 patients
undergoing robotic surgery for stage I ECa. The authors reported that ICG-SLN
biopsy can safely replace lymphadenectomy with a sensitivity of 97.2% and a NPV
of 99.6%. Cusimano et al. [64], supported the same finding in 156
high-grade ECa patients undergoing minimally invasive surgery (laparoscopic or
robotic) showing a detection of 97.4% per patient, 87.5% per hemipelvis, and
77.6% bilaterally. In this prospective cohort of patients, ICG-SLN biopsy showed
a sensitivity of 96.3%, FNR of 3.7%, and a NPV of 99.2% [64]. Similar to SLNs
in cervical cancer, the combination of ICG with
According to the GLOBCAN study 2020, prostate cancer (PCa) is the second most
common male malignancy worldwide with an incidence and mortality of 14.1% and
6.8%, respectively [12]. Nerve sparing radical prostatectomy (RP) is considered
the current standard of care for patients with clinically localized prostate
cancer and life expectancy of
The extent of LND is another point of debate, where the literature describes several templates extending from minimal or limited LND (including only the obturator fossa), standard dissection (obturator fossa and external iliac LNs), to extended dissection (extends to the common iliac up to the crossing of the ureter) [70]. Generally, the European Association of Urology (EAU) guidelines recommends the extended template of PLND [69].
Currently, the robotic approach to RP is the most commonly used approach for treating patients with PCa rendering robotic-assisted laparoscopic radical prostatectomy (RALP) the most commonly performed robotic procedure worldwide [10]. This may be attributed to the technical advantages of robotic surgery over laparoscopic and open surgeries [72]. Furthermore, there is some evidence that RALP may provide superior outcomes as regards the oncological and functional domains [73, 74, 75, 76]. In this setting, robotic PLND as a part of RP is common in the urological discipline [70].
Over the last two decades, there was a decrease in the rate and indications of
PLND during RP even among patients with intermediate and high risk PCa. Some
surgeons related this finding to the wide adoption of the robotic approach to RP
as surgeons wanted to avoid longer operative times, which may subsequently
increase the risk of complications and the operative costs [7, 77]. Interestingly,
Gandaglia et al. [77] used the Surveillance, Epidemiology, and End
Results Program (SEER) database to assess the impact of robotic surgery on PLND
during RP between October 2008 and December 2009, showing that patients
undergoing open RP were more likely to undergo PLND compared to RALP (71.2%
vs 48.6%, p
LN yield in PCa patients is an important predictor of lymph node positivity and surrogate marker of the quality of LND [79]. Two systematic reviews reported that the lymph node yield during robotic PLND ranges from 3.3 to 24 based on the template of dissection [7, 80]. Results from RCTs showed that that the nodal yield is comparable among robotic and laparoscopic approaches [81], while it was higher for RALP compared to open RP [82]. Noteworthy, these studies were not designed to compare the nodal yield among different approaches [81, 82].
SLN biopsy in patients undergoing RALP aims to provide the balance between the potential value of PLND and its associated morbidities through identifying the patients who might benefit from PLND [83]. However, it is still considered an experimental procedure because of the complex lymphatic drainage of the prostate and the heterogeneous results of SLN biopsy in the medical literature [70]. Currently, ICG is the most commonly used dye for the SLN biopsy in PCa patients.
Hence, PCa is a multifocal neoplasm, it is not clearly known which lesion will metastasize or which one is the index lesion [84]. In this setting, the site of injection of the dye might have an impact on the outcomes of SLN biopsy. A recent RCT showed that ultrasound guided, transrectal, intratumoral injection of ICG-Technetium 99 m was associated with significantly higher percentage of positive SLNs compared to intraprostatic injection in the peripheral zone of the prostate [85].
Considering the outcomes of SLN biopsy, a systematic review and meta-analysis of 21 studies accounting for 2509 patients undergoing SLN biopsy through either transrectal or transperineal injection of tracers in the peripheral zone of the prostate or the whole prostate during RP (open, robotic, or laparoscopic), reported a pooled non-diagnostic ratio, sensitivity, specificity, positive predictive value (PPV), and NPV of 4.1%, 95.2%, 100%, 100%, and 98%, respectively [86]. Noteworthy, this meta-analysis included studies using different types of tracers [86]. In this setting, a more recent systematic review and meta-analysis assessed only the performance of ICG-SLN biopsy in patients undergoing RP concluded that the diagnostic performance of this procedure is relatively low (sensitivity = 0.75, and specificity = 0.66) rendering it a suboptimal alternative to PLND [87]. However, the combination of prostate specific membrane antigen positron emission tomography and computed tomography (PSMA PET/CT) and SLN biopsy is capable of improving the detection rate of positive lymph nodes by 26% [88]. Generally, a consensus meeting in Germany considered that extended PLND remains the standard of care for lymph node staging, while SLN biopsy can be considered in conjunction with PLND in intermediate- and high-risk PCa patients [89].
Bladder cancer (BCa) is one of the most common urological neoplasms [12]. Approximately, 75% of bladder cancers are confined to the mucosa without invasion of the detrusor muscle. The treatment those patients with non-muscle invasive BCa consists of complete endoscopic resection of the mass followed by intravesical chemo- or immune-therapy [90]. Unfortunately, the remaining 25% are muscle invasive BCa, which is a more aggressive form of the disease that requires a more radical intervention in the form of radical cystectomy (RC) with bilateral PLND [70]. Generally, the extent of LND in patients with BCa is debatable as the lymphatic drainage of the bladder is complex as it mainly includes the obturator, external and internal iliac, and presacral lymph nodes. However, it may also extend to the common iliac, paraaortic, interaortocaval, and paracaval LNs [91]. Unlike PCa, the advantage of PLND in patients with BCa is not limited to its prognostic value but it extends to include also a survival benefit [92]. In this setting, an extended PLND template is recommended as a standard template may underestimate the presence of LN metastasis by 11% [93], and is generally associated with significantly higher all-cause and cancer-specific mortalities [94]. In these settings, PLND is considered an integral part of the treatment of patients with BCa.
Robotic approach to RC started to gain popularity among urologists due to the high complexity of open approach with its associated morbidity and mortality together with the steep learning curve of pure laparoscopic RC [95]. Despite the lack of high-level evidence, robotic assisted laparoscopic radical cystectomy (RARC) continues to expand at the expenses of open and laparoscopic approaches. Noteworthy, results from RCTs comparing RARC to open and laparoscopic approaches showed that RARC is associated with significantly longer operative times, lower estimated blood loss, lower postoperative pain and shorter hospitalization. Yet, there was no significance difference as regards the post-operative complication rates and the oncological outcomes. It should be mentioned that most of the RCTs comparing the robotic approach to other approaches was limited to patients undergoing RARC with extracorporeal urinary diversion, which may limit the benefits of minimally invasive surgery [96]. In this setting, the most recent RCT comparing open radical cystectomy to RARC with intracorporeal urinary diversion showed significantly higher rates of perioperative blood transfusion in patients undergoing open RC (41% vs 22%, p = 0.047) [97].
Theoretically, minimally invasive approaches to RC are associated with better
quality of LND in the form of higher Lymph node yield and lower density compared
to open approach because minimally invasive approaches allow enbloc resection of
lymphatic tissue with a 10
Some authors demonstrated that RARC may be associated with higher LN yield compared to other approaches (16–20 nodes vs 11–14 nodes based on the extent of dissection, respectively) [103, 104]. However, when considering the results from RCTs, the lymph node yield in patients undergoing RARC seems to be comparable to open and laparoscopic approaches [97, 105, 106, 107, 108].
LN density was proposed as an alternative to LN yield in the assessment of the
quality of LND as LN yield is related to several factors that may affect its
assessment including the method of submission (enbloc or separate packets), the
surgeon’s experience and technique, and the pathologists’ experience [70]. Lymph
node density refers to the number of positive LNs to the total number of nodes
retrieved. A density of
The concept of SLN biopsy in patients with BCa is less commonly utilized as it
is still experimental [110]. In this setting, Schaafsma et al. [111]
injected ICG bound to human serum albumin (an experimental material not available
in market) cystoscopically around the bladder tumor after bladder distention
demonstrating the feasibility of this technique in identifying of SLNs in BCa
patients. In line with this study, Rietbergen et al. [112] demonstrated
the feasibility of ICG-
PLND is an integral part of gynecological and urological oncology for its role in tumor staging and planning of further treatment plan. Furthermore, it may play an important therapeutic role in bladder cancer. Robotic approach to PLND seems to be an interesting alternative to open and laparoscopic approaches as it may decrease the associated morbidities without compromising the quality of LND (nodal yield). SLN-biopsy can be applied during minimally invasive surgery to improve the quality of LND, while reducing the associated morbidity.
BCa, Bladder cancer; ECa, Endometrial cancer; EAU, European Association of
Urology; FNR, False negative rate; ICG, Indocyanine green; LND, Lymph node
dissection; LN, Lymph nodes; MRI, Magnetic resonance imaging; NPV, Negative
predictive value; PCa, Prostate cancer; PPV, Positive predictive value; PSMA
PET/CT, Prostate specific membrane antigen positron emission tomography and
computed tomography; PLND, Pelvic lymph node dissection; RP, Radical
prostatectomy; RALP, Robotic-assisted laparoscopic radical prostatectomy; RCTs,
Randomized controlled trials; RALRH, Robotic-assisted laparoscopic radical
hysterectomy; RC, Radical cystectomy; RARC, Robotic-assisted laparoscopic radical
cystectomy; SLN, Sentinel lymph node; SPECT/CT, single-photon emission
computerized tomography and computed Tomography;
Conceptualization—AEis, MCS, GG, AZ, BR, SM, AHE; Methodology—GH, IE, AEls, AM, MAE; Database Search & Data Extraction—GH, IE, SP, AEls, AZ, ME, MR; Original Drafting—AEis, MCS, SP, MR, MAE, GG; Article Writing—ME, AEis, AM, MR; Review & Supervision—MAE, ME, AHE, SM, BR. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work to take public responsibility for appropriate portions of the content and agreed to be accountable for all aspects of the work in ensuring that questions related to its accuracy or integrity.
Not applicable.
We would like to express our gratitude to all those who helped us during the writing of this manuscript. Thanks to all the peer reviewers for their opinions and suggestions.
This research received no external funding.
The authors declare no conflict of interest. Giorgia Gaia is serving as one of the Guest editors of this journal. We declare that Giorgia Gaia had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to Ugo Indraccolo.
References
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