Newswise — Bernard H. Bochner, M.D., Associate Urology Attending, Memorial Sloan-Kettering Cancer Center, Joel Sheinfeld, M.D., Urology Attending, Memorial Sloan-Kettering Cancer Center, Mitchell C Benson, M.D., Professor and Chair Department of Urology Columbia University Medical Center, and Muhammad Choudhury, M.D., Professor of Urology, New York Medical College discussed the value of lymph node dissection in bladder, testes, prostate and renal cell cancer surgery at the 2007 Annual Meeting of the New York Section of the AUA.

Dr. Bochner indicated that unless extended pelvic lymph node dissection (bifurcation of aorta to node of Cloquet) metastatic bladder cancer could be left behind. Limiting the upper limit of the node dissection to the bifurcation of the common iliac vessels risks leaving nodal disease in 7-8% of patients. What is not clear is how many patients are actually cured by the resection of the more extensive nodal disease? The take home message was that a complete pelvic lymph node dissection is an important component to radical cystectomy. How high the dissection should extend remains controversial.

Dr. Sheinfeld indicated that the most important aspect of retroperitoneal lymph node dissection (RPLND) is the complete removal of all potential areas of lymph node drainage. Many have suggested that the use of templates in primary RPLND procedures will result in the removal of an adequate area of lymph node drainage while preserving antegrade ejaculation. Dr. Sheinfeld indicated that every template sacrifices the adequacy of resection for preservation of antegrade ejaculation. Dr. Sheinfeld reported that a better solution is a complete RPLND and preservation of antegrade ejaculation by virtue of micro dissection of the sympathetic trunks. The take home message was that complete RPLND with nerve sparing micro dissection allows for a maximal resection of all nodal areas while still preserving ejaculation.

Dr. Benson reported on the value of pelvic lymph node dissection in the treatment of high-risk prostate cancer. In an in depth review of the literature, Dr. Benson demonstrated that between 25 to 40% of patients with nodal metastasis can be expected to have a prolonged disease free interval of 10 years or more by virtue of radical prostatectomy and lymph node dissection alone. A study by Wechermann et al. from Oldenburg, Germany evaluated 1,055 patients, 207 of whom had lymph node metastasis to determine the value of 99-technetium nanocolloid in the identification of sentinel lymph nodes. What they demonstrated was that 81 of the 142 sentinel lymph nodes (54.7%) were outside of the obturator fossa. The take home message was that a limited (obturator fossa only) lymph node dissection is not sufficient for patients with high-risk prostate cancer.

Dr. Choudhury reviewed the very variable lymph node drainage of the right and left kidneys. He reported that there are 11 to 15 lymphatic channels draining the right (RK) and left kidneys (LK). The lymphatics form three trunks " Anterior, Middle and Posterior and run along renal vessels. The first site of Lymph node drainage form the RK is inter-aorto "caval and retro " caval. On some occasions, the RK drains into hilar nodes. The lymphatic drainage of the LK forms two trunks " Anterior and Posterior. The trunks run along renal vessels. The first site of drainage is para-aortic, pre and retro. Like the RK, some of the channels drain into hilar nodes. Dr. Choudhury concluded in his take home message that in clinically negative nodes, LND does not improve survival and no impact on local recurrence. Dr. Choudhury noted that the survival of patients with metastatic disease undergoing cyto-reductive nephrectomy prior to planned systemic Immunotherapy was significantly better in patients having LND. He also reported that in a small number of cases, who present with N(+) disease, but no other metastases, LND can be curative.

Reported by Mitchell C. Benson, MD, a Contributing Editor with UroToday.

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CITATIONS

New York Section of the American Urological Association 2007 Annual Meeting