SLIDES & TRANSCRIPTS
Friday, December 5, 2003

Laparoscopic RPLND

Louis Kavoussi, M.D.

Now, in terms of laparoscopy in urology, why has this become a mainstay of urology today? And the rationale is because it provides patients with less pain, a more rapid convalescence and optimal cosmesis. And these are issues which are important, not only to older patients, but also to younger patients; and because of this, back in the early nineties we began to apply this to a variety of different diseases, including testicular carcinoma, and I have to acknowledge the first laparoscopic node dissection was performed by Dan Rickstalis. We followed there shortly, and have to give a lot of credit to my colleagues at the Brigham at that time, including Jerry Ritchie and Phil Cantle, for letting us go ahead and attempt this at that time.

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In terms of our technique it is important to realize that just like open surgery why do we make incisions? We make incisions to get at a disease to move it. Laparoscopy just like open surgery is an access technique. There is nothing magical that is being done inside the patient nor is there something un-magical going on inside or evil going on inside the patient, again, once you understand the technique and how to go ahead and do the procedure.

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Now, I am not going to go through the procedure right now. I am going to give two slides only on the procedure. One is just port placement. We usually at our institution utilize four ports. We try to put them in the midline and the fellows always joke with me and say that is because if you have to open up you already have your incision half made, but we put four ports in the midline here and this procedure has evolved over the years, and I will talk about that a little bit in terms of the results, but I am just going to show an end result of a left-sided dissection that Peter Pinto here helped me with last year.

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And this is the right side, rather, and here is the aorta right here. And we are looking here at the IMA (inferior mesenteric artery) coming off. So, you can see we took the tissue off anteriorly here. We are going up the aorta. To the contralateral side here you see the right renal artery coming off over here, your spinous ligament right here. We cleaned out the interaortocaval region right here. You can get up to the renal vein on this side. Here is vena cava, and I think I am going to dissolve over [on the slide] now to look at further on this side and to look underneath the vena cava. But you can go up as high as you would like to go during this dissection. And here, we are coming back down in the pelvis. Here is the ureter which crosses over the iliac vessels. We have cleaned out this area lateral to the vena cava, and with laparoscopic techniques you can go ahead and lift up the vena cava. We have already clipped the lumbars here and preserved the sympathetic nerves. You get a very nice view of your sympathetic chain laparoscopically, with things magnified, and there is equipment available nowadays to do these procedures. Vascular surgeons are doing aortic graft replacement, etc. So, you can get to the retroperitoneum safely with equipment these days. So, it is feasible to do as little or as much of the dissection that you want to do nowadays with the equipment and with the expertise.

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I am going to just talk about our experience. And this is a group of men [referring to slide], and we stopped, for purposes of this discussion, in 2001. The first 51 patients we did, and these are all the men that I attempted this on and I was the surgeon on, and age [referring to slide], right and left sides [dissected]. And these were higher-risk patients in terms of having risk for retroperitoneal disease.

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In terms of operative procedure the mean operative time is 258 minutes. We could get it down a little under 3 hours in the best case scenario. And early on it took the better part of the day to go ahead and do the dissection.

Our blood loss: the largest blood loss we lost 3 liters early on. This is a patient that we had to do open conversion that we avulsed a vein on. But, for the most part, blood losses, as [with] most laparoscopic procedures in people who have experience with the prostate surgery, they tend to have [increasingly] less problems with bleeding. And, again, open conversion [occurred in] two patients. Again, both of these patients were quite early in our experience, and both of these patients required transfusions.

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Postoperatively the hospital stay was 2-1/2 days, 30 milligrams of morphine, for what it is worth [was required], and these patients were back to usual activities. So, we had a patient who was a UPS truck driver. He is back driving his UPS truck [and] those kinds of activities in an average of 17 days. Antegrade ejaculation: in our series we were able to preserve it in 49 out of 51 patients. So, again you can see the nerves, and you can accomplish these things with experience. And clinical follow-up: at least in these series, a minimum of 24 months on these patients I am presenting here.

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Complications: again, early on, one of the first complications I had was a patient who developed a lymphocele. And just to give a history on this, this was up in Boston ; and this is a gentleman in whom we did the procedure. He went home on the very next day, and you know you think that you are the greatest surgeon in the world. And he was on his bike 2 days later, and 3 days later he is back in the emergency room with flank pain. And so they got a pyelogram in those days, and the thing for the residents in the audience to notice, what is wrong with this picture [is] there is one clip in this picture. In terms of doing a retroperitoneal lymphadenectomy, this was the early days when we were doing pelvic node dissections and not using clips and trying to save the 120 bucks of a clip applier. So, we said, "Sure, you don't need to put clips on any lymphatics;" and so I think the problem is this is what happened here. Here is the CT scan, and this required percutaneous drainage. And, fortunately, this patient did well with conservative management.

I think this complication has also been seen, and I will talk a little bit about the University of Washington experience that Dr. Porter shared with me. But, also, I think it is a matter of something just with experience, again, using clips. Taking from what we have learned with open surgery, we wouldn't have this problem. We had another patient with a flank compartment syndrome. Again, a very thin person who was on the table a long period of time on a beanbag, developed a compartmental syndrome and it took him a while to get over that. But other than that, we haven't had any major complications in this group of patients.

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In terms of pathology we had positive nodes in 41 percent of patients. The number of nodes averaged 18. And in terms of chemotherapy, 18 went for chemotherapy; 3 did not go for chemotherapy.

In this group one of these had a biological recurrence 13 months out, and then, subsequently, received chemotherapy. We have had no local recurrences in this group in the retroperitoneum, including these three patients.

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In terms of the patients with negative nodes, and I think this is most interesting, we have more nodes in these; and I could talk about this a little bit later on. We had one patient [who] had a chest recurrence and one patient with a positive Beta HCG at 1 month and one at 3 months postoperatively. And again, in this group, none of these patients who had negative nodes had retroperitoneal recurrences at, again, 2 years out follow-up in this group of patients.

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Jim Porter at the University of Washington has the other largest series in the US and shared with me this data, recently. In 27 patients, they had 16 patients with positive nodes and, again, broken down, 5 went for chemotherapy, 4 for observation in [stage] 2A and 2B; 7 patients went for chemotherapy. They had, in the observation group, one patient [who] had a recurrence. Again, all these patients have had a minimum of one year [of follow-up], and this [referring to slide] was a pulmonary metastasis at 1 year. Again no retroperitoneal recurrences [have occurred] in his group at this time.

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The complication rate - 14 percent; and again the majority of these were lymphocele formation. I think that is something that is coming down, again, with experience. [The] average day of discharge [was] similar to ours; average back to work similar to ours; and again, in his group all patients were able to preserve antegrade ejaculation.

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So, I think the conclusions that can be drawn: Number 1, can you do a laparoscopic retroperitoneal lymphadenectomy? And the answer is yes, it is feasible. And, now, it depends upon what you define as the definition of a retroperitoneal lymphadenectomy. But I think with current equipment and seeing Joel's slide earlier, I think we can accomplish similarly with current technology what can be done open.

With experience, again, you can get an identical template. You can do nerve sparing which is equivalent to open, and you can minimize morbidity with experience. And, thus far in the US series, there have been no retroperitoneal recurrences, again, even in patients for whom the nodes were said to be negative.

Now, in oncology, laparoscopy has been used in a variety of different modalities. In terms of kidney, I think it has become, at least at our institution, and I think in most places in the United States , the procedure of choice for most of the tumors we are seeing.

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And for prostate [cancer], it is currently being evaluated; but I think people are saying that you can do a similar procedure.

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Now, what are the problems with it? There are several problems. Number 1, there are limited studies. Whereas, you saw the wonderful studies that Dr. Sheinfeld showed in the thousands range, I think that Jim Porter did a survey of what is in the literature, and there are probably about between two and three hundred cases of laparoscopic retroperitoneal lymphadenectomy that have been reported.

The early European data is the largest but there are differences in terms of dissection and what they consider an adequate dissection, different than what the people in the open centers say here in the States. And the technique has evolved.

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More problems [were encountered with] postop chemotherapy, and this is something that I get beat up on all the time. And the reason we do this is that the philosophy that is at some of the bigger places, which I am not arguing that it shouldn't be the philosophy at all institutions around the world, but isn't shared by all oncologists or hadn't been shared by all oncologists and/[or] at our institution. Even patients undergoing open node dissections, if they had positive nodes, they were advised to get chemotherapy.

So, that is where that came from. Now, the problem is that after having presented this and people pointing out to me that primary retroperitoneal lymphadenectomy can be curative, why do you not give these patients chemotherapy? The problem is that our oncologists have patients who were referred from outside who would talk to their oncologists and they would call major centers and say, "No, the laparoscopic retroperitoneal lymphadenectomy is experimental. You had better give him chemotherapy." So, even now patients we would like to not give chemotherapy for are being steered towards getting chemotherapy. So, we even have a real hard time in not doing this at our institution.

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And the solution that is being looked at now with the prostate, and which needs to be done to answer this question once and for all, is that everyone needs to get game. We as the minimally invasive surgeons need to understand testicular cancer as well as the oncologists do, and the oncologists need to get game in terms of being able to do laparoscopic surgery. And we are very fortunate now that most major centers in the country have surgeons that are adept in both disciplines.

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And it is very important and I agree with Joel 100 percent. The primary goal is curing these patients, but we cannot be desensitized that big incisions are good. We can't be desensitized as minimally invasive surgeons that even these are good.

What we need to go for eventually is this: no incision in these patients. And I think some of the wonderful work that is being looked at in terms of trying to predict which patients really need a node dissection versus observation versus primary chemotherapy are so, so important.

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And I am sure both of these individuals are going to partner together, and I predict that Joel will be calling me up in about 4 years asking to borrow a slide that is titled this, “Laparoscopic RPLND, the new standard.”

Again, thank you very much for this opportunity.

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