British Journalof Urology (1992), 70,216-219 01992 British Journal of Urology
Laparoscopic Pelvic Lymph Node Dissection W. G. BOWSHER,A. CLARKE, D. G. CLARKE and A. J. COSTELLO Department of Urology, St Vincent‘s Hospital, Melbourne, Australia
Summary-The infiltration of pelvic lymph nodes by carcinoma of the prostate or carcinoma of the bladder is an important factor in disease staging. Until now, this could be accurately assessed only by means of open surgery, an undesirable option a s an investigation. Recent advances in laparoscopic instruments and camera systems have allowed the performance of laparoscopic pelvic lymph node dissection. A series of dissections in 14 patients is reported.
There has been increasing interest recently in laparoscopic surgery, 90 years since Kelling (1902) presented his concept of “coelioscopy” at the Congress of German Naturalists and Physicians in Hamburg. The diagnostic potential of the technique was emphasised by Jacobaeus (1910), who also coined the word “laparoscopy”. Kalk (1929) developed new lens systems and is regarded as the father of modern laparoscopy. In 1989, Dubois et al. performed the first laparoscopic cholecystectomy, which spawned interest in the applications of laparoscopy to technically challenging surgical problems such as pelvic lymph node dissection. Patients and Methods A series of 12 patients had carcinoma o f the prostate. Their disease was staged locally using rectal examination, transrectal ultrasonography and cystourethroscopy.All patients had histological evidence of carcinoma of the prostate following either transurethral resection (n = 4) or ultrasoundguided needle biopsy using the “Biopty” gun (n = 8). Screening for metastatic disease included serum acid phosphatase, serum prostate specific antigen (P.S.A. Hybritech radio-immunoassay), chest Xray and radio-isotope bone scanning. Two patients had GI11 pT2 carcinoma of the bladder. Both were originally diagnosed and staged using intravenous urography, cystoscopy, examination under anaesthesia, transurethral resection, chest X-ray and Accepted for publication 20 September 1991
pelvic and abdominal computed tomography (CT) scanning. One of these patients, a female, had been subjected to 4 courses of M-VAC chemotherapy after a laparotomy 8 months previously had revealed iliac nodes infiltrated by transitional cell carcinoma. Subsequent CT scanning had shown no evidence of residual lymphadenopathy. The other patient, a male, was subjected to laparoscopic node dissection to establish his suitability for radical cystectomy. Details of the patients are summarised in Tables 1 and 2. Patients were admitted the day before surgery. Informed consent was obtained for both laparoscopic pelvic node dissection and laparotomy. Two units of blood were cross-matched. An enema was given on the night prior to surgery and an abdominal shave was performed. Antibiotic prophylaxis was not given routinely. All patients were prescribed T.E.D. anti-thrombotic stockings. Under general anaesthesia, the patient was placed in the lithotomy position on Lloyd Davies stirrups with each arm beside the trunk. The pelvis was hyper-extended by placing a rolled blanket under the buttocks and the table given 10” of Trendelenburg tilt. The abdomen was prepared and draped to allow access to both iliac fossae. The surgeon stood on the side undergoing surgery, the camera operator opposite and the assistant between the patient’s legs. A 1 4 F urethral catheter was placed in the bladder and left on free drainage. A Veress needle was inserted through a sub-umbilical incision and a pneumoperitoneum produced and maintained at 14 mm Hg. An 11 mm trocar was inserted through this incision and the telescope
276
277
LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION
Table 1 Carcinoma of the Prostate
Patient no.
Age (years)
P.S.A (pg1.U
Previous abdominal surgery
Pre-operative staging (TNM)
No No No Yes No No Yes No No Yes No No
T3NXMO T2bNXMO T3NXMO TlbNXMO T3NXMO T3NXMO T2aNXMO T3NXMO T3NXMO T3NXMO T3NXMO T2bNXMO
Gleason grade (primary tumour)
Node histology
-~
1 2 3 4 5 6
I 8 9
10 11 12
-
70 69
43.4
64 71
142.0
76 76 65 69 67
90.0 8.3 26.4
16.5 6.0
68.0
34.8
73
55.0
60
42.0 11.8
73
Table 2 Carcinoma of the Bladder
-
Patient no.
Age (years)
13 14
12 68
Previous abdominal surgery
Pre-operative staging (TNM)
Node histology
Yes Yes
pT2NXMO pT2NXMO
Negative Negative
inserted into the peritoneal cavity to visualise the crucial landmarks on the television monitors. Where necessary, the Trendelenburg tilt was increased to displace bowel from the pelvis. Two 10 mm ports were placed in the right iliac fossa under camera vision and used with 5 mm adaptors as working channels. Blunt grasping forceps were used to pick up the peritoneum midway between the medial umbilical ligament and the pulsation of the external iliac artery. A peritoneal incision was then made between these 2 structures using hook diathermy and the peritoneal window extended using blunt dissection with 2 pairs of grasping forceps. The vas deferens was identified at the base of the wound, lifted with the hook diathermy, coagulated and divided. The medial aspect of the external iliac vein was then exposed by teasing the adjacent fat with 2 pairs of blunt grasping forceps. The lymph nodes in the area between the medial aspect of the external iliac vein, the pelvic side wall and over the obturator nerve were then cleared using blunt grasping forceps, hook diathermy and diathermy scissors. Nodes were removed piecemeal through the most convenient 10 mm port after removing the 5 mm adaptor or, when necessary, the endoscope was moved to 1 of the 10mm ports and the nodes
6 5
7 6
8 2 5
8 8 6
8 5
Negative Negative Positive Negative Negative Negative Negative Negative Positive Negative Negative Negative
extracted through the 11 mm port in 11 mm cup forceps. Bleeding small vessels were secured using either coagulating diathermy or clips after they were clearly seen with the help of a suction irrigation device (irrigating with 1000 units heparin/L of Hartmann’s solution). The 10 mm ports were then removed and the associated wounds closed with nylon. The procedure was then repeated on the left, retracting the sigmoid colon, where necessary, in blunt grasping forceps. At the end of each operation, haemostasis was carefully checked using irrigation and aspiration of the operative fields. After desufflation of the abdomen, wounds were closed with nylon. All nodes were sent for paraffin section. When the nodes appeared to be infiltrated by carcinoma, an individual node biopsy was performed: a node was dissected free using blunt dissection with grasping forceps and sharp dissection with diathermy scissors, removed in 11 mm cup forceps through the 11 mm port and sent for frozen section. When this proved positive, the dissection went no further. If persistent bleeding could not be controlled during the operation, a laparotomy was performed, haemostasis obtained and the operation completed by open operation.
Results No patient had evidence of distant metastases. The meanoperation time was 1 h 50 min (range 45 min3 h). Five patients had unilateral dissections and 6 had bilateral dissections. A mean number of 5
278
BRITISH JOURNAL OF UROLOGY
scopic pelvic lymph node dissection. Firstly, it is worthwhile spending some time examining the anatomical landmarks to ensure the correct positioning of the peritoneal window over the pelvic nodes. If this window is incorrectly positioned, even by millimetres, the potentially straightforward dissection on to the vas and pelvic nodes will prove difficult and time-consuming. Secondly, it is important to examine the nodes carefully in situ. If there is reasonable suspicion that the nodes are positive, a single node biopsy by sharp dissection followed by frozen section is indicated. This ensures that the unnecessary dissection of positive nodes, with its inherent risk of bleeding, is avoided. The result of the patient’s preoperative prostatic specific antigen may give some guidance to the likelihood of nodal involvement. Discussion Thirdly, as for all laparoscopic surgery, haemoLymph node dissection is the most accurate method stasis should be even more meticulous than at open available for assessing pelvic lymph node involve- surgery. Quantifying blood loss is difficult laparoment with carcinoma of the prostate. Both com- scopically and haemostasis should be checked and puted tomography and nuclear magnetic reson- checked again using irrigation and aspiration. With ance imaging are unlikely to detect tumour in experience, the use of diathermy and clips to stop normal-sized nodes (Chadwick et al., 1991). Pedal bleeding, even from small vessels, becomes easier. lymphography is less accurate than node dissecThe operation can be considered for those who tion (O’Donoghue et al., 1976) and prostatic have undergone previous abdominal surgery, allymphoscintigraphy lacks the precision and clarity though careful precautions must be taken when required for disease staging (Stone et al., 1979). introducing the Veress needle, insufflating the Careful histological examination of pelvic lymph abdomen and introducing trocars (Semm and nodes may avoid inappropriate local therapy for Friedrich, 1987). For thoroughness, a bilateral carcinoma of the prostate (McDowell et al., 1990). dissection is preferable. The unilateral dissections There is evidence that once this disease has spread were performed early in the series. With increased to pelvic nodes, distant metastases can be expected operating speed, bilateral laparoscopic dissection within 2 to 3 years (Catalona and Kelly, 1983). has become routine. Knowledge of such nodal disease may be sufficient The positioning of the surgeon and assistants, as evidence to institute early hormonal therapy (Pol- with open surgery, is a matter of personal preferlen, 1983; van Aubel et al., 1985). ence. Unlike Schuessler et al. (1991), we have not In the past, pelvic node dissection for carcinoma found that it is difficult, for example, to operate of the prostate has been criticised owing to the risk with laparoscopic instruments in the right pelvis of lymphocele, suprapubic and genital oedema and whilst standing on the patient’s right. The use of laparoscopic pelvic node dissection thromboembolic disease. The technique for laparoscopic node dissection includes some modifica- has several implications. The surgical assault on tions which are important in this respect. The the patient is lessened, resulting in a comfortable incidence of lymphoedema is greatly reduced by and speedy return to normal activity. The operation leaving the deep inguinal nodes and those along the is possible without making great demands on lateral border of the external iliac artery, and the hospital bed occupancy. As a result, node dissection risk of venous thrombosis is reduced by avoiding is more appealing as an investigation and staging manipulation of the pelvic veins (Lytton, 1986). procedure. If nodal status is known, a fairer Furthermore, the incidence of lymphocele is likely comparison of treatments is possible : for example, a more accurate audit of the results of radical to be reduced by a transperitoneal approach. The general techniques for laparoscopic abdom- prostatectomy versus radiotherapy for localised inal surgery have been described elsewhere (Semm carcinoma of the prostate. It may also prove to be and Friedrich, 1987). There are 3 specific points a useful technique in the staging and management which are critical in the performance of laparo- of carcinoma of the bladder. lymph nodes was dissected per side. Two patients with carcinoma of the prostate had positive nodes : in 1 of these, this was confirmed by frozen section. Both patients with carcinoma of the bladder had negative nodes. In 3 patients the operation was completed by necessity as an open procedure; 2 of these patients had persistent bleeding from a branch of the obturator artery and 1 bled from the inferior epigastric artery near its origin. Only 1 patient required a blood transfusion (2 units). All patients had an uneventful post-operative recovery. Following laparoscopic dissection, all were discharged the morning after surgery.
279
LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION
Acknowledgements W.G.B. is grateful for the Shackman Travelling Fellowship and the Sir Alexander McCormick Travelling Fellowship of the Royal College of Surgeons of England. The authors are also indebted to Dr R. Stillwell of the Department of P a t h o h ’ , St Vincent’s Hospital, for his examination of the specimens.
References Catalona, W. J. and Kelly, D. R. (1983). Accuracy of frozen section detection of lymph node metastases in prostatic carcinoma. J. Urol., 127,460. Chadwick, D. J., Cobby, M., Goddard, P. er al. (1991). Comparison of transrectal ultrasound and magnetic resonance imaging in the staging of prostate cancer. Br. J. Urol., 67, 61-21. Dubois, F., Bertelot, G. and Levard, H. (1989). CholCcystectomie par coelioscopie. Presse Med., 18,980-982. Jacobaeus, H. C. (1910). Ueber die Moglichkeit die Zystoskopie bei Untersuchung seroeser Hoehlungen anzuwenden. Muenchen. Med. Wchnschr.,57,2090-2092. Kalk, H. (1929). Erfahungen mit der Laparoskopie (zugleich mit Beschreibung eines neuen Instrumentes). Ztschr. Klin. Med., 111,303-348. Kelling, G. (1902). Ueber Oesophagoskopie, Gastroskopie und Kolioskopie. Muenchen. Med. Wchnschr., 49,21-24. Lytton, B. (1986). Early prostatic cancer. In The Prostate, ed. Blandy, J. P. and Lytton, B. Chapter 12, p. 166. London: Butterworths. McDowell, G. C., Johnson, J. W., Tenney, D. et aL (1990). Pelvic
lymphadenectomy for staging clinically localized prostate cancer. Urology, 35,476482. O’Donoghue, E. P. N., Shridar, P., Shemood, T. et al. (1976). Lymphography and pelvic lymphadenectomy in carcinoma of the prostate, Br, J . urol., 48, 689-696, Pollen, J. J. (1983). Endocrine treatment for prostatic cancer. U ~ O ~ 21, O ~555-558. V, Schuessier, W.W., Vancaillie, H. R., Reich, H. et aL (1991). Transperitoneal endosurgical lymphadenectomy in patients with localised prostate cancer. J. Urol., 145, 988-991. Semm, K. and Friedrich, E. R. (1987). Operafive Manual for Endoscopic Abdominal Surgery. Chicago : Year Book Medical Publishers. Stone, A. R., Merrick, M. V. and Chisholm, C. D. (1979). Prostatic lymphoscintigraphy. Br. J. Urol., 51, 556-560. van Aubel, 0. G. J. M., Hoekstra, W. J. and Schriider, F. H. (1985). Early orchiectomy for patients with stage D1 prostatic carcinoma. J . Urol., 134,292.
The Authors W. G. Bowsher, MA, MChir, FRCSUrol, Lecturer in Urology, The Royal London Hospital. Now Senior Fellow in Urology, St Vincent’s Hospital. A. Clarke, MB,BS, Research Fellow, Department of Urology. D. G. Clarke, MB,BS, Research Fellow, Department of Urology. A. J. Costello, FRACS, Head of Department of Urology. Requests for reprints to: W. G. Bowsher, Department of Urology, St Vincent’s Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia.
Laparoscopic Pelvic Lymph Node Dissection W. G. BOWSHER,A. CLARKE, D. G. CLARKE and A. J. COSTELLO Department of Urology, St Vincent‘s Hospital, Melbourne, Australia
Summary-The infiltration of pelvic lymph nodes by carcinoma of the prostate or carcinoma of the bladder is an important factor in disease staging. Until now, this could be accurately assessed only by means of open surgery, an undesirable option a s an investigation. Recent advances in laparoscopic instruments and camera systems have allowed the performance of laparoscopic pelvic lymph node dissection. A series of dissections in 14 patients is reported.
There has been increasing interest recently in laparoscopic surgery, 90 years since Kelling (1902) presented his concept of “coelioscopy” at the Congress of German Naturalists and Physicians in Hamburg. The diagnostic potential of the technique was emphasised by Jacobaeus (1910), who also coined the word “laparoscopy”. Kalk (1929) developed new lens systems and is regarded as the father of modern laparoscopy. In 1989, Dubois et al. performed the first laparoscopic cholecystectomy, which spawned interest in the applications of laparoscopy to technically challenging surgical problems such as pelvic lymph node dissection. Patients and Methods A series of 12 patients had carcinoma o f the prostate. Their disease was staged locally using rectal examination, transrectal ultrasonography and cystourethroscopy.All patients had histological evidence of carcinoma of the prostate following either transurethral resection (n = 4) or ultrasoundguided needle biopsy using the “Biopty” gun (n = 8). Screening for metastatic disease included serum acid phosphatase, serum prostate specific antigen (P.S.A. Hybritech radio-immunoassay), chest Xray and radio-isotope bone scanning. Two patients had GI11 pT2 carcinoma of the bladder. Both were originally diagnosed and staged using intravenous urography, cystoscopy, examination under anaesthesia, transurethral resection, chest X-ray and Accepted for publication 20 September 1991
pelvic and abdominal computed tomography (CT) scanning. One of these patients, a female, had been subjected to 4 courses of M-VAC chemotherapy after a laparotomy 8 months previously had revealed iliac nodes infiltrated by transitional cell carcinoma. Subsequent CT scanning had shown no evidence of residual lymphadenopathy. The other patient, a male, was subjected to laparoscopic node dissection to establish his suitability for radical cystectomy. Details of the patients are summarised in Tables 1 and 2. Patients were admitted the day before surgery. Informed consent was obtained for both laparoscopic pelvic node dissection and laparotomy. Two units of blood were cross-matched. An enema was given on the night prior to surgery and an abdominal shave was performed. Antibiotic prophylaxis was not given routinely. All patients were prescribed T.E.D. anti-thrombotic stockings. Under general anaesthesia, the patient was placed in the lithotomy position on Lloyd Davies stirrups with each arm beside the trunk. The pelvis was hyper-extended by placing a rolled blanket under the buttocks and the table given 10” of Trendelenburg tilt. The abdomen was prepared and draped to allow access to both iliac fossae. The surgeon stood on the side undergoing surgery, the camera operator opposite and the assistant between the patient’s legs. A 1 4 F urethral catheter was placed in the bladder and left on free drainage. A Veress needle was inserted through a sub-umbilical incision and a pneumoperitoneum produced and maintained at 14 mm Hg. An 11 mm trocar was inserted through this incision and the telescope
276
277
LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION
Table 1 Carcinoma of the Prostate
Patient no.
Age (years)
P.S.A (pg1.U
Previous abdominal surgery
Pre-operative staging (TNM)
No No No Yes No No Yes No No Yes No No
T3NXMO T2bNXMO T3NXMO TlbNXMO T3NXMO T3NXMO T2aNXMO T3NXMO T3NXMO T3NXMO T3NXMO T2bNXMO
Gleason grade (primary tumour)
Node histology
-~
1 2 3 4 5 6
I 8 9
10 11 12
-
70 69
43.4
64 71
142.0
76 76 65 69 67
90.0 8.3 26.4
16.5 6.0
68.0
34.8
73
55.0
60
42.0 11.8
73
Table 2 Carcinoma of the Bladder
-
Patient no.
Age (years)
13 14
12 68
Previous abdominal surgery
Pre-operative staging (TNM)
Node histology
Yes Yes
pT2NXMO pT2NXMO
Negative Negative
inserted into the peritoneal cavity to visualise the crucial landmarks on the television monitors. Where necessary, the Trendelenburg tilt was increased to displace bowel from the pelvis. Two 10 mm ports were placed in the right iliac fossa under camera vision and used with 5 mm adaptors as working channels. Blunt grasping forceps were used to pick up the peritoneum midway between the medial umbilical ligament and the pulsation of the external iliac artery. A peritoneal incision was then made between these 2 structures using hook diathermy and the peritoneal window extended using blunt dissection with 2 pairs of grasping forceps. The vas deferens was identified at the base of the wound, lifted with the hook diathermy, coagulated and divided. The medial aspect of the external iliac vein was then exposed by teasing the adjacent fat with 2 pairs of blunt grasping forceps. The lymph nodes in the area between the medial aspect of the external iliac vein, the pelvic side wall and over the obturator nerve were then cleared using blunt grasping forceps, hook diathermy and diathermy scissors. Nodes were removed piecemeal through the most convenient 10 mm port after removing the 5 mm adaptor or, when necessary, the endoscope was moved to 1 of the 10mm ports and the nodes
6 5
7 6
8 2 5
8 8 6
8 5
Negative Negative Positive Negative Negative Negative Negative Negative Positive Negative Negative Negative
extracted through the 11 mm port in 11 mm cup forceps. Bleeding small vessels were secured using either coagulating diathermy or clips after they were clearly seen with the help of a suction irrigation device (irrigating with 1000 units heparin/L of Hartmann’s solution). The 10 mm ports were then removed and the associated wounds closed with nylon. The procedure was then repeated on the left, retracting the sigmoid colon, where necessary, in blunt grasping forceps. At the end of each operation, haemostasis was carefully checked using irrigation and aspiration of the operative fields. After desufflation of the abdomen, wounds were closed with nylon. All nodes were sent for paraffin section. When the nodes appeared to be infiltrated by carcinoma, an individual node biopsy was performed: a node was dissected free using blunt dissection with grasping forceps and sharp dissection with diathermy scissors, removed in 11 mm cup forceps through the 11 mm port and sent for frozen section. When this proved positive, the dissection went no further. If persistent bleeding could not be controlled during the operation, a laparotomy was performed, haemostasis obtained and the operation completed by open operation.
Results No patient had evidence of distant metastases. The meanoperation time was 1 h 50 min (range 45 min3 h). Five patients had unilateral dissections and 6 had bilateral dissections. A mean number of 5
278
BRITISH JOURNAL OF UROLOGY
scopic pelvic lymph node dissection. Firstly, it is worthwhile spending some time examining the anatomical landmarks to ensure the correct positioning of the peritoneal window over the pelvic nodes. If this window is incorrectly positioned, even by millimetres, the potentially straightforward dissection on to the vas and pelvic nodes will prove difficult and time-consuming. Secondly, it is important to examine the nodes carefully in situ. If there is reasonable suspicion that the nodes are positive, a single node biopsy by sharp dissection followed by frozen section is indicated. This ensures that the unnecessary dissection of positive nodes, with its inherent risk of bleeding, is avoided. The result of the patient’s preoperative prostatic specific antigen may give some guidance to the likelihood of nodal involvement. Discussion Thirdly, as for all laparoscopic surgery, haemoLymph node dissection is the most accurate method stasis should be even more meticulous than at open available for assessing pelvic lymph node involve- surgery. Quantifying blood loss is difficult laparoment with carcinoma of the prostate. Both com- scopically and haemostasis should be checked and puted tomography and nuclear magnetic reson- checked again using irrigation and aspiration. With ance imaging are unlikely to detect tumour in experience, the use of diathermy and clips to stop normal-sized nodes (Chadwick et al., 1991). Pedal bleeding, even from small vessels, becomes easier. lymphography is less accurate than node dissecThe operation can be considered for those who tion (O’Donoghue et al., 1976) and prostatic have undergone previous abdominal surgery, allymphoscintigraphy lacks the precision and clarity though careful precautions must be taken when required for disease staging (Stone et al., 1979). introducing the Veress needle, insufflating the Careful histological examination of pelvic lymph abdomen and introducing trocars (Semm and nodes may avoid inappropriate local therapy for Friedrich, 1987). For thoroughness, a bilateral carcinoma of the prostate (McDowell et al., 1990). dissection is preferable. The unilateral dissections There is evidence that once this disease has spread were performed early in the series. With increased to pelvic nodes, distant metastases can be expected operating speed, bilateral laparoscopic dissection within 2 to 3 years (Catalona and Kelly, 1983). has become routine. Knowledge of such nodal disease may be sufficient The positioning of the surgeon and assistants, as evidence to institute early hormonal therapy (Pol- with open surgery, is a matter of personal preferlen, 1983; van Aubel et al., 1985). ence. Unlike Schuessler et al. (1991), we have not In the past, pelvic node dissection for carcinoma found that it is difficult, for example, to operate of the prostate has been criticised owing to the risk with laparoscopic instruments in the right pelvis of lymphocele, suprapubic and genital oedema and whilst standing on the patient’s right. The use of laparoscopic pelvic node dissection thromboembolic disease. The technique for laparoscopic node dissection includes some modifica- has several implications. The surgical assault on tions which are important in this respect. The the patient is lessened, resulting in a comfortable incidence of lymphoedema is greatly reduced by and speedy return to normal activity. The operation leaving the deep inguinal nodes and those along the is possible without making great demands on lateral border of the external iliac artery, and the hospital bed occupancy. As a result, node dissection risk of venous thrombosis is reduced by avoiding is more appealing as an investigation and staging manipulation of the pelvic veins (Lytton, 1986). procedure. If nodal status is known, a fairer Furthermore, the incidence of lymphocele is likely comparison of treatments is possible : for example, a more accurate audit of the results of radical to be reduced by a transperitoneal approach. The general techniques for laparoscopic abdom- prostatectomy versus radiotherapy for localised inal surgery have been described elsewhere (Semm carcinoma of the prostate. It may also prove to be and Friedrich, 1987). There are 3 specific points a useful technique in the staging and management which are critical in the performance of laparo- of carcinoma of the bladder. lymph nodes was dissected per side. Two patients with carcinoma of the prostate had positive nodes : in 1 of these, this was confirmed by frozen section. Both patients with carcinoma of the bladder had negative nodes. In 3 patients the operation was completed by necessity as an open procedure; 2 of these patients had persistent bleeding from a branch of the obturator artery and 1 bled from the inferior epigastric artery near its origin. Only 1 patient required a blood transfusion (2 units). All patients had an uneventful post-operative recovery. Following laparoscopic dissection, all were discharged the morning after surgery.
279
LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION
Acknowledgements W.G.B. is grateful for the Shackman Travelling Fellowship and the Sir Alexander McCormick Travelling Fellowship of the Royal College of Surgeons of England. The authors are also indebted to Dr R. Stillwell of the Department of P a t h o h ’ , St Vincent’s Hospital, for his examination of the specimens.
References Catalona, W. J. and Kelly, D. R. (1983). Accuracy of frozen section detection of lymph node metastases in prostatic carcinoma. J. Urol., 127,460. Chadwick, D. J., Cobby, M., Goddard, P. er al. (1991). Comparison of transrectal ultrasound and magnetic resonance imaging in the staging of prostate cancer. Br. J. Urol., 67, 61-21. Dubois, F., Bertelot, G. and Levard, H. (1989). CholCcystectomie par coelioscopie. Presse Med., 18,980-982. Jacobaeus, H. C. (1910). Ueber die Moglichkeit die Zystoskopie bei Untersuchung seroeser Hoehlungen anzuwenden. Muenchen. Med. Wchnschr.,57,2090-2092. Kalk, H. (1929). Erfahungen mit der Laparoskopie (zugleich mit Beschreibung eines neuen Instrumentes). Ztschr. Klin. Med., 111,303-348. Kelling, G. (1902). Ueber Oesophagoskopie, Gastroskopie und Kolioskopie. Muenchen. Med. Wchnschr., 49,21-24. Lytton, B. (1986). Early prostatic cancer. In The Prostate, ed. Blandy, J. P. and Lytton, B. Chapter 12, p. 166. London: Butterworths. McDowell, G. C., Johnson, J. W., Tenney, D. et aL (1990). Pelvic
lymphadenectomy for staging clinically localized prostate cancer. Urology, 35,476482. O’Donoghue, E. P. N., Shridar, P., Shemood, T. et al. (1976). Lymphography and pelvic lymphadenectomy in carcinoma of the prostate, Br, J . urol., 48, 689-696, Pollen, J. J. (1983). Endocrine treatment for prostatic cancer. U ~ O ~ 21, O ~555-558. V, Schuessier, W.W., Vancaillie, H. R., Reich, H. et aL (1991). Transperitoneal endosurgical lymphadenectomy in patients with localised prostate cancer. J. Urol., 145, 988-991. Semm, K. and Friedrich, E. R. (1987). Operafive Manual for Endoscopic Abdominal Surgery. Chicago : Year Book Medical Publishers. Stone, A. R., Merrick, M. V. and Chisholm, C. D. (1979). Prostatic lymphoscintigraphy. Br. J. Urol., 51, 556-560. van Aubel, 0. G. J. M., Hoekstra, W. J. and Schriider, F. H. (1985). Early orchiectomy for patients with stage D1 prostatic carcinoma. J . Urol., 134,292.
The Authors W. G. Bowsher, MA, MChir, FRCSUrol, Lecturer in Urology, The Royal London Hospital. Now Senior Fellow in Urology, St Vincent’s Hospital. A. Clarke, MB,BS, Research Fellow, Department of Urology. D. G. Clarke, MB,BS, Research Fellow, Department of Urology. A. J. Costello, FRACS, Head of Department of Urology. Requests for reprints to: W. G. Bowsher, Department of Urology, St Vincent’s Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia.
