minimally invasive lymphadenectomy for renal cell carcinoma · minimally invasive lymphadenectomy...
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Minimally Invasive Lymphadenectomy
for Renal Cell Carcinoma
James Porter
Director, Robotic Surgery
Swedish Medical Center
Seattle, WA
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Current Role for
Lymphadenectomy in RCCConfounding issues:
– Downward stage migration of RCC in contemporary population
– Unpredictable lymphatic drainage
– Low risk of node positive disease without systemic metastasis
• Retrospective Data: – Lack of consensus as there is no evidence to support a
therapeutic benefit in RCC
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Lymphadenectomy for RCC
• EORTC 30881 RCT of Radical Nephrectomy ±LND
– 389 Rad Neph vs. 383 Rad Neph with LND
– 14 (4%) positive lymph nodes
• No difference in:
– Overall survival
– Progression free survival
– Time to progression
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Lymphadenectomy for RCC
• EORTC 30881 Concerns:
– Mostly organ confined RCC
• High risk = 31%
• May not see benefit of LND in low risk
patients
– Extent of LND not standard
• Selection bias of dissection technique
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Lymphadenectomy for RCC
• Extent of dissection correlates with pN+ rate
– Terrone et al: 13 nodes removed a cut off for
high vs low rate of positive nodes
– Joslyn et al: higher node positive rate with
more nodes removed
BJU Int 2003;91:37–40.
Urology 2005;65:675–80.
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Lymphadenectomy for RCC
• Lymphatic drainage variable for RCC
• Extent of dissection varies among
studies
• Templates suggested, none validated
• Hilar vs. Extended
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Extended template for lymphadenectomy for RCC
From Capitanio et al. Eur Urol 2011(60), 1217.
Right side
Top: Adrenal vein
Bottom: IMA
Precaval
Retrocaval
Paracaval
Interaortocaval
Left side
Top: Crus of
diaphragm
Bottom: IMA
Para-aortic
Preaortic
Paracaval
Interaortocaval
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Lymphadenectomy for RCC• EORTC 30881 T3 Subgroup Analysis(Blom et al)
– 110 RN + LND vs. 101 RN
– 15% better survival at 5 yrs for LND (p=0.29)
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Lymphadenectomy in RCC
• Indications:
– High risk disease: T3 and T4 tumors
– Lymphadenopathy on pre-op imaging
– At time of cytoreductive nephrectomy
• Not Indicated for T1 and T2 tumors
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Lymphadenectomy for
High Risk Tumor
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Laparoscopic
Lymphadenectomy • Initial lap nephrectomies in 1990’s did not
include regional LND due to technical difficulty
• With evolution of technique, Gill reported on the largest series of patients treated with lap LND for RCC.
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MIS Lymphadenectomy for RCC
• Simmons and Gill: Lap LND(hilar)
and RN
– 14/700 underwent LND
– 7 patients with distant mets
– 9 patients T2 or higher
– Mean LN count: 2.7 nodes
– One grade I complicationUrology. 2007 Jul;70(1):43-6
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MIS Lymphadenectomy for RCC
• Chapman et al: Lap LND with RN vs. Lap RN
– Retrospective review: 50 RN+LND vs. 50 RN
– 5/50(10%) node positive in LND group
– Mean LN count: 7.8 for hilar, 12.1 for extended
– Complications minimal
Urology. 2008 Feb;71(2):287-91
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MIS Lymphadenectomy for RCC• Abaza: 36 patients with robotic RN
and LND
– 16 T3 patients + 4 caval thrombi (55%
high risk)
– Mean node count:13.9 nodes
– 1/36(2.8%) + node
– No complications
J Endourol. 2011 Jul;25(7):1155-9.
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Robotic Lymphadenectomy
for RCC• Lateral position
• Same port configuration
• Control lymphatics with clips
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Patient Positioning
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daVinci Xi
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Port Configuration - daVinci Xi
Camera
Xi port
Assist
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MIS Lymphadenectomy for RCC
Conclusions
• LND in RCC indicated for:– Enlarged nodes
– High risk tumors
– Cytoreductive procedures
• Extent of dissection not defined
• MIS LND safe and node yield depends on extent of dissection
• No survival benefit for LND in RCC
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MIS Lymphadenectomy for RCC
Recommendation
• LND for high risk patients
• Extended LND to improve nodal yield
• Open vs. MIS LND based on
surgeons preference
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Thank You!