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Central European Journal of Urology 2018To determine the effectiveness and safety of extended pelvic lymphadenectomy compared with standard lymphadenectomy in the overall, cancer-specific survival and... (Review)
Review
INTRODUCTION
To determine the effectiveness and safety of extended pelvic lymphadenectomy compared with standard lymphadenectomy in the overall, cancer-specific survival and biochemical recurrence-free survival of patients with localized prostate cancer who underwent radical prostatectomy.
MATERIAL AND METHODS
Clinical trials and cohort studies were included without language restrictions with the following participants: men older than 40 years of age diagnosed with localized prostate cancer who received radical prostatectomy plus pelvic lymphadenectomy. Standard vs. extended pelvic lymphadenectomy were compared. The primary outcomes were overall and cancer-specific survival. A search strategy in MEDLINE, EMBASE, CENTRAL, LILACS, and other databases was conducted to obtain published and unpublished literature. The risk of bias was evaluated with the Cochrane Collaboration tool. The statistical analysis was performed in STATA 14.
RESULTS
Six studies were included, of which only one was experimental; the other studies were cohort studies. The surgical technique was robot-assisted in three studies. Two studies only had information concerning the adverse effects. It was not possible to include one clinical trial that met the criteria because an erratum was published in which falsification of the experimental data was proven. There was a biochemical recurrence-free survival hazard ratio (HR) = 0.62 and a 95% confidence interval (CI) (0.36 to 0.87).
CONCLUSIONS
According to current literature, a mild difference was evident favoring the extended lymphadenectomy in biochemical recurrence-free survival. Additionally, there was no evidence to draw a conclusion regarding the overall survival since we did not find any studies concerning this outcome.
PubMed: 30386645
DOI: 10.5173/ceju.2018.1703 -
Taiwanese Journal of Obstetrics &... Oct 2018The presence of pelvic lymph node metastases is without doubt the most significant prognostic factor that determines recurrences and survival of women with early-stage...
The presence of pelvic lymph node metastases is without doubt the most significant prognostic factor that determines recurrences and survival of women with early-stage cervical cancer. To avoid the underdiagnosis of lymph node metastasis, pelvic lymphadenectomy procedure is routinely performed with radical hysterectomy procedure. However, the pelvic lymphadenectomy procedure may not be necessary in most of these women due to the relatively low incidence of pelvic lymph node metastasis. The removal of large numbers of pelvic lymph nodes could also render non-metastatic irreversible damages for these women, including vessel, nerve, or ureteral injuries; formation of lymphocysts; and lymphedema. Over the past decades, the concept of sentinel lymph node biopsy has emerged as a popular and widespread surgical technique for the evaluation of the pelvic lymph node status in gynecologic malignancies. The histological status of sentinel lymph node should be representative for all other lymph nodes in the regional drainage area. If metastasis is non-existent in the sentinel lymph node, the likelihood of metastatic spread in the remaining regional lymph nodes is very low. Further lymphadenectomy is therefore not necessary for a patient with negative sentinel lymph nodes. Since the uterine cervix has several lymphatic drainage pathways, it is a challenging task to assess the distribution pattern of sentinel lymph nodes in women with early-stage cervical cancer. This review article will adapt the methodology proposed in these studies to systematically review sentinel lymphatic mapping among women with early-stage cervical cancer.
Topics: Cervix Uteri; False Negative Reactions; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Lymphedema; Neoplasm Staging; Pelvis; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Uterine Cervical Neoplasms
PubMed: 30342642
DOI: 10.1016/j.tjog.2018.08.004 -
Taiwanese Journal of Obstetrics &... Oct 2018Pelvic lymphadenectomy procedure is included as part of the standard protocol of radical hysterectomy for women with early-stage cervical cancer (Stage IA to IB1)....
Pelvic lymphadenectomy procedure is included as part of the standard protocol of radical hysterectomy for women with early-stage cervical cancer (Stage IA to IB1). However, an important sequel to lymphadenectomy procedure is the possible occurrence of lymphedema in the lower abdomen and lower extremities. Previous researches also find that women with lymphedema experience many emotional impacts, including depression, anxiety, and adjustment problems. Only approximately 10% of women with clinical stage IB cervical carcinoma were involved with metastatic disease. If we could better define the relevant lymphatic nodes that must be removed, it is then possible to limit routinely performed lymphadenectomy for regional nodal metastasis in the pelvis, and hence reduce the need for extended surgical staging (para-aortic lymphadenectomy). We systematically reviewed a body of literature and updated available information concerning the current progress on the application of sentinel lymph node biopsy in women with early-stage cervical cancer. All detection methods (preoperative injection of radiocolloid tracer, intraoperative injection of blue dye, or a combination of both techniques) demonstrated reasonable sensitivity (with a few exceptions), high specificity, low false-negative rate and high negative predictive value. The review of the literature in this paper should convince the readers that sentinel lymph node biopsy has the potential to improve the quality of life and the possibility to maintain relapse-free survival for women with cervical cancer. The proper identification of negative sentinel lymph node allows individualized therapy and may preclude the need of lymphadenectomy procedure in most of these women.
Topics: Female; Humans; Hysterectomy; Lymph Node Excision; Lymphatic Metastasis; Lymphedema; Neoplasm Recurrence, Local; Neoplasm Staging; Quality of Life; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Uterine Cervical Neoplasms
PubMed: 30342641
DOI: 10.1016/j.tjog.2018.08.003 -
Minerva Urologica E Nefrologica = the... Aug 2018To date, bilateral pelvic lymph node dissection (PLND) represents the most accurate and reliable staging procedure for the detection of lymph node invasion in prostate... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
To date, bilateral pelvic lymph node dissection (PLND) represents the most accurate and reliable staging procedure for the detection of lymph node invasion in prostate cancer and bladder cancer. However, the procedure is not devoid of complications. In this field, Indocyanine green fluorescence-guided sentinel lymph node (SLN) identification is an emerging and promising technique, as accurate staging of urologic cancer could be enhanced by a thorough evaluation of the sentinel lymph nodes. Aim of the present review is to analyze available evidence and perform a metanalysis on ICG-guided SLN detection for urologic malignancies.
EVIDENCE ACQUISITION
A systematic review to assess the clinical value of Indocyanine green for the identification of sentinel lymphatic drainage for bladder, prostate, kidney and penile cancers was undertaken, with a meta-analysis to generate pooled detection rate concerning patients (clinical sensitivity) and nodes basin (technical sensitivity) separately. Studies reporting on the use of Indocyanine green for the detection of SLNs from the bladder, prostate and penile cancers were included.
EVIDENCE SYNTHESIS
A total of 10 clinical trials were included. Using the fixed effects model and the random effects model, the pooled patient detection rates and their 95% confidence intervals (95% CI) were 0.88 (0.82-0.92) and 0.92 (0.84-0.96), respectively. The pooled nodes detection rates were 0.71 (95% CI: 0.68-0.74) using the fixed effect model and 0.75 (95% CI: 0.56-0.87) using the random effect model. Significant heterogeneities existed among studies for patients and for nodes (I2=0.66, P<0.001 and I2=0.96, P<0.001, respectively). Significant publication bias was found in patient detection rate (P<0.001) and in nodes detection rate (P<0.001).
CONCLUSIONS
SLN mapping in bladder and prostate cancer is a method with a high detection rate, although its specificity to predict LN invasion remains poor. Large, well-constructed trails are needed to assess the impact of ICG-fluorescence guided SLN dissection on uro-oncologic surgery.
Topics: Coloring Agents; Humans; Indocyanine Green; Lymphatic Metastasis; Sentinel Lymph Node Biopsy; Urologic Neoplasms
PubMed: 29241310
DOI: 10.23736/S0393-2249.17.02932-0 -
European Urology Apr 2018The role of surgery in metastatic bladder cancer (BCa) is unclear.
CONTEXT
The role of surgery in metastatic bladder cancer (BCa) is unclear.
OBJECTIVE
In this collaborative review article, we reviewed the contemporary literature on the surgical management of metastatic BCa and factors associated with outcomes to support the development of clinical guidelines as well as informed clinical decision-making.
EVIDENCE ACQUISITION
A systematic search of English language literature using PubMed-Medline and Scopus from 1999 to 2016 was performed.
EVIDENCE SYNTHESIS
The beneficial role of consolidation surgery in metastatic BCa is still unproven. In patients with clinically evident lymph node metastasis, data suggest a survival advantage for patients undergoing postchemotherapy radical cystectomy with lymphadenectomy, especially in those with measurable response to chemotherapy (CHT). Intraoperatively identified enlarged pelvic lymph nodes should be removed. Anecdotal reports of resection of pulmonary metastasis as part of multimodal approach suggest possible improved survival in well-selected patients. Cytoreductive radical cystectomy as local treatment has also been explored in patients with metastatic disease, although its benefits remain to be assessed.
CONCLUSIONS
Consolidative extirpative surgery may be considered in patients with clinically evident pelvic or retroperitoneal lymph nodal metastases but only if they have had a response to CHT. Surgery for limited pulmonary metastases may also be considered in very selected cases. Best candidates are those with resectable disease who demonstrate measurable response to CHT with good performance status. In the absence of data from prospective randomized studies, each patient should be evaluated on an individual basis and decisions made together with the patient and multidisciplinary teams.
PATIENT SUMMARY
Surgical resection of metastases is technically feasible and can be safely performed. It may help improve cancer control and eventually survival in very selected patients with limited metastatic burden. In a patient who is motivated to receive chemotherapy and to undergo extirpative surgical intervention, surgery should be discussed with the patient among other consolidation therapies in the setting of multidisciplinary teams.
Topics: Clinical Decision-Making; Cystectomy; Cytoreduction Surgical Procedures; Humans; Neoplasm Metastasis; Practice Guidelines as Topic; Treatment Outcome; Urinary Bladder Neoplasms
PubMed: 29122377
DOI: 10.1016/j.eururo.2017.09.030 -
Archivos Espanoles de Urologia Nov 2017The aim of this article is to classify and describe the different types of complications of radical prostatectomy, their frequency of appearance, as well as the... (Review)
Review
OBJECTIVES
The aim of this article is to classify and describe the different types of complications of radical prostatectomy, their frequency of appearance, as well as the different factors that may influence their development.
METHODS
A systematic review of the literature was carried out, based on the search of published articles between 2002 and 2015.
RESULTS
Laparoscopic or robotic radical prostatectomy may require conversion into open surgery, and these cases are significantly associated with longer hospital stay and greater rate of complications. Vascular damage comprises from injuries to small and medium caliber vessels (Santorini plexus or epigastric vessels) to possible lesions of large vessels (iliac), although they are infrequent. The most common nerve injury is that of the obturator nerve, which can be treated in the case of a complete section, and in incomplete lesions, damage is usually reversible. Intestinal injury is one of the most serious complications because it could be lifethreatening. Rectal injury is a complication that needs a correct diagnosis and intraoperative treatment, since it may lead to the development of a secondary rectourethral fistula. Such fistulae in most cases require surgical treatment. Lymphocele is a characteristic complication of radical prostatectomy with pelvic lymphadenectomy, requiring treatment only in cases of complication. Anastomotic leakage is a frequent complication, and a prognostic factor for the later development of anastomosis stricture. Some of the factors that seem to influence the development of complications are associated comorbidity, anatomical factors, surgical approach and surgical experience, among others.
CONCLUSIONS
It is crucial to know the potential complications of radical prostatectomy, as well as the associated risk factors, in order to avoid their appearance.
Topics: Humans; Male; Postoperative Complications; Prostatectomy; Rectal Fistula; Rectum; Urethral Diseases; Urinary Fistula
PubMed: 29099379
DOI: No ID Found -
The Cochrane Database of Systematic... Oct 2017This is an update of a previous Cochrane review published in Issue 1, 2010 and updated in Issue 9, 2015. The role of lymphadenectomy in surgical management of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This is an update of a previous Cochrane review published in Issue 1, 2010 and updated in Issue 9, 2015. The role of lymphadenectomy in surgical management of endometrial cancer remains controversial. Lymph node metastases can be found in approximately 10% of women who before surgery are thought to have cancer confined to the womb. Removal of all pelvic and para-aortic lymph nodes (lymphadenectomy) at initial surgery has been widely advocated, and pelvic and para-aortic lymphadenectomy remains part of the FIGO (International Federation of Gynaecology and Obstetrics) staging system for endometrial cancer. This recommendation is based on data from studies that suggested improvement in survival following pelvic and para-aortic lymphadenectomy. However, these studies were not randomised controlled trials (RCTs), and treatment of pelvic lymph nodes may not confer a direct therapeutic benefit, other than allocating women to poorer prognosis groups. Furthermore, the Cochrane review and meta-analysis of RCTs of routine adjuvant radiotherapy to treat possible lymph node metastases in women with early-stage endometrial cancer found no survival advantage. Surgical removal of pelvic and para-aortic lymph nodes has serious potential short-term and long-term sequelae. Therefore, it is important to investigate the clinical value of this treatment.
OBJECTIVES
To evaluate the effectiveness and safety of lymphadenectomy for the management of endometrial cancer.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase to June 2009 for the original review, updated the search to June 2015 for the last updated version and further extended the search to March 2017 for this version of the review. We also searched registers of clinical trials, abstracts of scientific meetings, and reference lists of included studies, and we contacted experts in the field.
SELECTION CRITERIA
RCTs and quasi-RCTs that compared lymphadenectomy versus no lymphadenectomy in adult women diagnosed with endometrial cancer.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data and assessed risk of bias. Hazard ratios (HRs) for overall and progression-free survival and risk ratios (RRs) comparing adverse events in women who received lymphadenectomy versus those with no lymphadenectomy were pooled in random-effects meta-analyses. We assessed the quality of the evidence using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.
MAIN RESULTS
978 unique references were identified via the search strategy. All but 50 were excluded by title and abstract screening. Three RCTs met the inclusion criteria; for one small RCT, data were insufficient for inclusion in the meta-analysis. The two RCTs included in the analysis randomly assigned 1945 women, reported HRs for survival adjusted for prognostic factors and based on 1851 women and had an overall low risk of bias, as they satisfied four of the assessment criteria. The third study had an overall unclear risk of bias, as information provided was not adequate concerning random sequence generation, allocation concealment, blinding, or completeness of outcome reporting.Results of the meta-analysis remained unchanged from the previous versions of this review and indicated no differences in overall and recurrence-free survival between women who underwent lymphadenectomy and those who did not undergo lymphadenectomy (pooled hazard ratio (HR) 1.07, 95% confidence interval (CI) 0.81 to 1.43; HR 1.23, 95% CI 0.96 to 1.58 for overall and recurrence-free survival, respectively) (1851 participants, two studies; moderate-quality evidence).We found no difference in risk of direct surgical morbidity between women who underwent lymphadenectomy and those who did not undergo lymphadenectomy. However, women who underwent lymphadenectomy had a significantly higher risk of surgery-related systemic morbidity and lymphoedema/lymphocyst formation than those who did not undergo lymphadenectomy (RR 3.72, 95% CI 1.04 to 13.27; RR 8.39, 95% CI 4.06 to 17.33 for risk of surgery-related systemic morbidity and lymphoedema/lymphocyst formation, respectively) (1922 participants, two studies; high-quality evidence).
AUTHORS' CONCLUSIONS
This review found no evidence that lymphadenectomy decreases risk of death or disease recurrence compared with no lymphadenectomy in women with presumed stage I disease. Evidence on serious adverse events suggests that women who undergo lymphadenectomy are more likely to experience surgery-related systemic morbidity or lymphoedema/lymphocyst formation. Currently, no RCT evidence shows the impact of lymphadenectomy in women with higher-stage disease and in those at high risk of disease recurrence.
Topics: Adult; Disease-Free Survival; Endometrial Neoplasms; Female; Humans; Lymph Node Excision; Lymphatic Metastasis; Lymphedema; Lymphocele; Postoperative Complications; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 28968482
DOI: 10.1002/14651858.CD007585.pub4 -
The Cochrane Database of Systematic... Jun 2017This is an updated version of an original Cochrane review published in Issue 6, 2014. Pelvic lymphadenectomy is associated with significant complications including... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This is an updated version of an original Cochrane review published in Issue 6, 2014. Pelvic lymphadenectomy is associated with significant complications including lymphocyst formation and related morbidities. Retroperitoneal drainage using suction drains has been recommended as a method to prevent such complications. However, findings from recent studies have challenged this policy.
OBJECTIVES
To assess the effects of retroperitoneal drainage versus no drainage after pelvic lymphadenectomy on lymphocyst formation and related morbidities in women with gynaecological cancer.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2017) in the Cochrane Library, electronic databases MEDLINE (1946 to March Week 2, 2017), Embase (1980 to 2017 week 12), and the citation lists of relevant publications. We also searched the trial registries for ongoing trials on 20 May 2017.
SELECTION CRITERIA
Randomised controlled trials (RCTs) that compared the effect of retroperitoneal drainage versus no drainage after pelvic lymphadenectomy in women with gynaecological cancer. Retroperitoneal drainage was defined as placement of passive or active suction drains in pelvic retroperitoneal spaces. No drainage was defined as no placement of passive or active suction drains in pelvic retroperitoneal spaces.
DATA COLLECTION AND ANALYSIS
We assessed studies using methodological quality criteria. For dichotomous data, we calculated risk ratios (RRs) and 95% confidence intervals (CIs). We examined continuous data using mean difference (MD) and 95% CI.
MAIN RESULTS
Since the last version of this review, we have identified no new studies for inclusion. The review included four studies with 571 women. Regarding short-term outcomes (within four weeks after surgery), retroperitoneal drainage was associated with a comparable rate of overall lymphocyst formation when all methods of pelvic peritoneum management were considered together (2 studies; 204 women; RR 0.76, 95% CI 0.04 to 13.35; moderate-quality evidence). When the pelvic peritoneum was left open, the rates of overall lymphocyst formation (1 study; 110 women; RR 2.29, 95% CI 1.38 to 3.79) and symptomatic lymphocyst formation (2 studies; 237 women; RR 3.25, 95% CI 1.26 to 8.37) were higher in the drained group. At 12 months after surgery, the rates of overall lymphocyst formation were comparable between the groups (1 study; 232 women; RR 1.48, 95% CI 0.89 to 2.45; high-quality evidence). However, there was a trend toward increased risk of symptomatic lymphocyst formation in the group with drains (1 study; 232 women; RR 7.12, 95% CI 0.89 to 56.97; low-quality evidence).
AUTHORS' CONCLUSIONS
Placement of retroperitoneal tube drains has no benefit in the prevention of lymphocyst formation after pelvic lymphadenectomy in women with gynaecological malignancies. When the pelvic peritoneum is left open, the tube drain placement is associated with a higher risk of short- and long-term symptomatic lymphocyst formation. We found the quality of evidence using the GRADE approach to be moderate to high for most outcomes, except for symptomatic lymphocyst formation at 12 months after surgery, and unclear or low risk of bias.
Topics: Drainage; Female; Genital Neoplasms, Female; Humans; Lymph Node Excision; Lymphocele; Pelvis; Randomized Controlled Trials as Topic; Retroperitoneal Space; Suction
PubMed: 28660687
DOI: 10.1002/14651858.CD007387.pub4 -
Oncotarget Jul 2017The objectives of this study were to evaluate the rates of recurrence, survival and pregnancy, and characterize pregnancy outcomes of early-stage cervical cancer(eCC)... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The objectives of this study were to evaluate the rates of recurrence, survival and pregnancy, and characterize pregnancy outcomes of early-stage cervical cancer(eCC) treated with fertility-sparing methods such as cervical conization (CON) and radical trachelectomy(RT) with or without pelvic lymphadenectomy.
STUDY DESIGN
This was a meta-analysis of observational studies analyzed by a random-effects model and a meta-regression to assess heterogeneity.
RESULTS
Sixty observational studies encompassing 2,854 patients were included; 17 of which evaluated CON and 43 RT. Three hundred and seventy-five patients were included in the CON group: 176(46.9%) stage IA1 and 167(44.5%) stage IB1. In the RT group, 2479 cases were included: 143(6.0%) stage IA1, 299(12.1%) stage IA2, 1987(79.9%) stage IB1. CON was performed in 347(92.5%) cases, resulting in a recurrence rate of 0.4%(95%CI: 0.0%-1.4%), a death rate of 0%(0%-0%), a pregnancy rate of 36.1%(26.4%-46.2%), a spontaneous abortion rate of 14.8%(9.3%-21.2%) and a preterm delivery rate of 6.8%(1.5%-15.5%). For the RT group, 2273(91.7%) underwent successful surgeries with a recurrence rate of 2.3%(1.3%-3.4%),a death rate of 0.7%(0.3%-1.1%), a pregnancy rate of 20.5%(16.8%-24.5%), a spontaneous abortion rate of 24.0%(18.8%-29.6%) and a preterm delivery rate of 26.6%(19.6%-34.2%). From a subgroup analysis, the recurrence rates for stage IA tumors treated with CON and RT were 0.4%(0.0%-1.9%) and 0.7%(0.0%-2.3%), respectively; and for stage IB were 0.6%(0.0%-2.7%) and 2.3%(0.9%-4.1%).
CONCLUSION
Fertility-sparing treatment including CON or RT for eCC is feasible and carefully selected women can preserve fertility and achieve pregnancy resulting in live births. CON seems to result in better pregnancy outcomes than RT with similar rates of recurrence and mortality.
Topics: Combined Modality Therapy; Conization; Female; Fertility; Humans; Neoplasm Staging; Organ Sparing Treatments; Pregnancy; Pregnancy Outcome; Prognosis; Radiotherapy; Trachelectomy; Treatment Outcome; Uterine Cervical Neoplasms
PubMed: 28418849
DOI: 10.18632/oncotarget.16233 -
Oncotarget Jul 2017Endometrial cancer is the most frequent tumor in the female reproductive system, while the sentinel lymph node (SLN) mapping for diagnostic efficacy of endometrial... (Meta-Analysis)
Meta-Analysis Review
Endometrial cancer is the most frequent tumor in the female reproductive system, while the sentinel lymph node (SLN) mapping for diagnostic efficacy of endometrial cancer is still controversial. This meta-analysis was conducted to evaluate the diagnostic value of SLN in the assessment of lymph nodal involvement in endometrial cancer. Forty-four studies including 2,236 cases were identified. The pooled overall detection rate was 83% (95% CI: 80-86%). The pooled sensitivity was 91% (95% CI: 87-95%). The bilateral pelvic node detection rate was 56% (95% CI: 48-64%). Use of indocyanine green (ICG) increased the overall detection rate to 93% (95% CI: 89-96%) and robotic-assisted surgery also increased the overall detection rate to 86% (95% CI: 79-93%). In summary, our meta-analysis provides strong evidence that sentinel node mapping is an accurate and feasible method that performs well diagnostically for the assessment of lymph nodal involvement in endometrial cancer. Cervical injection, robot-assisted surgery, as well as using ICG, optimized the sensitivity and detection rate of the technique. Sentinel lymph mapping may potentially leading to a greater utilization by gynecologic surgeons in the future.
Topics: Endometrial Neoplasms; Female; Humans; Reproducibility of Results; Sensitivity and Specificity; Sentinel Lymph Node; Sentinel Lymph Node Biopsy
PubMed: 28410225
DOI: 10.18632/oncotarget.16662