The template of the primary lymphatic landing sites of the prostate should be revisited: results of a multimodality mapping study.

OBJECTIVES: To map the primary prostatic lymphatic landing sites using a multimodality technique. METHODS: Thirty-four patients with organ-confined prostate cancer (cT1-cT2; cN0) underwent single-photon emission computed tomography fused with data from computed tomography (SPECT/CT) (n=33) or magnetic resonance imaging (SPECT/MRI) (n=1) 1h after ultrasound-guided intraprostatic injection of technecium (Tc-99m) nanocolloid. The presence of lymph nodes (LNs) containing Tc-99m was confirmed intraoperatively with a gamma probe. A backup extended pelvic lymphadenectomy (PLND) was performed to preclude missed primary lymphatic landing sites. The SPECT/CT/MRI data sets were used to generate a three-dimensional projection of each LN site. RESULTS: A total of 317 LNs (median, 10 per patient; range, 3-19) were detected by SPECT/CT/MRI, 314 of which were confirmed by gamma probe. With an "extended" PLND, two thirds of all primary prostatic lymphatic landing sites are resected compared with only one third with a "limited" PLND. CONCLUSIONS: The multimodality technique presented here enables precise mapping of the primary prostatic lymphatic landing sites. PLND for prostate cancer should include not only the external and obturator regions as well as the portions medial and lateral to the internal iliac vessels, but also the common iliac LNs at least up to the ureteric crossing, thus removing approximately 75% of all nodes potentially harbouring metastasis.

Nerve-sparing radical cystectomy and orthotopic bladder replacement in female patients.

OBJECTIVES: Orthotopic diversion, initially performed solely in men, has now become a viable option in women. Approximately 15 yr ago, at several centres, urethra-sparing cystectomy and orthotopic diversion were initiated in women with bladder cancer. Several studies have since addressed both the oncologic and functional outcomes of this procedure. METHODS: We describe our surgical technique of cystectomy and orthotopic urinary diversion in female patients, with an emphasis on how we preserve the neurovascular bundle. RESULTS AND CONCLUSIONS: An improved understanding of the anatomic neurovascular and fascial planes related to the rhabdosphincter has facilitated identification of elements needed for orthotopic diversion in female patients. The technique of en bloc anterior exenteration includes the anterior portion of the vagina; however, preservation of the rhabdosphincter and its autonomic nerve supply necessitates specific modifications of the standard operation. The video provides a detailed description of our surgical technique with attention to anatomic details necessary to avoid damage to the proximal urethra and to preserve the autonomic innervation of the rhabdosphincter.

Idiopathic ureteral strictures without evidence of malignancy.

Benign strictures of the ureter without known antecedent cause are rare. In the absence of prior instrumentation, infection, radiotherapy, or ureteral calculi, strictures intrinsic to the ureter are usually of malignant origin. We describe two recent cases of idiopathic ureteral strictures without evidence of malignancy.

No difference in six-year biochemical failure rates with or without pelvic lymph node dissection during radical prostatectomy in low-risk patients with localized prostate cancer.

OBJECTIVES: To compare differences in the actuarial biochemical relapse-free survival rates at 6 years in a contemporary series of patients who underwent radical prostatectomy with and without pelvic lymph node dissection (PLND). Biochemical failure was defined as a serum prostate-specific antigen level greater than 0.2 ng/mL confirmed at least 1 week later. METHODS: The records of 806 consecutive radical prostatectomy cases performed between January 1995 and June 1999 were reviewed. A total of 336 patients with favorable tumor characteristics (prostate-specific antigen 10 ng/mL or less, biopsy Gleason score 6 or less, and clinical Stage T1 or T2) not receiving adjuvant or neoadjuvant therapy were divided into two groups according to whether PLND was performed (PLND group, n = 140) or omitted (no-PLND group, n = 196). A Cox proportional hazards model was used to analyze the effect of age, race, family history, initial prostate-specific antigen level, tumor stage, biopsy Gleason score, PLND, extracapsular extension, and seminal vesicle invasion on the likelihood of biochemical failure. Biochemical relapse-free survival for each group was estimated by Kaplan-Meier analysis. The mean follow-up time for the entire group was 60.0 months, with a similar follow-up for both cohorts (mean 61.8 and 58.2 months, respectively, P value not statistically significant). Follow-up information was obtained through an institutional review board-approved prospective patient registry. RESULTS: The 6-year biochemical relapse-free rate for the PLND versus no-PLND group was 86% and 88%, respectively (P = 0.28). On multivariate analysis, PLND was not an independent predictor of outcome (P = 0.33). CONCLUSIONS: Our study results demonstrated that the omission of PLND in patients with favorable tumor characteristics does not adversely affect biochemical relapse rates at 6 years after surgery. Such patients can be spared the morbidity and cost of PLND without affecting the chance for cure.