Reduction in incidence of lymphocele following extraperitoneal radical prostatectomy and pelvic lymph node dissection by bilateral peritoneal fenestration.

INTRODUCTION: In our series of 1,900 endoscopic extraperitoneal radical prostatectomies (EERPE) the incidence of symptomatic lymphocele following simultaneous pelvic lymph node dissection (PLND) is between 3 and 14% depending on the extent of lymph node dissection. We report the impact of bilateral peritoneal fenestration after completion of extraperitoneal prostatectomy and PLND on the incidence of lymphocele, postoperative pain and complications. PATIENTS AND METHODS: A total of 100 consecutive patients undergoing EERPE and extended PLND were allocated into two groups. In Group A (n = 50) a 4-6 cm incision was performed bilaterally over the external iliac vessels down to the obturator fossa after completion of the main procedure. In Group B (n = 50) no peritoneal incisions were made. The postoperative assessment protocol included a visual analogue pain scale administered three times daily for 6 days, analgesia requirement, and ultrasound examination on 4th and 8th days, and 3 months postoperatively. CRP and leucocyte counts were measured on 1st and 2nd postoperative days. Complications were recorded according to our standard protocol using the Clavien classification. RESULTS: Three patients (6%) in Group A were found to have lymphoceles, none of which were symptomatic. Significantly more patients in Group B developed a lymphocele, (n = 16, 32%, P < 0.001) of which a significant number were symptomatic (n = 7, 14%, P < 0.001) and required laparoscopic fenestration. No significant difference was observed between the pain score in either group. Mean pain scores were 3.4 versus 3.8 at 6 h, and 0.8 versus 1.1 at 6 days, respectively. No difference in analgesia requirement, serum inflammatory markers and return to normal bowel activity was observed between the groups. CONCLUSIONS: This study demonstrates that peritoneal fenestration significantly reduces the incidence of both symptomatic and asymptomatic lymphocele, without an increase in postoperative morbidity. As symptomatic lymphocele is one of the most common complications of extraperitoneal PLND requiring reintervention, we recommend that peritoneal fenestration should be performed routinely after extraperitoneal radical prostatectomy and PLND.

Prevention and management of perioperative complications in laparoscopic and endoscopic radical prostatectomy.

INTRODUCTION: Laparoscopic transperitoneal radical prostatectomy (LRP) and endoscopic extraperitoneal radical prostatectomy (EERPE) are established techniques for the management of localized prostate cancer in numerous specialized urologic centers worldwide. RESULTS: The complication rates of LRP and EERPE are ranging between 2 and 17%. Rare but possible complications are vascular injuries, bowel injury, lymphocele formation, port-site hernia, anastomotic leakage, gas embolism and catheter obstruction and other rare events. CONCLUSION: Prevention and management of complications requires high surgical expertise and adequate standardization of the technique. MATERIALS AND METHODS: We herein review our experience with the endoscopic extraperitoneal radical prostatectomy in a series of 1,800 consecutive patients regarding the appearance of complications and their management.