Lymphoblock surgical solution for the prevention of lymphogenic complications during robot-assisted radical prostatectomy and pelvic lymphadenectomy: first-use experience

Introduction. The clinical guidelines recommend performing extended pelvic lymph node dissection for patients with intermediateor high-risk cancer prostate. The incidence of lymphocele development reaches 10.3%.

Objective. The aim of this study was to evaluate the efficiency of the drug Lymphoblock after radical prostatectomy with pelvic lymphadenectomy.

Materials & methods. The study involved 79 patients with prostate cancer who underwent robot-assisted radical prostatectomy with pelvic lymphadenectomy, that were randomized into three treatment groups: 1. Patients with free peritoneal flap fixed to the pubic bone (n = 26); 2. Patients who received Lymphoblock: during the surgery (n = 26); 3. Control group (n = 27). The median follow-up was 180 d.

Results. In postoperative period lymphocele was diagnosed in 8 (10.1%) patients: group 1 — 2 (7.7%) patients, group 2 — 1 (3.8%), group 3 — 5 (18.5%). Lymphocele had no clinical manifestation in group patients who received Lymphoblock.

Conclusions. Preliminary results of Lymphobloc use indicate that it can reduce the incidence of lymphogenic complications in the postoperative period in patients undergoing robot-assisted radical prostatectomy with pelvic lymphadenectomy.

1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-249. DOI: 10.3322/caac.21660

2. Mottet N, van den Bergh RCN, Briers E, Van den Broeck T, Cumberbatch MG, De Santis M, Fanti S, Fossati N, Gandaglia G, Gillessen S, Grivas N, Grummet J, Henry AM, van der Kwast TH, Lam TB, Lardas M, Liew M, Mason MD, Moris L, Oprea-Lager DE, van der Poel HG, Rouvière O, Schoots IG, Tilki D, Wiegel T, Willemse PM, Cornford P. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2021;79(2):243-262. DOI: 10.1016/j.eururo.2020.09.042

3. Ramazanov K.K., Kolontarev K.B., Gens G.P., Govorov A.V., Vasilyev A.O., Sadcheko А.V., Alaverdyan A.I., Stroganov R.V., Skrupskiy K.S., Kim Yu.A., Shiryaev A.А., Pushkar D.Yu. Long-term oncological and functional results of robot-assisted radical prostatectomy. Cancer Urology. 2021;17(3):121-128. (In Russian). DOI: 10.17650/1726-9776-2021-17-3-121-128

4. Fujimoto N, Shiota M, Tomisaki I, Minato A, Yahara K. Reconsideration on Clinical Benefit of Pelvic Lymph Node Dissection during Radical Prostatectomy for Clinically Localized Prostate Cancer. Urol Int. 2019;103(2):125-136. DOI: 10.1159/000497280

5. Kolontarev K.B., Pushkar D.Y., Akhvlediani N.D., Veliev E.I., Govorov A.V., Druzhinina N.K., Dyakov V.V., Zingerenko M.B., Zyryanov A.V., Kovylina M.V., Medvedev V.L., Mosoyan M.S., Pavlov V.N., Seregin A.A., Sheptunov S.A. Robot-assisted urology: national handbook. Moscow: GEOTAR-Media, 2023. (In Russian). DOI: 10.33029/9704-7511-9-ROB-2023-1-464

6. Abdollah F, Cozzarini C, Suardi N, Gallina A, Capitanio U, Bianchi M, Tutolo M, Salonia A, La Macchia M, Di Muzio N, Rigatti P, Montorsi F, Briganti A. Indications for pelvic nodal treatment in prostate cancer should change. Validation of the Roach formula in a large extended nodal dissection series. Int J Radiat Oncol Biol Phys. 2012;83(2):624-629. DOI: 10.1016/j.ijrobp.2011.06.2014

7. Dell’Oglio P, Abdollah F, Suardi N, Gallina A, Cucchiara V, Vizziello D, Zaffuto E, Cantiello F, Damiano R, Shariat S, Montorsi F, Briganti A. External validation of the European association of urology recommendations for pelvic lymph node dissection in patients treated with robot-assisted radical prostatectomy. J Endourol. 2014;28(4):416-423. DOI: 10.1089/end.2013.0571

8. Hinev AI, Anakievski D, Kolev NH, Hadjiev VI. Validation of nomograms predicting lymph node involvement in patients with prostate cancer undergoing extended pelvic lymph node dissection. Urol Int. 2014;92(3):300-305. DOI: 10.1159/000354323

9. Gandaglia G, Martini A, Ploussard G, Fossati N, Stabile A, De Visschere P, Borgmann H, Heidegger I, Steinkohl F, Kretschmer A, Marra G, Mathieu R, Surcel C, Tilki D, Tsaur I, Valerio M, Van den Bergh R, Ost P, Gontero P, Montorsi F, Briganti A; EAU-YAU Prostate Cancer Working Group. External Validation of the 2019 Briganti Nomogram for the Identification of Prostate Cancer Patients Who Should Be Considered for an Extended Pelvic Lymph Node Dissection. Eur Urol. 2020;78(2):138-142. DOI: 10.1016/j.eururo.2020.03.023

10. Cacciamani GE, Maas M, Nassiri N, Ortega D, Gill K, Dell’Oglio P, Thalmann GN, Heidenreich A, Eastham JA, Evans CP, Karnes RJ, De Castro Abreu AL, Briganti A, Artibani W, Gill I, Montorsi F. Impact of Pelvic Lymph Node Dissection and Its Extent on Perioperative Morbidity in Patients Undergoing Radical Prostatectomy for Prostate Cancer: A Comprehensive Systematic Review and Meta-analysis. Eur Urol Oncol. 2021;4(2):134-149. DOI: 10.1016/j.euo.2021.02.001

11. Briganti A, Chun FK, Salonia A, Suardi N, Gallina A, Da Pozzo LF, Roscigno M, Zanni G, Valiquette L, Rigatti P, Montorsi F, Karakiewicz PI. Complications and other surgical outcomes associated with extended pelvic lymphadenectomy in men with localized prostate cancer. Eur Urol. 2006;50(5):1006-1013. DOI: 10.1016/j.eururo.2006.08.015

12. Epstein JI, Zelefsky MJ, Sjoberg DD, Nelson JB, Egevad L, Magi-Galluzzi C, Vickers AJ, Parwani AV, Reuter VE, Fine SW, Eastham JA, Wiklund P, Han M, Reddy CA, Ciezki JP, Nyberg T, Klein EA. A Contemporary Prostate Cancer Grading System: A Validated Alternative to the Gleason Score. Eur Urol. 2016;69(3):428-435. DOI: 10.1016/j.eururo.2015.06.046

13. Mottrie A, Van Migem P, De Naeyer G, Schatteman P, Carpentier P, Fonteyne E. Robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of 184 cases. Eur Urol. 2007;52(3):746-750. DOI: 10.1016/j.eururo.2007.02.029

14. Stolzenburg JU, Wasserscheid J, Rabenalt R, Do M, Schwalenberg T, McNeill A, Constantinides C, Kallidonis P, Ganzer R, Liatsikos E. Reduction in incidence of lymphocele following extraperitoneal radical prostatectomy and pelvic lymph node dissection by bilateral peritoneal fenestration. World J Urol. 2008;26(6):581-586. DOI: 10.1007/s00345-008-0327-3

15. Lebeis C, Canes D, Sorcini A, Moinzadeh A. Novel Technique Prevents Lymphoceles After Transperitoneal Robotic-assisted Pelvic Lymph Node Dissection: Peritoneal Flap Interposition. Urology. 2015;85(6):1505-1509. DOI: 10.1016/j.urology.2015.02.034

16. Lee M, Lee Z, Eun DD. Utilization of a Peritoneal Interposition Flap to Prevent Symptomatic Lymphoceles After Robotic Radical Prostatectomy and Bilateral Pelvic Lymph Node Dissection. J Endourol. 2020;34(8):821-827. DOI: 10.1089/end.2020.0073

17. Stolzenburg JU, Arthanareeswaran VKA, Dietel A, Franz T, Liatsikos E, Kyriazis I, Ganzer R, Yaney K, Do HM. Four-point Peritoneal Flap Fixation in Preventing Lymphocele Formation Following Radical Prostatectomy. Eur Urol Oncol. 2018;1(5):443-448. DOI: 10.1016/j.euo.2018.03.004

18. Dal Moro F, Zattoni F. P.L.E.A.T.-Preventing Lymphocele Ensuring Absorption Transperitoneally: A Robotic Technique. Urology. 2017;110:244-247. DOI: 10.1016/j.urology.2017.05.031

19. Bründl J, Lenart S, Stojanoski G, Gilfrich C, Rosenhammer B, Stolzlechner M, Ponholzer A, Dreissig C, Weikert S, Burger M, May M. Peritoneal Flap in Robot-Assisted Radical Prostatectomy. Dtsch Arztebl Int. 2020;117(14):243-250. DOI: 10.3238/arztebl.2020.0243

20. Student V Jr, Tudos Z, Studentova Z, Cesak O, Studentova H, Repa V, Purova D, Student V. Effect of Peritoneal Fixation (PerFix) on Lymphocele Formation in Robot-assisted Radical Prostatectomy with Pelvic Lymphadenectomy: Results of a Randomized Prospective Trial. Eur Urol. 2023;83(2):154-162. Erratum in: Eur Urol. 2024;85(3):e95. DOI: 10.1016/j.eururo.2022.07.027

21. Gloger S, Ubrig B, Boy A, Leyh-Bannurah SR, Siemer S, Arndt M, Stolzenburg JU, Franz T, Oelke M, Witt JH. Bilateral Peritoneal Flaps Reduce Incidence and Complications of Lymphoceles after Robotic Radical Prostatectomy with Pelvic Lymph Node Dissection-Results of the Prospective Randomized Multicenter Trial ProLy. J Urol. 2022;208(2):333-340. DOI: 10.1097/JU.0000000000002693

22. Kotov S.V., Prostomolotov A.O., Nemenov A.A. Risk factors of developing lymphogenic complications after radical prostatectomy with lymph node dissection. Urologiia. 2021;(3):114-121. (In Russian). DOI: 10.18565/urology.2021.3.114-121.

23. Grande P, Di Pierro GB, Mordasini L, Ferrari M, Würnschimmel C, Danuser H, Mattei A. Prospective Randomized Trial Comparing Titanium Clips to Bipolar Coagulation in Sealing Lymphatic Vessels During Pelvic Lymph Node Dissection at the Time of Robot-assisted Radical Prostatectomy. Eur Urol. 2017;71(2):155-158. DOI: 10.1016/j.eururo.2016.08.006

24. Abaza R, Henderson SJ, Martinez O. Robotic Vessel Sealer Device for Lymphocele Prevention After Pelvic Lymphadenectomy: Results of a Randomized Trial. J Laparoendosc ADV Surg Tech A. 2022;32(7):721-726. DOI: 10.1089/lap.2021.0531

25. Basourakos SP, Zhu A, Lewicki PJ, Ramaswamy A, Cheng E, Dudley V, Yu M, Karir B, Hung AJ, Khani F, Hu JC. Clipless Robotic-assisted Radical Prostatectomy and Impact on Outcomes. Eur Urol Focus. 2022;8(5):1176-1185. DOI: 10.1016/j.euf.2021.06.010

26. Waldert M, Remzi M, Klatte T, Klingler HC. FloSeal reduces the incidence of lymphoceles after lymphadenectomies in laparoscopic and robot-assisted extraperitoneal radical prostatectomy. J Endourol. 2011;25(6):969-973. DOI: 10.1089/end.2010.0635

27. Simonato A, Varca V, Esposito M, Venzano F, Carmignani G. The use of a surgical patch in the prevention of lymphoceles after extraperitoneal pelvic lymphadenectomy for prostate cancer: a randomized prospective pilot study. J Urol. 2009;182(5):2285-2290. DOI: 10.1016/j.juro.2009.07.033

28. Gilbert DR, Angell J, Abaza R. Evaluation of Absorbable Hemostatic Powder for Prevention of Lymphoceles Following Robotic Prostatectomy With Lymphadenectomy. Urology. 2016;98:75-80. DOI: 10.1016/j.urology.2016.06.071

29. Garayev A, Aytaç Ö, Tavukcu HH, Atug F. Effect of Autologous Fibrin Glue on Lymphatic Drainage and Lymphocele Formation in Extended Bilateral Pelvic Lymphadenectomy in Robot-Assisted Radical Prostatectomy. J Endourol. 2019;33(9):761-766. DOI: 10.1089/end.2018.0853