Hip and Knee Replacement as a Relative Contraindication to Laparoscopic Pelvic Lymph Node Dissection

Vol 158, 128-130.July 1997 Printed in U S A

HIP AND KNEE REPLACEMENT AS A RELATIVE CONTRAINDICATION TO LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION CHRISTOPHER S. COOPER, JAMES F. DONOVAN, R. BRENTON TERRELL, MICHAEL B. COHEN AND

HOWARD N. WINFIELD

From the Departments of Urology and Pathology, University of Iowa, Iowa City,Iowa

ABSTRACT

Purpose: We investigated the effect of lower extremity joint prostheses on subsequent laparoscopic pelvic lymph node dissection. Materials and Methods: We reviewed the records and pathology studies of 5 patients who underwent laparoscopic pelvic lymph node dissection subsequent to total hip or knee replacement from 1990 through 1995. Results: Four of the 5 laparoscopic operations were complicated, 3 were unsuccessful i n obtaining bilateral pelvic lymph nodes and 2 required conversion t o an open procedure. Examination of the lymph nodes revealed sinus histiocytosis in the 4 cases in which nodal tissue was removed. Conclusions: The increased risk of complications i n certain patients with lower extremity joint prostheses m a y contraindicate attempted laparoscopic pelvic lymph node dissection. KEYWORDS:prostate, histiocytosis, lymph nodes, prosthesis, prostatic neoplasms Since the initial report by Gray et al,' others have confirmed the development of sinus histiocytosis in Pelvic lymph nodes after total hip or knee replacement.2-12 Nodal sinus histiocytosis is believed to occur as an inflammatory reaction to debris released from the prosthetic joint and transported by lymphatic channels to regional lymph Nodal enlargement, necrosis and fibrosis may also be Part of this reaction.~5,'0-12 The relevance of this phenomenon to the urolo?@ and Patholo&t was illustrated by a Patient who underwent bilateral OrchiectomY due to Pelvic 1 P P h node histiocytosis mimicking metastatic adenocarcinoma.2 The possibility of sinus histiocytosis after lower extremity joint prosthesis surgery is especially pertinent in regard to laparoscopic pelvic lymph node dissection, in which nodal enlargement, fibrosis and necrosis may hinder the delicate dissection and removal of obturator nodes. To investigate the effect of lower extremity Joint Prostheses on laParoscoPic pelvic lymph node dissection, we reviewed the ~-ecordsand PatholW' repods of Patients who umkrwent this Procedure subsequent to total hip Or knee replacement in a 6-Year period. Accepted for publication December 6, 1996.

MATERIALS AND METHODS

We reviewed the computer data base records of 223 cases of laparoscopic pelvic lymph node dissection from 1990 through 1995. Four operations were performed after total hip replacement and 1 was done after total knee replacement. Factors evaluated included patient age, weight, grade and stage of prostate cancer, type and duration of prosthesis, operative time and complications as well as a pathology review of the nodal tissue. Operative time was compared to that of 131 other laparoscopic pelvic lymph node dissections performed at our institution using the Mann-Whitney rank sum test with <0.05 considered significant, RESULTS

ln a &year

~aparoscopic pelvic lymph node dissec-

tion was performed after total hip replacement in 4 cases and after total knee replacement in 1. The table shows patient age, weight, grade and stage of cancer, type and duration of prosthetic implant before lymph node dissection, operative time and complications. Medical history was unremarkable with previous abdominal and pelvic surgery limited to ap-

Patient and operation characteristics pt, - ARe

Wt,

lyrs.1 I kg.1

DB - 66

Prostate Ca Prosthesis Type Grade

Stage

Prosthesis SlteNrs. to Operation (operation d a t e )

o~~~~ (mins.)

75.5

313

T2a

Rt. Charnley with methyl methacry late

Rt. hipi21. revisionl7, It. hip and kneel8 t3/911

263

MW - 67

82

314

T2a

Lt. kneeI5. rt. kneel3 (11/92r

245

GT - 69

105

3/3

7%

Rt. hip/7. It. hipN (10/95)

240

SS - 79

68

:1/4

T2bfI3

Rt. hipi8.5, It. hip/3 17/98)

135

RN-772

91

3/:3

Tlc

Lt. Miller/Calante porous titanium. Zimaloy tihial plate. rt. unknown Rt. Iowa tutal hip with methyl methacrylate, It. hybrid Iowa total hip with cement-free cup and ccmmted femur Kt. and It. cemrnt-free Harris Galante porous titanium acc-tahulum with cemented Zimaloy femur Unknown

1.t. h i ~ i 4 5(Illy51

205

128

Complications Operation aborted due to adherent fibrotic tissue, attempted open provtatectomy also failed Operation aborted on It. side due to extensive adhesions in iliac obturator region Rt. nodes fibrous and dense, d i f i cult dissection, branch of iliac vein severed, leading to open rt. and It. dissection Rt. nodal tissue dense and adherent, requiring traction of obturator nerve, postop. adduction nruropraxia None

CONTRAINDICATION TO LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION

pcwdectomy in 3 cases and hernia repair in 1. All pathology specimens demonstrated bilateral sinus histiocytosis of the 1) inph nodes and no nodes were involved by prostate cancer ( s(>cfigure). Average operative time plus or minus standard dcwiation was markedly increased in the prosthetic versus nonprosthetic group (217 ? 22.7 versus 158 ? 3.8 minutes). 1,;iparoscopic pelvic lymph node dissection in patients with lower extremity prostheses required significantly more operative time ( p = 0.016). In 3 of the 5 cases surgery was unsuccessful in removing the lymph nodes. Two operations I-(squired conversion to an open approach, including 1 that \\ as aborted without nodal retrieval due to dense fibrosis and fixation of tissues to surrounding structures. Only 1 of the 5 operations was performed without complications.

129

lodes and prosthesis.5 Joints with evident loosening on raliography studies likely shed increased wear debris and, ,hus, increase the likelihood of pelvic lymph node sinus hisiocytosis. A review of our cases revealed that 4 of the 5 complications were related to difficult dissection from fibrous adherent :issue. While conversion from laparoscopy to open surgery is not a complication, in the majority of cases this change in Jperative approach is the direct result of a complication, such as injury to abdominal viscera or a blood vessel. While it is not a complication, a change from laparoscopic to open surgical techniques due to failure to complete the intended surgery by laparoscopic methods serves as a reminder that limits exist to the appropriate use of laparoscopy. There appeared to be a correlation between increased duDISCUSSION ration and number of prostheses, and difficulty with the Wear debris from joint prostheses, including cement, poly- operation. Patient D. B., who had a history of migratory cxthylene and metallic particles, accumulates in regional and osteomyelitis, had undergone bilateral hip prostheses begindistant lymph nodes, liver and ~ p l e e n . ~ . ~ . The mecha- ning 21 years before laparoscopic pelvic lymph node dissecnism of wear remains unclear, although the debris undergoes tion, followed by revision of the right and loosening of the left phagocytosis by histiocytes that are identified in lymph hip prostheses. These additional factors may have created nodes by a b u n d a n t foamy and finely granular cyto- increased wear debris, leading to a more intense sinus histiplasm.2 4.7. I(I-12 Other disease processes with a similar ocytic reaction during many years. After a n unsuccessful appearance include leprosy, Whipple’s disease, silicone attempt at laparoscopic node dissection, open pelvic lymph lymphadenopathy, sinus histiocytosis with massive lymph- node dissection and prostatectomy were also aborted due to adenopathy, histiocytosis X, the lymphangiographic effect, extensive dense fibrous tissue. Methyl methacrylate was atypical mycobacterial infection, Gaucher’s disease and used in patients G. T. and D. B., who required open opera1,angerhans’ cell reticulocytosis.4~~4 Various metastatic neo- tions but there was no radiographic evidence of methyl plasms, including prostate cancer, may also have an appear- methacylate outside of the hip joint. Radiography studies ance similar t o sinus histiocytosis.2 revealed loosening of the prosthetic joint in both patients, reThe incidence of sinus histiocytosis after hip replacement quiring conversion to open operations, as well as in patient remains unknown but it appears to be high. In our review the M. W., in whom left nodal dissection was aborted. Patient M. W. condition developed bilaterally in all cases in which nodes also had a history of a ruptured appendix and previous were obtained. Albores-Saavedra e t al reviewed the records abdominal exploratory laparotomy with adhesiolysis, which of 207 men undergoing open pelvic lymph node dissection may have contributed to the overall difficulty of the operaand prostatectomy or cystoprostatectomy, and identified 6 in tion. During dissection on the right side in patient G. T., whom previous hip replacement surgery was done within 5 years of node dissection.4 All 6 men in this study had sinus fibrous dense nodal tissue made dissection difficult and a histiocytosis in the ipsilateral nodes. In a dog model Mendes branch of the iliac vein was severed. Surgery was converted ct al observed that wear debris accumulated in the regional to an open approach but dissection remained difficult due to nodes within 5 months after hip replacement? and others the densely adherent fibrous tissue. Patient S. S. underwent bilateral hip replacements with no have described that histiocytosis and nodal fibrosis increase with time following joint replacement.+]() The studies of evidence of loosening beginning with the right side 3.5 years Bjornsson2 and Morawski:j et a1 also confirmed contralateral before laparoscopic pelvic lymph node dissection. This opersinus histiocytosis in patients with a hip prosthesis. Case et ation involved deliberate grasping of the right obturator al reported that the amount of debris in the nodes tends to nerve to dissect the densely adherent nodal tissue free, redecrease in inverse proportion to the distance between the sulting in postoperative adduction neuropraxia. Patient N. M., who underwent a n uncomplicated procedure, was the only patient with a single joint replacement, which was done 4.5 years before laparoscopic pelvic lymph node dissection. Before operative intervention the surgeon must weigh the risks against the benefits of any surgery. The role of laparoscopic pelvic lymph node dissection before therapy for prostate cancer continues t o be defined. With the aid of the recent reviews of Partin’“ and Bluestein‘” e t al the urologist may estimate the chance of metastatic disease in a patient based on clinical stage, grade and prostate specific antigen value. This information helps the urological surgeon to refine the indications for laparoscopic pelvic lymph node dissection. Consideration of the lower extremity prostheses of a patient, including number, duration and condition, may provide necessary information regarding risk and permit informed consent before the operation. Our review revealed that an increased number or duration of prostheses, joint revisions or loosening of prosthetic joints as well as the use of methyl methacrylate may have contributed to operative complications. In conclusion, the increased risk of complications in Representative histological section of lymph node shows extensive some patients with a history of joint replacement, combined sinus histiocytosis and replacement of normal lymph node by m a c rophages with abundant granular eosinophilic cytoplasm. Foreign with other risk and benefit considerations, may contraindicate attempted laparoscopic pelvic lymph node dissection. body fragment is not readily identifiable. Reduced from x200.

130

CONTRAINDICATION TO LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION REFERENCES

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