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Laparoscopic examination of pelvic lymph nodes
INVESTIGATIVE UROLOGY
LAPAROSCOPIC
EXAMINATION
OF PELVIC
LYMPH NODES DONALD
E. FUERST,
From the Department Akron, Ohio
M.D. of Urology, Akron City Hospital,
ABSTRACT-A new technique for examining pelvic lymph nodes is presented. The procedure has been used successfully on dogs. A correlative study is being undertaken to evaluate its usefulness in staging genitourinary malignancies.
To date, the accurate staging of prostate and bladder malignancies requires examination of the adjacent lymph nodes. These nodes, however, are not well seen on pedal lymphangiography. Several other procedures have been tried to evaluate these nodes, including ultrasound, computerized tomography (CT) scans, and radiocolloid injection with scanning, along with pedal lymphangiograms. 1,2Formal lymph node dissection has become the ultimate procedure to determine the presence of metastasis, however, it has a complication rate ranging from 9.8 to 20 per cent. 3,4 In addition, the procedure requires approximately three hours of operating time plus hospitalization averaging seven to eight days.3 In this report, I will outline a procedure that allows direct visualization and aspiration biopsy of the pelvic lymph nodes. Material and Methods Six mongrel male dogs were examined under thiopental (Pentothal) anesthesia using a Wolf operating laparoscope (Fig. 1). One and onehalf hours prior to laparoscopy the animals were injected with 1 cc of isosulfan blue (Lymphazurin) into the area adjacent to the bladder, between the bladder and rectum. This dosage gave the best visualization of the lymph nodes. Isosulfan blue is a contrast agent for visualizing lymphatics and lymph nodes presumably by
482
FIGURE1.
Wolf operating laparoscope.
being bound to serum protein (albumin). It is excreted 10 per cent in urine and 90 per cent in bile. Results After one hour, visualization of dye in lymph nodes was appreciated. These nodes were easily reached with a needle inserted through the laparoscope, making biopsy under direct vision easy (Fig. 2). Comment The use of pelvic lymphadenectomy as a staging procedure for prostatic cancer is well recognized. When these lymph nodes are negative, it is highly likely that the tumor has not
UROLOGY
/ NOVEMBER
1985
:
VOLUME
XXVI. NUMBER 5
FIGURE2. Lymph jacent to vas.
node below branches
of vein ad-
spread beyond the capsule and the patient is potentially curable with radical prostatectomy.5 However, pelvic node dissection does carry a significant morbidity of approximately 20 per cent, with such complications as pulmonary embolus, thrombophlebitis, and ureteral injury. 5.’ This morbidity could be reduced if a better way of evaluating the lymph nodes could be found. Several authors have reported on aspiration of these nodes either percutaneously, by inserting a scope into the retroperitoneal space,7 or under CT or ultrasound guidance. These techniques have the advantage of being simple procedures with little risk to the patient. However, Correa6 reported finding metastasis 5 to 15 per cent less than with formal node dissection but with no false positive results. Belinsor? reported one false positive and two false negative results of ninety specimens of needle aspirations . The use of a visual dye to better visualize lymph nodes has been well studied in breast
CROLOGk
NOVEMBER
1985
/
VOLUME
XXVI. NUMBER
cancer and the internal mammary chain of nodes. There appears to be good tolerance of the dye with few complications. Adverse reactions to isosulfan blue are mostly cell-mediated allergies and are more likely to occur in patients with asthma, significant allergies, or drug reactions. These reactions are generally handled by supportive and resuscitative measures such as oxygen maintenance of airway and use of appropriate drugs. Whitmore et ~2.’ injected a similar dye into several dog and human prostates without any adverse effect. The use of a laparoscope and visual dye should make the identification of lymph nodes easier and hence their biopsy more successful. Accordingly, a correlative study is being undertaken to determine whether or not formal pelvic lymphadenectomy can be replaced by laparoscopy in the staging of prostate and bladder malignancies. 1655 West Market Street Suite 410 Akron, Ohio 44313 References 1. Whitmore WF III, Blute RD II, Kaplan WD, and Gittes RF: Radiocolloid scintographic mapping of the lymphatic drainage of the urostate. I Urol 124: 62 11980). 2. E>e GN: Augmented iliopelvic lymphoscintigraphy. Application in the management of genitourinarv malignancy, ibid 127: 265 (1982). 3. Grossman IC, et al: Staging pelvic lymphadenectomy for carcinoma of the prostate. ibid 124: 632 (1980). 4. Lieskovsky G, Skinner DG, and Weisenburger T: Pelvic lymphadenectomy in the management of carcinoma of the prostate, ibid 124: 635 (1980). 5. Wilson CS, Dahl DS, and Middleton RG: Pelvic lymphadenectomy for the staging of apparently localized prostate cancer, ibid 117: 197 (1977). 6. Correa RJ: Percutaneous pelvic lymph node aspiration in carcinoma of the prostate, ibid 126: 190 (1981). 7. Hald T, and Rasmussen F: Extraperitoneal pelvioscopy: a new aid in staging of lower urinary tract tumors, ibid 124: 245 (1980). 8. Belinson JL: Fine needle aspiration cytology in the management of gynecologic cancer, Am J Obstet Gynecol 139: 148 (1981).
5
483
LAPAROSCOPIC
EXAMINATION
OF PELVIC
LYMPH NODES DONALD
E. FUERST,
From the Department Akron, Ohio
M.D. of Urology, Akron City Hospital,
ABSTRACT-A new technique for examining pelvic lymph nodes is presented. The procedure has been used successfully on dogs. A correlative study is being undertaken to evaluate its usefulness in staging genitourinary malignancies.
To date, the accurate staging of prostate and bladder malignancies requires examination of the adjacent lymph nodes. These nodes, however, are not well seen on pedal lymphangiography. Several other procedures have been tried to evaluate these nodes, including ultrasound, computerized tomography (CT) scans, and radiocolloid injection with scanning, along with pedal lymphangiograms. 1,2Formal lymph node dissection has become the ultimate procedure to determine the presence of metastasis, however, it has a complication rate ranging from 9.8 to 20 per cent. 3,4 In addition, the procedure requires approximately three hours of operating time plus hospitalization averaging seven to eight days.3 In this report, I will outline a procedure that allows direct visualization and aspiration biopsy of the pelvic lymph nodes. Material and Methods Six mongrel male dogs were examined under thiopental (Pentothal) anesthesia using a Wolf operating laparoscope (Fig. 1). One and onehalf hours prior to laparoscopy the animals were injected with 1 cc of isosulfan blue (Lymphazurin) into the area adjacent to the bladder, between the bladder and rectum. This dosage gave the best visualization of the lymph nodes. Isosulfan blue is a contrast agent for visualizing lymphatics and lymph nodes presumably by
482
FIGURE1.
Wolf operating laparoscope.
being bound to serum protein (albumin). It is excreted 10 per cent in urine and 90 per cent in bile. Results After one hour, visualization of dye in lymph nodes was appreciated. These nodes were easily reached with a needle inserted through the laparoscope, making biopsy under direct vision easy (Fig. 2). Comment The use of pelvic lymphadenectomy as a staging procedure for prostatic cancer is well recognized. When these lymph nodes are negative, it is highly likely that the tumor has not
UROLOGY
/ NOVEMBER
1985
:
VOLUME
XXVI. NUMBER 5
FIGURE2. Lymph jacent to vas.
node below branches
of vein ad-
spread beyond the capsule and the patient is potentially curable with radical prostatectomy.5 However, pelvic node dissection does carry a significant morbidity of approximately 20 per cent, with such complications as pulmonary embolus, thrombophlebitis, and ureteral injury. 5.’ This morbidity could be reduced if a better way of evaluating the lymph nodes could be found. Several authors have reported on aspiration of these nodes either percutaneously, by inserting a scope into the retroperitoneal space,7 or under CT or ultrasound guidance. These techniques have the advantage of being simple procedures with little risk to the patient. However, Correa6 reported finding metastasis 5 to 15 per cent less than with formal node dissection but with no false positive results. Belinsor? reported one false positive and two false negative results of ninety specimens of needle aspirations . The use of a visual dye to better visualize lymph nodes has been well studied in breast
CROLOGk
NOVEMBER
1985
/
VOLUME
XXVI. NUMBER
cancer and the internal mammary chain of nodes. There appears to be good tolerance of the dye with few complications. Adverse reactions to isosulfan blue are mostly cell-mediated allergies and are more likely to occur in patients with asthma, significant allergies, or drug reactions. These reactions are generally handled by supportive and resuscitative measures such as oxygen maintenance of airway and use of appropriate drugs. Whitmore et ~2.’ injected a similar dye into several dog and human prostates without any adverse effect. The use of a laparoscope and visual dye should make the identification of lymph nodes easier and hence their biopsy more successful. Accordingly, a correlative study is being undertaken to determine whether or not formal pelvic lymphadenectomy can be replaced by laparoscopy in the staging of prostate and bladder malignancies. 1655 West Market Street Suite 410 Akron, Ohio 44313 References 1. Whitmore WF III, Blute RD II, Kaplan WD, and Gittes RF: Radiocolloid scintographic mapping of the lymphatic drainage of the urostate. I Urol 124: 62 11980). 2. E>e GN: Augmented iliopelvic lymphoscintigraphy. Application in the management of genitourinarv malignancy, ibid 127: 265 (1982). 3. Grossman IC, et al: Staging pelvic lymphadenectomy for carcinoma of the prostate. ibid 124: 632 (1980). 4. Lieskovsky G, Skinner DG, and Weisenburger T: Pelvic lymphadenectomy in the management of carcinoma of the prostate, ibid 124: 635 (1980). 5. Wilson CS, Dahl DS, and Middleton RG: Pelvic lymphadenectomy for the staging of apparently localized prostate cancer, ibid 117: 197 (1977). 6. Correa RJ: Percutaneous pelvic lymph node aspiration in carcinoma of the prostate, ibid 126: 190 (1981). 7. Hald T, and Rasmussen F: Extraperitoneal pelvioscopy: a new aid in staging of lower urinary tract tumors, ibid 124: 245 (1980). 8. Belinson JL: Fine needle aspiration cytology in the management of gynecologic cancer, Am J Obstet Gynecol 139: 148 (1981).
5
483