New Keyhole Surgery Technique for Prostate Cancer Reduces Postoperative Complications

Robot-assisted keyhole surgery entails the removal of prostate cancer and lymph nodes, with around 10% of patients undergoing the procedure for symptoms induced by lymphatic fluid buildup, known as lymphocele, in the pelvis. Almost a third of patients are seen to have lymphocele when systematically examined, although without any symptoms being reported. Lymphocele can have various consequences such as superinfection, pelvic pain, bladder pressure, and swollen legs due to vein compression. If left untreated, symptomatic lymphocele can result in severe infections or deep vein thrombosis. The drainage process for a lymphocele can take anywhere from three days to three weeks, and patients may require hospital admission until the treatment is concluded after the fluid accumulation finally stops.

Surgeons at the University Medical Centre Mannheim (Mannheim, Germany) have demonstrated that a minor technical alteration to prostate cancer keyhole surgery can reduce one of the most prevalent post-operative complications by more than half, namely lymphatic fluid accumulation in the pelvis. The method involves fashioning a small peritoneal flap or opening, which is attached into the pelvis, thereby creating an exit route for lymphatic fluid to drain into the abdomen for better absorption. Prior studies of this approach had produced inconclusive outcomes, prompting the surgeons to conduct a more substantial and robust trial to achieve statistically significant findings. The trial featured over 550 patients and four different surgeons from the University Medical Centre Mannheim, who were informed about the peritoneal flap only after completing the rest of the operation.

In addition, patient selection between both categories - with flap or without - was randomized, while considering other factors such as diabetes, lymph node removal extent, anticoagulants intake, and the surgeon conducting the procedure that could heighten the likelihood of lymphocele. The patients were monitored for six months after the procedure. During this time, only 10 patients in the peritoneal flap group developed symptomatic lymphocele, as compared to 25 in the control group. At the time of discharge, 20 patients from the flap group had asymptomatic lymphocele, as compared to 46 patients in the control group. During the follow-up, this figure only increased to 27 in the flap group, but 74 in the control group.

“When they’ve only just returned home following a cancer operation, the last thing patients need is to return to hospital with this kind of complication, which unfortunately is fairly common,” said urology specialist Manuel Neuberger from University Medical Centre Mannheim and Heidelberg University. “If drainage doesn’t cure the problem, then – in rare cases - the final treatment is to create an artificial opening in the peritoneum, which provides a route out for the lymph so it’s no longer stuck in the pelvis. As it’s such a simple step, why not create a flap as standard, to prevent the condition in the first place?”

“Most problems in these operations are linked to the lymph node removal, rather than the prostate surgery itself,” added Professor Jochen Walz, from the EAU Scientific Congress Office. “Removal of the lymph nodes allows us to see if the cancer has spread, so it’s important to do, particularly as surgery is now mainly used in higher risk patients. Creating a peritoneal flap is a simple, small, easy and quick procedure that takes about five minutes to complete. It is totally safe and this trial has shown it can substantially reduce complications, so there’s no reason why surgeons should not now do this as standard.”

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University Medical Centre Mannheim

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