Pelvic lymphadenectomy

As the role of robotic surgery in urologic oncology has evolved, pelvic lymphadenectomy remains an important part of the staging of patients with prostate, bladder, and penile cancer. Complications associated with robotic pelvic lymphadenectomy are related to the proximity of the lymph nodes to major vascular, nerves, and lymphatic channels. The most common complication after pelvic lymphadnectomy is lymphocele formation and occurs due to incomplete control of lymphatic channels. The extent of lymphatic dissection correlates with lymphocele formation. Most lymphoceles are subclinical and do not require treatment; however, some may result in leg swelling, pelvic pain, or infection and require drainage. Vascular injury is rare during pelvic lymphadenectomy but can be repaired by experienced laparoscopic and robotic surgeons. The principles of gaining proximal and distal control of the injured vessel and precise repair are keys to successful outcomes. The obturator nerve is at risk for injury from cautery, clips, and traction during pelvic lymphadenectomy. Complete transection can be repaired by precise approximation of the epineural tissues using fine suture. Injury to the ureter can be avoided during pelvic lymphadenectomy by understanding that the ureter travels deep to the median umbilical ligament as it travels distally to the bladder.