Minimally Invasive Lymphadenectomy

for Renal Cell Carcinoma

James Porter

Director, Robotic Surgery

Swedish Medical Center

Seattle, WA

Current Role for

Lymphadenectomy in RCCConfounding issues:

– Downward stage migration of RCC in contemporary population

– Unpredictable lymphatic drainage

– Low risk of node positive disease without systemic metastasis

• Retrospective Data: – Lack of consensus as there is no evidence to support a

therapeutic benefit in RCC

Lymphadenectomy for RCC

• EORTC 30881 RCT of Radical Nephrectomy ±LND

– 389 Rad Neph vs. 383 Rad Neph with LND

– 14 (4%) positive lymph nodes

• No difference in:

– Overall survival

– Progression free survival

– Time to progression

Lymphadenectomy for RCC

• EORTC 30881 Concerns:

– Mostly organ confined RCC

• High risk = 31%

• May not see benefit of LND in low risk

patients

– Extent of LND not standard

• Selection bias of dissection technique

Lymphadenectomy for RCC

• Extent of dissection correlates with pN+ rate

– Terrone et al: 13 nodes removed a cut off for

high vs low rate of positive nodes

– Joslyn et al: higher node positive rate with

more nodes removed

BJU Int 2003;91:37–40.

Urology 2005;65:675–80.

Lymphadenectomy for RCC

• Lymphatic drainage variable for RCC

• Extent of dissection varies among

studies

• Templates suggested, none validated

• Hilar vs. Extended

Extended template for lymphadenectomy for RCC

From Capitanio et al. Eur Urol 2011(60), 1217.

Right side

Top: Adrenal vein

Bottom: IMA

Precaval

Retrocaval

Paracaval

Interaortocaval

Left side

Top: Crus of

diaphragm

Bottom: IMA

Para-aortic

Preaortic

Paracaval

Interaortocaval

Lymphadenectomy for RCC• EORTC 30881 T3 Subgroup Analysis(Blom et al)

– 110 RN + LND vs. 101 RN

– 15% better survival at 5 yrs for LND (p=0.29)

Lymphadenectomy in RCC

• Indications:

– High risk disease: T3 and T4 tumors

– Lymphadenopathy on pre-op imaging

– At time of cytoreductive nephrectomy

• Not Indicated for T1 and T2 tumors

Lymphadenectomy for

High Risk Tumor

Laparoscopic

Lymphadenectomy • Initial lap nephrectomies in 1990’s did not

include regional LND due to technical difficulty

• With evolution of technique, Gill reported on the largest series of patients treated with lap LND for RCC.

MIS Lymphadenectomy for RCC

• Simmons and Gill: Lap LND(hilar)

and RN

– 14/700 underwent LND

– 7 patients with distant mets

– 9 patients T2 or higher

– Mean LN count: 2.7 nodes

– One grade I complicationUrology. 2007 Jul;70(1):43-6

MIS Lymphadenectomy for RCC

• Chapman et al: Lap LND with RN vs. Lap RN

– Retrospective review: 50 RN+LND vs. 50 RN

– 5/50(10%) node positive in LND group

– Mean LN count: 7.8 for hilar, 12.1 for extended

– Complications minimal

Urology. 2008 Feb;71(2):287-91

MIS Lymphadenectomy for RCC• Abaza: 36 patients with robotic RN

and LND

– 16 T3 patients + 4 caval thrombi (55%

high risk)

– Mean node count:13.9 nodes

– 1/36(2.8%) + node

– No complications

J Endourol. 2011 Jul;25(7):1155-9.

Robotic Lymphadenectomy

for RCC• Lateral position

• Same port configuration

• Control lymphatics with clips

Patient Positioning

daVinci Xi

Port Configuration - daVinci Xi

Camera

Xi port

Assist

MIS Lymphadenectomy for RCC

Conclusions

• LND in RCC indicated for:– Enlarged nodes

– High risk tumors

– Cytoreductive procedures

• Extent of dissection not defined

• MIS LND safe and node yield depends on extent of dissection

• No survival benefit for LND in RCC

MIS Lymphadenectomy for RCC

Recommendation

• LND for high risk patients

• Extended LND to improve nodal yield

• Open vs. MIS LND based on

surgeons preference

Thank You!