Surgeons in Germany have shown a small technical change to keyhole surgery for prostate cancer can more than halve one of the most common post-operative complications – where lymphatic fluid collects in the pelvis.
The technique, presented at the 2023 European Association of Urology (EAU) Annual Congress in Milan, involves creating a small flap in the peritoneum and attaching this flap down into the pelvis. This creates a route for lymphatic fluid to escape from the pelvis into the abdomen where it can be more easily absorbed.
Around 10 per cent of patients whose prostate cancer and lymph nodes are removed through robot-assisted keyhole surgery require treatment for symptoms caused by lymphatic fluid collecting in the pelvis, known as lymphocele. Lymphocele can also be seen in nearly a third of patients when they are systematically checked, without them reporting symptoms. Symptoms include superinfection, pain in the pelvis, pressure on the bladder, and swollen legs due to compression of the veins. If left untreated, symptomatic lymphocele can lead to serious infections or deep vein thrombosis. Draining a lymphocele can take from three days to three weeks.
Urology specialist Manuel Neuberger from University Medical Centre Mannheim and Heidelberg University said: “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? Previous studies of the technique have been inconclusive, so we designed a larger, more robust trial to ensure our findings were statistically significant.”
The trial involved over 550 patients and four different surgeons working at University Medical Centre Mannheim. During the six month follow-up period, only 10 patients in the peritoneal flap group had developed a symptomatic lymphocele, compared to 25 in the control group. At the time of discharge, 20 patients in the flap group had lymphocele with no symptoms, compared to 46 in the control group. During the follow-up, this had risen to just 27 in the flap group, but 74 in the control group.
Prof Philip Nuhn, Professor of Urology at University Medical Centre Mannheim, who led the research, said: “Using the peritoneal flap reduced the incidence of lymphocele from 9 per cent to less than 4 per cent. We now use this as the new standard in Mannheim, and hope that – following these results – it will become common practice elsewhere as well.”
Prof Jochen Walz, from the EAU Scientific Congress Office and the Institut PaoliCalmettes Cancer Centre in Marseille, said: “Most problems in these operations are linked to the lymph node removal, rather than the prostate surgery itself. 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.”