Researchers have found that a novel technique used during prostate cancer surgery may reduce the risk of postoperative lymphocele by 50%, according to new findings presented by Neuberger et al at the 2023 European Association of Urology Annual Congress (Abstract A0656). The technique—involving the creation of a small flap in the peritoneum and attaching it down into the pelvis—is designed to create a route for lymphatic fluid to escape from the pelvis into the abdomen, where it can be more easily absorbed.
Background
Around 10% of patients whose prostate cancer and lymph nodes are removed through robot-assisted keyhole surgery may require treatment for symptoms caused by lymphocele—lymphatic fluid that collects in the pelvis. Lymphocele can also be seen in nearly one-third of patients who were systematically checked, without them reporting symptoms such as superinfection, pain in the pelvis, pressure on the bladder, and swollen legs from compression of the veins. If left untreated, symptomatic lymphocele can lead to serious infections or deep vein thrombosis.
Draining a lymphocele can take from 3 days to 3 weeks—with treatment ceased only when the fluid is no longer accumulating. For some patients, this may require a stay in hospital.
“When they’ve only just returned home following a cancer operation, the last thing patients need is to [come back] to [the] hospital with this kind of complication, which unfortunately is fairly common. 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 [procedure], to prevent the condition in the first place?” suggested lead study author Manuel Neuberger, MD, a urology specialist at the Prostate Cancer Center at the University Medical Centre Mannheim and Heidelberg University. “Previous studies of the technique have been inconclusive, so we designed a larger, more robust trial to ensure our findings were statistically significant,” he added.
Study Methods and Results
In the new trial, the researchers involved over 550 patients—who were randomly assigned to either receive or not receive a peritoneal flap—and 4 surgeons who were only informed whether a patient was to receive the flap once the rest of the operation had been completed. When determining which patients would receive the peritoneal flap, the researchers took into account other factors that might have increased the risk of lymphocele such as diabetes, the extent of lymph node removal, use of anticoagulants, and which surgeon was performing the operation.
During 6 months of follow-up, only 10 patients in the peritoneal flap group had developed a symptomatic lymphocele, compared with 25 in the control group. At the time of discharge, 20 patients who received the peritoneal flap had a lymphocele with no symptoms, compared with 46 in the control group. During the follow-up, this figure rose to 27 and 74, respectively.
Conclusions
“Using the peritoneal flap reduced the incidence of lymphocele from 9% to less than 4%. We now use this as the new standard [procedure], and hope that—following these results—it will become common practice elsewhere as well,” stressed senior study author Philipp Nuhn, MD, Professor of Urology at the University Medical Centre Mannheim.
“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 5 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,” highlighted Jochen Walz, MD, Associate Professor and Head of the Department of Urology at the Institut Paoli-Calmettes Cancer Centre. “Randomized, controlled trials to evaluate technical changes in surgery are notoriously difficult to do—but this study has shown that they are both possible and effective. That’s good news for surgeons and for patients, who will benefit from better outcomes as a result,” he concluded.
Disclosure: For full disclosures of the study authors, visit resource-centre.uroweb.org.
