Simplified approach to the medial internal iliac region using a uretero‐hypogastric nerve fascia development procedure for extended pelvic lymph node dissection during robot‐assisted radical prostatectomy for high‐risk prostate cancer

Abstract

Introduction Although several clinical guidelines for prostate cancer (PC) recommend extended pelvic lymph node dissection (ePLND) during radical prostatectomy for high‐risk cases, there are several issues to consider, including certain technical aspects. A simplified approach to the medial internal iliac region and paravesical arteries has not been established. The uretero‐hypogastric nerve fascia (UHF) envelopes the ureter, hypogastric nerve, and pelvic autonomic nerves. To preserve the UHF, it is possible to approach the medial side of the internal iliac vessels without injuring any important tissue. We analyzed technical feasibility and lymph node (LN) yields. Patients and methods After obtaining institutional review board approval, 265 high‐risk PC patients with ePLND were identified. A da Vinci S or Xi robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used. We divided the patients into conventional (non‐UHF) method and modified (UHF) groups. The numbers of LNs removed, procedure‐related complications, and surgical outcomes were analyzed. Results The median number of LNs removed was 19.0 in the non‐UHF group and 22.0 in the UHF group (p = 0.004). Significantly more LNs were removed from the internal iliac region in the UHF group (p = 0.042). There was no difference in overall operative, console, or LN dissection time, or the severe complication rate (Clavien‐Dindo grade ≥ III), between the non‐UHF and UHF groups. Conclusions Our simplified approach using the UHF development technique is technically feasible, has no major complications, and allows for the removal of significantly more LNs compared with the conventional method.