Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Impact of peritoneal reconfiguration on lymphocele formation after robot-assisted radical prostatectomy with pelvic lymph node dissection: a systematic review and meta-analysis of randomized controlled trials

Prostate Cancer and Prostatic Diseases (2023)Cite this article

Subjects

Abstract

Background

Different strategies have been proposed to prevent lymphocele (LC) formation after radical prostatectomy (RARP) with pelvic lymph node dissection (PLND). According to several recently published randomized control trials (RCTs) on the topic, peritoneal reconfiguration appears to be associated with promising results. This systematic review aimed to assess the impact of peritoneal reconfiguration on LC formation in patients undergoing RARP and PLND.

Methods

A comprehensive bibliographic search was conducted in August 2023. Studies assessing patients with prostate cancer undergoing RARP with PLND (P) and concomitant peritoneal reconfiguration (I) compared or not with other techniques (C) to prevent LC formation (O) were included. Original prospective and retrospective studies (S) were selected. LC and symptomatic LC rates were chosen as co-primary outcomes. Only RCTs were included in the meta-analysis.

Results

Eleven studies investigating 2991 patients were included in the systematic review, and five RCTs evaluating 1712 subjects were deemed eligible for meta-analysis. Peritoneal flap (PF) was the most common surgical technique used for LC prevention (9 studies). A significantly lower likelihood of LC was observed after PF (OR 0.82, 95% CI 0.27–1.37, I2 = 74.54%), with no significant difference in terms of symptomatic LC (OR 0.21, 95% CI −0.41–0.84, I2 = 0%). Probability of LC-related complications (OR 0.36, 95% CI 0.04–0.67, I2 = 0%), Clavien-Dindo ≥ 3 overall complications (OR 0.61, 95% CI 0.21–1.0, I2 = 0%), and Clavien-Dindo ≥ 3 LC-related complications (OR 0.98, 95% CI 0.29–1.67, I2 = 0%) were significantly lower after PF.

Conclusions

PF after RARP with PLND reduces LC formation, LC-related complications, and severe postoperative adverse events.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: PRISMA flow-diagram for study selection.
Fig. 2: Peritoneal reconfiguration techniques.
Fig. 3: Forest plots of primary outcomes in PF vs. no PF.
Fig. 4: Forest plots of secondary outcomes in PF vs. no PF.
Fig. 5: Risk of bias assessment.

Similar content being viewed by others

Data availability

Sheets containing raw data (extracted variables, statistical analyses) are available upon request to the corresponding author.

References

  1. Mottet N, Cornford P, Van den Bergh R, Eberli D, De Meerleer G, De Santis M, et al. EAU Guidelines on Prostate Cancer. Edn presented at the EAU Annual Congress Milan. 2023. ISBN 978-94-92671-19-6

  2. Eastham JA, Auffenberg GB, Barocas DA, Chou R, Crispino T, Davis JW, et al. Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, Part II: Principles of Active Surveillance, Principles of Surgery, and Follow-Up. J Urol. 2022;208:19–25.

    Article  PubMed  Google Scholar 

  3. Fiori C, Checcucci E, Stura I, Amparore D, De Cillis S, Piana A, et al. Development of a novel nomogram to identify the candidate to extended pelvic lymph node dissection in patients who underwent mpMRI and target biopsy only. Prostate Cancer Prostatic Dis. 2023;26:388–94.

    Article  PubMed  Google Scholar 

  4. Masterson J, Luu M, Naser-Tavakolian A, Freedland S, Sandler H, Zumsteg Z, et al. Concurrent prognostic utility of lymph node count and lymph node density for men with pathological node-positive prostate cancer. Prostate Cancer Prostatic Dis. 2023. https://doi.org/10.1038/s41391-022-00635-1

  5. Creta M, Manfredi C, Arcaniolo D, Spirito L, Kaplan SA, Woo HH, et al. Functional and oncological outcomes after radical prostatectomy in patients with history of surgery for lower urinary tract symptoms related to benign prostatic enlargement: A systematic review with meta-analysis. Prostate Cancer Prostatic Dis. 2023. https://doi.org/10.1038/s41391-023-00678-y

  6. Briganti A, Chun FKH, Salonia A, Suardi N, Gallina A, Da Pozzo LF, et al. Complications and Other Surgical Outcomes Associated with Extended Pelvic Lymphadenectomy in Men with Localized Prostate Cancer. Eur Urol. 2006;50:1006–13.

    Article  PubMed  Google Scholar 

  7. Orvieto MA, Coelho RF, Chauhan S, Palmer KJ, Rocco B, Patel VR. Incidence of lymphoceles after robot-assisted pelvic lymph node dissection. BJU Int. 2011;108:1185–90.

    Article  PubMed  Google Scholar 

  8. Keskin MS, Argun ÖB, Öbek C, Tufek I, Tuna MB, Mourmouris P, et al. The incidence and sequela of lymphocele formation after robot-assisted extended pelvic lymph node dissection. BJU Int. 2016;118:127–31.

    Article  PubMed  Google Scholar 

  9. Lebeis C, Canes D, Sorcini A, Moinzadeh A. Novel technique prevents lymphoceles after transperitoneal robotic-assisted pelvic lymph node dissection: Peritoneal flap interposition. Urology. 2015;85:1505–9.

    Article  PubMed  Google Scholar 

  10. Stolzenburg JU, Wasserscheid J, Rabenalt R, Do M, Schwalenberg T, McNeill A, et al. Reduction in incidence of lymphocele following extraperitoneal radical prostatectomy and pelvic lymph node dissection by bilateral peritoneal fenestration. World J Urol. 2008;26:581–6.

    Article  PubMed  Google Scholar 

  11. Naselli A, Andreatta R, Introini C, Fontana V, Puppo P. Predictors of Symptomatic Lymphocele After Lymph Node Excision and Radical Prostatectomy. Urology. 2010;75:630–5.

    Article  PubMed  Google Scholar 

  12. Waldert M, Remzi M, Klatte T, Klingler HC. Floseal reduces the incidence of lymphoceles after lymphadenectomies in laparoscopic and robot-assisted extraperitoneal radical prostatectomy. J Endourol. 2011;25:969–73.

    Article  PubMed  Google Scholar 

  13. Grande P, Di Pierro GB, Mordasini L, Ferrari M, Würnschimmel C, Danuser H, et al. Prospective Randomized Trial Comparing Titanium Clips to Bipolar Coagulation in Sealing Lymphatic Vessels During Pelvic Lymph Node Dissection at the Time of Robot-assisted Radical Prostatectomy. Eur Urol. 2017;71:155–8.

    Article  PubMed  Google Scholar 

  14. Yılmaz K, Ölçücü MT, Arı Ö, Karamik K, Aktaş Y, Savaş M, et al. The Results of Peritoneal Re-Approximation Methods on Symptomatic Lymphocele Formation in Robot-Assisted Laparoscopic Radical Prostatectomy and Extended Pelvic Lymphadenectomy. Arch Esp Urol. 2022;75:447–52.

    Article  PubMed  Google Scholar 

  15. Student V, Tudos Z, Studentova Z, Cesak O, Studentova H, Repa V, et al. Effect of Peritoneal Fixation (PerFix) on Lymphocele Formation in Robot-assisted Radical Prostatectomy with Pelvic Lymphadenectomy: Results of a Randomized Prospective Trial. Eur Urol. 2023;83:154–62.

    Article  PubMed  Google Scholar 

  16. Neuberger M, Kowalewski K, Simon V, von Hardenberg J, Siegel F, Wessels F, et al. Peritoneal Flap for Lymphocele Prophylaxis Following Robotic-assisted Radical Prostatectomy with Lymph Node Dissection: The Randomised Controlled Phase 3 PELYCAN Trial. Eur Urol Oncol. 2023; https://doi.org/10.1016/j.euo.2023.07.009 S2588-931100152-9.

  17. Bründl J, Lenart S, Stojanoski G, Gilfrich C, Rosenhammer B, Stolzlechner M, et al. Peritoneal flap in robot-assisted radical prostatectomy: Results of a multicenter, randomized, single-blind study (PIANOFORTE) of the efficacy in reducing postoperative lymphocele. Dtsch Arztebl Int 2020;117:243–50.

    PubMed  PubMed Central  Google Scholar 

  18. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Bramer WM, Rethlefsen ML, Kleijnen J, Franco OH. Optimal database combinations for literature searches in systematic reviews: A prospective exploratory study. Syst Rev. 2017;6:245.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Amir-Behghadami M, Janati A. Population, Intervention, Comparison, Outcomes and Study (PICOS) design as a framework to formulate eligibility criteria in systematic reviews. Emerg Med J. 2020;37:387.

    Article  PubMed  Google Scholar 

  21. Motterle G, Morlacco A, Zanovello N, Ahmed ME, Zattoni F, Karnes RJ, et al. Surgical Strategies for Lymphocele Prevention in Minimally Invasive Radical Prostatectomy and Lymph Node Dissection: A Systematic Review. J Endourol. 2020;34:113–20.

    Article  PubMed  Google Scholar 

  22. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.

    Article  PubMed  Google Scholar 

  24. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberatiet A, al. The Oxford 2011 Levels of Evidence. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence. Last access: August 12, 2023.

  26. Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014;14:135.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Ma J, Liu W, Hunter A, Zhang W. Performing meta-analysis with incomplete statistical information in clinical trials. BMC Med Res Methodol. 2008;8:56.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21:1539–58.

    Article  PubMed  Google Scholar 

  29. Lin L, Chu H. Quantifying publication bias in meta-analysis. Biometrics. 2018;74:785–94.

    Article  PubMed  Google Scholar 

  30. Wagner J, McLaughlin T, Pinto K, Tortora J, Gangakhedkar A, Staff I. The Effect of a Peritoneal Iliac Flap on Lymphocele Formation After Robotic Radical Prostatectomy: Results From the PLUS Trial. Urology. 2023;173:104–10.

    Article  PubMed  Google Scholar 

  31. Harland N, Alfarra M, Erne E, Maas M, Amend B, Bedke J, et al. A Peritoneal Purse-String Suture Prevents Symptomatic Lymphoceles in Retzius-Sparing Robot-Assisted Radical Prostatectomy. J Clin Med. 2023;12:791.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Gloger S, Ubrig B, Boy A, Leyh-Bannurah SR, Siemer S, Arndt M, et al. Bilateral Peritoneal Flaps Reduce Incidence and Complications of Lymphoceles after Robotic Radical Prostatectomy with Pelvic Lymph Node Dissection - Results of the Prospective Randomized Multicenter Trial ProLy. J Urol. 2022;208:333–40.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Boğa MS, Sönmez MG, Karamik K, Yilmaz K, Savaş M, Ateş M. The effect of peritoneal re-approximation on lymphocele formation in transperitoneal robot-assisted radical prostatectomy and extended pelvic lymphadenectomy. Turk J Urol. 2020;46:460–7.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Lee M, Lee Z, Eun DD. Utilization of a Peritoneal Interposition Flap to Prevent Symptomatic Lymphoceles after Robotic Radical Prostatectomy and Bilateral Pelvic Lymph Node Dissection. J Endourol. 2020;34:821–7.

    Article  PubMed  Google Scholar 

  35. Dal Moro F, Zattoni F. P.L.E.A.T.—Preventing Lymphocele Ensuring Absorption Transperitoneally: A Robotic Technique. Urology. 2017;110:244–7.

    Article  PubMed  Google Scholar 

  36. Pose RM, Knipper S, Würnschimmel C, Tennstedt P, Michl U, Maurer T, et al. Significant reduction of lymphoceles after radical prostatectomy and pelvic lymph node dissection. BJU Int. 2021;128:728–33.

    Article  PubMed  Google Scholar 

  37. Kallappan S, Manickam R, Nachimuthu S, Ganesapandi T. Unusual lymphocele following radical cystectomy with orthotopic neobladder. Indian J Urol. 2019;35:168–9.

    PubMed  PubMed Central  Google Scholar 

  38. Basourakos SP, Zhu A, Lewicki PJ, Ramaswamy A, Cheng E, Dudley V, et al. Clipless Robotic-assisted Radical Prostatectomy and Impact on Outcomes. Eur Urol Focus. 2022;8:1176–85.

    Article  PubMed  Google Scholar 

  39. Danuser H, Di Pierro GB, Stucki P, Mattei A. Extended pelvic lymphadenectomy and various radical prostatectomy techniques: Is pelvic drainage necessary? BJU Int. 2013;111:963–9.

    Article  PubMed  Google Scholar 

  40. Territo A, Baboudjian M, Diana P, Gallioli A, Verri P, Uleri A, et al. To drain or not to drain in uro-oncological robotic surgery? A systematic review and meta-analysis. Minerva Urol Nephrol. 2023;75:144–53.

    Article  PubMed  Google Scholar 

  41. Capitanio U, Pellucchi F, Gallina A, Briganti A, Suardi N, Salonia A, et al. How can we predict lymphorrhoea and clinically significant lymphocoeles after radical prostatectomy and pelvic lymphadenectomy? Clinical implications. BJU Int. 2011;107:1095–101.

    Article  PubMed  Google Scholar 

  42. Seetharam Bhat KR, Onol F, Rogers T, Ganapathi HP, Moschovas M, Roof S, et al. Can we predict who will need lymphocele drainage following robot assisted laparoscopic prostatectomy (RALP)? J Robot Surg. 2020;14:439–45.

    Article  CAS  PubMed  Google Scholar 

  43. May M, Gilfrich C, Bründl J, Ubrig B, Wagner JR, Gloger S, et al. Impact of Peritoneal Interposition Flap on Patients Undergoing Robot-assisted Radical Prostatectomy and Pelvic Lymph Node Dissection: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Eur Urol Focus. 2023. https://doi.org/10.1016/j.euf.2023.07.007 S2405-456900181-5.

Download references

Author information

Author notes

  1. These authors contributed equally: Francesco Ditonno, Celeste Manfredi, Antonio Franco.

Authors and Affiliations

  1. Department of Urology, Rush University Medical Center, Chicago, IL, USA

    Francesco Ditonno, Celeste Manfredi, Antonio Franco & Riccardo Autorino

  2. Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy

    Francesco Ditonno, Alessandro Veccia & Alessandro Antonelli

  3. Unit of Urology, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy

    Celeste Manfredi & Marco De Sio

  4. Department of Urology, Sant’Andrea Hospital, Sapienza University, Rome, Italy

    Antonio Franco & Cosimo De Nunzio

  5. Department of Surgery, Oncology, and Gastroenterology, Urology Clinic, University of Padua, Padua, Italy

    Fabrizio Dal Moro

Authors
  1. Francesco Ditonno
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Celeste Manfredi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Antonio Franco
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Alessandro Veccia
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Fabrizio Dal Moro
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Cosimo De Nunzio
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Marco De Sio
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Alessandro Antonelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Riccardo Autorino
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conceptualization and supervision: RA; Study screening, paper selection, data extraction, and risk of bias assessment: FD, AF; Data analysis and interpretation: FD, CM; Paper drafting: FD, CM, AF; Drawing: FDM; Statistical review: AV; Scientific and grammatical review: AA, CDN, MDS. All authors approved the final version of the paper.

Corresponding author

Correspondence to Riccardo Autorino.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ditonno, F., Manfredi, C., Franco, A. et al. Impact of peritoneal reconfiguration on lymphocele formation after robot-assisted radical prostatectomy with pelvic lymph node dissection: a systematic review and meta-analysis of randomized controlled trials. Prostate Cancer Prostatic Dis (2023). https://doi.org/10.1038/s41391-023-00744-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1038/s41391-023-00744-5

Search

Advanced search

Quick links