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228
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H.G. van der Poel et al.
15.1 Introduction
The “sentinel node concept” was fi rst described by
Gould et al. in 1960 for parotid gland cancer [ 1 ].
Later, in 1977, Cabanas utilized this same concept
in urological surgery for penile cancer, as based
upon lymphangiographic studies in 100 men
(including 10 healthy volunteers and 10 patients
with a benign penile lesion) to identify the fi rst
draining lymph node [ 2 ]. Cabanas found this sen-
tinel lymph node (SLN) to be anatomically located
in a fi xed, predetermined location close to the
superfi cial epigastric vein. In this initial experience, Cabanas reported that a SLN biopsy was
performed in 64 penile cancer patients, of whom
15 patients had a lymph node metastasis within the
SLN and 12 patients had a lymph node metastasis
only within the SLN. From that point forward in
time, SLN surgery in penile cancer surgery subsequently consisted of removal of the lymph node in
this fi xed, predetermined location, not taking into
account possible individual variations in lymphatic drainage patterns. However, secondary to
false-negative results, this fi xed, predetermined
anatomical location technique for identifi cation of
the SLN fell into disfavor and was subsequently
abandoned and has been replaced by radioguided
SLN biopsy methodologies [ 3 ].
In current urological surgery practice,
radioguided SLN biopsy has also been used or
clinically been evaluated in other urologic tumor
types, such as prostate, bladder, testicular, and
renal cancer. However, no consensus exists on
the value of radioguided SLN biopsy in these
urologic malignancies, and its use is not a standard of care currently. Even in penile cancer, the
use of radioguided SLN biopsy remains subject
to much discussion, and its use is not as widespread in the USA as it is in Europe.
Novel technical approaches such as imageguided surgery using fl uorophores in the nearinfrared (NIR) spectrum and improved
scintigraphic staging with SPECT-CT have
drawn attention towards the SLN approach in
abovementioned cancers. The lack of consensus of the value of the SLN approach in urological cancers is mainly due to the scarcity of
high-level clinical studies. In this chapter, we
will present the available literature on SLN
biopsy in urological cancers and defi ne the
state-of-the-art approaches and recommendations in the urological guidelines.
15.2 Penile Cancer
About 95 % of penile tumors are squamous cell
carcinomas. It has a predominantly lymphogenic
dissemination pattern. The fi rst draining nodes are
the inguinal lymph nodes. Occult inguinal metastases occur in around 20 % of patients with clinically node-negative groins. A prophylactic
bilateral inguinal lymph node dissection may thus
be unnecessary in the majority of patients, while
this procedure has high morbidity – a possible
explanation for its reported underutilization [ 4 ].
SLN biopsy plays an important role reducing overtreatment and morbidity. The complication rate of
SLN biopsy is around 5–7 %, while complication
rates of inguinal lymph node dissection are up to
74 %, even in contemporary series [ 5 – 8 ].
Although survival in men with cN0 penile cancer improved in recent years, nodal metastases are
seen in a large portion of men [ 9 ]. With improve-
ments in lymphatic mapping techniques and the
gradual acceptance of radioguided SLN biopsy
techniques in melanoma and breast cancer, SLN
biopsy, using radioguided techniques (combined
blue dye and radioactive technetium- 99m (99mTc)
tracer utilization), was introduced into penile cancer surgery in 2000 [ 10 ]. Since then, several modi-
fi cations to the procedure have been made to
improve its reliability [
no randomized trials exist, and all reported studies
contain a limited number of cases or are case
reports. A meta-analysis from 2012 containing 18
studies showed a 88.3 % pooled detection rate
increasing to 90.1 % when blue dye was added to
the radiotracer; no report on false-negative rate
was available from this analysis [ 47 ]. A review of
10 studies published in 2011 showed a 3.5 % falsenegative rate for the SLN biopsy [ 48 ].
According to the EAU guidelines, SLN biopsy
is indicated in men with cN0 and at least cT1G2
disease [ 49 ]. In low-risk penile cancer patients
with larger exophytic tumor, the yield of positive
SLN is high and maybe therefore considered
[ 50 ]. In intermediate-risk patients with micro-
scopic SLN biopsy metastases, Akduman et al.
found no further metastases in completing
7 , 11 – 46 ]. Unfortunately,
15 Radioguided Sentinel Lymph Node Biopsy and Lymphatic Mapping in Urogenital Malignancies
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229
inguinal node dissection, but additional inguinal
node dissection is still recommended in all men
with nodal metastases on SLN biopsy [ 49 , 51 ]. In
a recently updated prognostic scoring system,
SLN biopsy added predictive value [ 52 ].
Currently, several centers in Europe have confi rmed the reliability and reproducibility of SLN
biopsy in penile cancer. Reported false-negative
rates of contemporary series vary between 3 and
15 % [ 28 , 29 , 37 , 53 ]. In combination with ingui-
nal ultrasound, SLN biopsy had a sensitivity of
94 % in a large series [ 53 , 54 ].
15.2.1 Preoperative Visualization
of Lymphatic Drainage
The day before SLN surgery, a radioactive tracer
99m
(
Technetium-nanocolloid), is injected around
the tumor subcutaneously in 2–3 injection at a
total dose of 50–90 MBq in 0.2–0.4 cc volume
[ 14 , 24 ]. Subsequently, timed planar scinti-
graphic imaging is performed at 10–20 min and 2
h postinjection (Fig. 15.1 ) [ 7 , 16 , 18 ]. Some cen-
ters add single-photon emission computed
tomography-computed tomography (SPECT-CT)
imaging to the preoperative imaging to acquire
additional anatomical information of the SLN
and drainage patterns (Fig. 15.2 ) [ 55 ].
Interestingly, SLN detection seems feasible
even after removal of the primary penile cancer by
partial penectomy, allowing for rapid removal of
the primary tumor where needed and subsequent
SLN dissection in a specialized center in a separate
procedure [ 35 ]. Moreover, repeat SLN after an ini-
tial negative SLN procedure in patients with a local
(penile) recurrence is possible [ 56 ]. Proper patho-
logical node evaluation is essential to avoid
Fig. 15.1 Early scintigram for penile cancer SLN detection
li lat 10 min
Ant 10 min
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Fig. 15.2 SPECT/CT for SLN detection in penile cancer
H.G. van der Poel et al.
false-negative SLN removal [ 11 ]. The reproduc-
ibility of preoperative imaging of SLN is high [ 57 ].
Preoperative inguinal ultrasound improves the clinical diagnosis of nodal metastases, in particular
when combined with a cytological aspiration
biopsy of suspicious lymph nodes [ 12 ]. It also
seems to improve the false-negative rate of SLN
biopsy by reducing the chance of tumor blockage
[ 58 ]. In men with a tumor- positive cytological aspi-
ration, SLN should only be considered to detect
contralateral inguinal metastases, and an ipsilateral
inguinal node dissection is recommended [
11 ].
15.2.2 Intraoperative SLN Detection
Using Gamma Tracing
Based on the preoperative scintigraphic imaging,
the location of the SLN is marked on the skin.
Directly before the SLN procedure, patent blue is
injected into the skin surrounding the tumor as an
additional tracer. A small incision (3–4 cm) is then
made, preferably just below the inguinal plica. The
incision is made preferably somewhat lower than
the inguinal plica, since this allows for a lower
incision in cases where an additional inguinal
node dissection is required because of a positive
SLN. A lower inguinal incision in these men is
associated with more favorable wound healing.
The SLN is then identifi ed using the combination of blue dye and a handheld gamma probe to
identify the radioactive nodes. Preoperative
imaging using SPECT/CT was shown to improve
inguinal detection of SLN by providing superior
3D information on lymph node location as compared to conventional scintigraphy imaging [ 13 ,
59 ]. Interestingly, SLN location was found to be
limited to the superior and central inguinal lymph
nodes. This knowledge could be used to determine
the extent of a lymph node dissection when the
SLN method is not used [ 60 ].
15.2.3 Optical Tracers and SLN
Detection in Penile Cancer
As mentioned before, the most widely used
visual marker is blue dye. The visualization rate
of lymph nodes with blue dye alone is between
55 and 70 % [ 14 , 18 ]. An advantage of blue dye
15 Radioguided Sentinel Lymph Node Biopsy and Lymphatic Mapping in Urogenital Malignancies
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231
is the visualization of the lymphatic ducts what
aids in a more rapid identifi cation of the SLN.
Near infrared (NIR) imaging options have
become available as an additional visual tracer.
Fluorescent tracers in the NIR spectrum of light
provide the benefi t of visualization of lymph
drainage without obscuring anatomical planes in
the white light surgical setting. Indocyanine
green (ICG) is a fl uorophore that can be visualized by using NIR imaging systems and emits
light at 820 nm when excitated by 770 nm light,
both in the invisible spectrum of the NIR light.
When injected locally, ICG rapidly migrates
through the lymphatic system enabling intraoperative visualization of tracts and nodes. Hybrid
tracers, comprised of the fl uorescent dye ICG
covalently attached to the
99m
Tc nanocolloid,
have been developed that can be used to provide
both preoperative SPECT imaging and intraoperative fl uorescence guidance for surgery [ 14 ].
Intraoperative visualization of ICG is superior to
the visualization of SLNs with blue dye [ 14 ].
15.2.4 Clinical Outcome
Similar to many other tumors, the lymph node
status is the most important prognostic factor in
penile carcinoma [ 61 ]. Prediction of nodal metas-
tases based on clinical factors is inaccurate, and
prophylactic inguinal lymph node dissection
would imply overtreatment in the majority of
patients [
of inguinal nodal metastases by SLN biopsy
improved survival in comparison to a cohort that
was observed (albeit retrospectively) [ 17 , 63 ].
with cN0 disease has increased after the introduction of the SLN method [ 9 ]. In the majority of
cases, the SLN was the only node containing
metastases [ 18 ]. Size of the nodal metastases in
SLNs was the best predictor of additional positive nodes [ 64 ].
with SLNpN0 penile cancer in particular in centers with limited experience in SLN detection
[ 65 ]. In a series of men with recurrent disease,
nonpalpable tumor-positive lymph nodes were
34 , 62 ]. Early detection and treatment
Staging has improved and survival of men
Close follow-up is therefore indicated in men
frequently detected using ultrasound methods,
and therefore, the role of ultrasound in the follow- up of these men is useful [ 66 ].
15.3 Prostate Cancer
Prostate cancer initially metastasizes to the
lymph nodes, and intermediate- and high-risk
prostate cancer patients have a risk of 5–70 % to
develop nodal metastases. Predictive nomograms are generally used to defi ne the indication
for a nodal dissection concomitant to a prostatectomy in men with localized prostate cancer
[ 67 – 69 ]. Guidelines recommend nodal dissec-
tion when nomograms predict a risk of more
than 5 % on the presence of nodal metastases.
For optimal nodal yield, an extended nodal dissection is recommended, and recent retrospective data suggest that removal of less than 14
nodes resulted in poorer outcome when compared to removal of more lymph nodes [ 70 ].
Prognosis of men with nodal metastases from
prostate cancer is relatively good with the majority surviving more than 10 years [ 71 , 72 ].
However, an extended nodal dissection is not
without morbidity, and complications of the procedure are strongly correlated with the number
of nodes removed [ 73 ]. Despite extended nodal
dissection, pelvic recurrences do occur, and the
false-negative rate of extended pelvic nodal dissection for prostate cancer was estimated to be
around 12.5 % [
The fi rst results of SLN biopsy in prostate
cancer have been published in 1999 [ 76 – 80 ].
Unlike in penile cancer, the routine use of SLN
dissection in prostate cancer is still topic of
debate. Although the SLN can be detected,
some studies have found that metastases are frequently occurring in nodes besides the tumorbearing SLN. Lymph drainage targeting therapy
rather than SLN-targeted diagnostics has therefore been proposed [ 81 – 85 ]. A recent meta-
analysis in prostate cancer was supportive of the
use of SLN, despite the lack of high-level evidence, for the reason that it may reduce morbidity of the extended nodal dissection often
propagated [ 86 ].
74 , 75 ].
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H.G. van der Poel et al.
15.3.1 Preoperative Imaging
Most studies use the transperineal or transrectal
tracer injection method. One study described
intraoperative optical tracer injection transperitoneally [ 87 ], but in general, preoperative injec-
tion is used and allows preoperative imaging by
SPECT/CT (Figs. 15.3 and 15.4 ). Buckle et al.
showed variable tracer distribution within the
prostate [ 88 ]. Ongoing studies should reveal
whether intratumoral injection is superior to
several tracer depots within the entire prostate.
After injection, imaging with scintigraphy and
SPECT/CT is applied. Both open [ 78 , 89 – 95 ]
and laparoscopic [ 96 – 99 ] gamma probe SLN
detection has been extensively studied in prostate cancer, and over 7000 cases were reported
in the literature. The 99m technetium tracer is
either bound to sulfur [ 100 ], phylate [ 101 , 102 ],
or nanocolloid with varying sizes from 80 nm
[ 78 , 97 ] to 1500 nm [ 101 – 103 ]. The amount of
radioactive tracer injected varied from 60 MBq
[ 100 ] to 267 MBq [ 104 ]. No comparative stud-
ies are available on the optimal dose and injection volume.
15.3.2 Intraoperative Detection
Various groups distinguished SLNs and higherechelon LNs based on the (dynamic) lymphatic
drainage routes, enabling selective removal.
During open surgical procedures, standard
gamma probes can be used to detect activity and
identify the draining patterns during open prostatectomy [ 78 , 105 , 106 ]. In most studies, the SLN
or landing site resection is combined with a routine or extended nodal dissection. Since a secondary resection of lymph nodes in the small
pelvis is cumbersome, most studies combine
SLN resection with more extensive pelvic node
dissection. A novel portable gamma camera
(Sentinella, Oncovision; Valencia, Spain) has
provided intraoperative imaging of 99mTc containing lymph nodes [ 107 ]. This two-dimensional
imaging system was shown to aid in confi rmation
of accurate SLN removal in the laparoscopic setting [ 108 ]. Besides gamma probe and camera
tracing, visual detection of SLN is applied using
fl uorophore dyes (Fig. 15.5 ). As described ear-
lier, these tracers are injected intraprostatically
and allow for visual confi rmation of the gamma
Ant 15min
Ant 2 uur p.i
Fig. 15.3 Scintigraphy for prostate cancer SLN detection
Re Lat 15min Li Lat 15min
15 Radioguided Sentinel Lymph Node Biopsy and Lymphatic Mapping in Urogenital Malignancies
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233
a
b
Fig. 15.4 SPECT/CT for SLN detection in prostate
cancer
probe signal. The relatively low penetrance of
NIR light systems does still require close-up
resection often guided by the gamma probe.
Initial studies used ICG bound to nanocolloid to
retain the optical tracer in the lymph nodes and
allow combined pre- and perioperative imaging
[ 98 ]. More recently, free ICG was used as tracer.
Free-ICG has the benefi t of rapid migration into
the lymph nodes draining the prostate after intraprostatic injection. Retention of tracer in lymph
nodes, however, is much lower than with the use
of nanocolloid bound ICG. Injection of free ICG,
Fig. 15.5 Intraoperative image of sentinel lymph node.
( a ) SPIES system from Storz (Tuttlingen, Germany). ( b )
FireFly system from Intuitive Surgical (Sunnyvale, USA)
therefore, is applied briefl y (10–30 min) prior to
the nodal dissection. Moreover, at longer intervals or damage of lymphatic ducts due to surgical
manipulation, ICG may leak from the lymphatic
system and stain surrounding tissue rendering
identifi cation of draining lymph nodes more diffi cult. Several groups have successfully used free
ICG to identify lymph nodes draining the prostate. Jeschke et al. compared free ICG to preoperatively injected and imaged gamma tracer and
found high correlation between both tracing
methods [
109 ]. Manny et al. reported a 100 %
sensitivity for predicting nodal metastases by
SLN detection using an intraoperative ICG injection during robot-assisted radical prostatectomy
[ 87 ]. Although free ICG seems to provide a prac-
tical alternative gamma tracing, it lacks the preoperative option of anatomical location of
alternative lymph draining patterns that may be
missed due to the low penetrance of the NIR signal of ICG. A study is ongoing to confi rm the
value of free ICG in comparison for nanocolloid
bound multimodal tracer (NL41285.031.12).
Nanocolloid bound ICG has the advantage that
it remains in the prostate at the injection site. This
allows for postoperative localization of the injection site inside the prostate. Analysis of 19 prostatectomy specimen showed remarkable variation
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H.G. van der Poel et al.
of location of ICG deposits inside the prostate
after ultrasound-guided tracer injection [ 88 ].
Interestingly, draining patterns of tracer in the
lymphatic system seemed dependent on location
of the tracer inside the prostate [ 88 ]. To evaluate
the effects of tracer injection location, a randomized study between intraprostatic and intratumoral
injections is ongoing (NL46580.031.13).
Ultrasmall superparamagnetic nanoparticle
MRI has been described to improve nodal metastases detection in prostate cancer [ 110 , 111 ]. A
handheld magnetometer was used to detect intraprostatically injected superparamagnetic iron
oxide in 20 men with prostate cancer. Metastases
were found only in lymph nodes detected using
the magnetometer and identifi ed as SLNs in this
analysis [ 112 ]. The role of this new tracer for intra-
operative detection of lymphatic drainage patterns
needs further evaluation but holds promise.
15.3.3 Outcome
Different studies report different outcome of SLN
approaches in prostate cancer. The median number of resected SLNs was 6 (range 2–26) per
patient. The detection rate of SLN ranged
76–100 % [ 87 , 91 , 96 – 98 , 100 , 101 , 104 , 108 ,
113 – 119 ]. In 13–75 % of patients, one or more
SLN(s) outside the limited pelvic lymph node dissection (PLND) template were found. In addition,
tumor-bearing SLNs were detected outside the
standard PLND in 51.8–76.9 % of the patients. In
4.1–25 % of patients, SLNs outside the extended
PLND template were found, whereas 3.5–17 % of
patients with positive LNs had SLN metastases
outside the extended PLND template [
91 , 96 , 98 – 102 , 113 – 116 , 119 – 125 ]. In these
studies, the median percentage of positive LNs
was 20.4 % (range 4.7–50) with a false-negative
rate of 1 % (range 0–20), respectively (Table 15.1 ).
75 , 76 , 78 ,
15.4 Bladder Cancer
Lymph drainage from the bladder shows a wide
variation [ 136 ] and contralateral drainage is fre-
quent [ 137 ]. The application of SLN detection in
bladder cancer is complicated by the complexity
of tracer injection. Both intraoperative [ 138 ] and
transurethral injection [ 137 ] may yield different
draining patterns. In a study on 60 patients with
radioactive tracer injections in the nontumorbearing bladder site, extended nodal dissection
included 92 % of the active nodes. In a more limited resection of external and obturator template,
only 50 % of the radioactive lymph nodes were
included [ 137 ]. In a smaller series of bladder can-
cer patients, SLN were detected in 85 % of cases
suggesting that diagnostic yield of the SLN
approach in bladder cancer may be lower than
generally found in penile cancer [ 136 ]. The
method of injection did infl uence drainage in a
study using ICG tracers [ 136 , 138 , 139 ].
Moreover, multiple tumors may result in falsenegative SLN biopsies [ 140 ], reported as high as
19 % [ 141 ]. Interestingly, one report introduces
the use of SLN biopsy to harvest T-cells for
immunotherapy for bladder cancer [ 142 ]. The
complexity of injection and additional need of an
extended nodal dissection has so far prohibited
the extensive use of SLN for bladder cancer
management.
15.5 Testis and Renal Cancer
Experience with the application of SLN methods
for testis [ 143 – 146 ] and renal cancer [ 147 – 151 ]
is limited. For testicular cancer, injection of tracer
into the funiculus of the tumor-bearing testis
resulted in visualization of a retroperitoneal SLN
in 16 of 17 men with clinically node-negative testicular cancer. A median number of 2 lymph
nodes were laparoscopically removed. Nodal
metastasis was found in 1 men with testis cancer.
Treatment in this case consisted of additional
bleomycin, etoposide, and cisplatin chemotherapy. Whereas men with a negative SLN were followed according to guidelines, none of the men
with a negative SLN developed a retroperitoneal
recurrence at a median follow-up of 43 months.
In renal cancer, SLN visualization was possible
in 70–77 % of cases. In one small series, 2 of 20
patients had SLN outside the retroperitoneal
region. These observations in small groups
15 Radioguided Sentinel Lymph Node Biopsy and Lymphatic Mapping in Urogenital Malignancies
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235
(continued)
Percentage
of SLN
outside of
Percentage
of SLN
outside of
Percentage
Percentage
extended
LND
plate (%
limited
LND
plate (%
of false
negative
lymph
of positive
lymph
node (%
Percentage
of SLN
Excised
SLN
( n )
No complication
patients) Complications
7.4 (in
patients)
node (%)
23.9 4 51.8 (in
patients)
detection
(median)
LN(+)
patients)
LN(+)
patients)
LN(+)
patients)
NR
3.5 (in
5.6 (mean) 97.1 24.5 0.5 59.3 (in
LN(+)
patients)
LN(+)
patients)
2 ext. iliac artery
injury
3 pulmonary
embolism
1 deep vein
thrombosis
3 lymphoceles
50 20 62 10 1 neuropraxia
LN(+)
patients)
Table 15.1 Results
Primary
treatment
Patient features
(D’Amico risk
classifi cation)
SLN dissection
method
Number
of
patients
117 Open All risk groups NR 4 96 (in
Wawroschek
Authors
78 ]
et al. [
radiotherapy
350 Open All risk groups RRP and
104 ]
Wawroschek
et al. [
34 Open All risk groups RRP 85.3 11.7 66.6 NR
24 Open All risk groups NR 4.2 (mean) 87.5 12.5 0 25 4.1 NR
102 ]
Bastide et al.
Takashima
et al. [
27 Open All risk groups RRP 3.5 (mean) 100 14.8 0 55.5 11.1 NR
100 ]
93 ]
Brenot-Rossi
et al. [
[
23 Open All risk groups NR 3 95.6 13 4.3 13 NR NR
126 ]
Silva et al.
[
71 Laparoscopic All risk groups LRP 4.7 (mean) 97.2 12.7 0 54.7 NR 1 prostatitis
108 ]
Jeschke et al.
[
LRP NR 70 (in
11 Open NR NR 3 100 9 0 45.4 NR NR
20 Laparoscopic Intermediate-
127 ]
Häcker et al.
Kizu et al.
[
and high-risk
groups
113 ]
[
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H.G. van der Poel et al.
NR
Percentage
of SLN
outside of
extended
LND
plate (%
patients) Complications
Percentage
of SLN
outside of
limited
LND
plate (%
patients)
Percentage
of false
negative
lymph
node (%)
Percentage
of positive
lymph
node (%
patients)
Percentage
of SLN
detection
Excised
SLN
(n)
(median)
NR NR
LN(+)
patients)
NR NR
LN(+)
patients)
15.3 (in
26 97.6 30.9 4.8 76.9 (in
LN(+)
LN(+)
bleeding
patients)
patients)
2 mild leg edema
81.5 40 0 NR 17.1 5 lymphocele
(mean)
Table 15.1 (continued)
Patient features
Numb er
Primary
(D’Amico risk
SLN dissection
of
treatment
classi cation)
method
patients
Auth ors
RRP 1.6 (mean) 87 NR NR NR 25 No complication
pT2N0M0,
7 patients
pT3-4N0M0
23 Open 16 patients
128 ]
Krengli et al.
[
Radiotherapy 2.1 (mean) 93 23 3.5 52 35.7 No complication
and high-risk
groups
28 Laparoscopic Intermediate-
Corvin et al.
1055 Open All risk groups RRP 7 100 19.6 1 76(in
96 ]
[
Weckermann
118 ]
et al. [
RRP 6 100 9.2 0 75 (in
with presumed
unilateral
disease
564 Open All risk groups
129 ]
Weckermann
et al. [
RRP or
42 Open All risk groups
Fukuda et al.
RRP 8/10 99.5/98.5 4.7/6.6 0 NR NR 1 retroperitoneal
radiotherapy
with/without
NHT
36 Open Low- and
101 ]
Warncke et al.
[
intermediate-
risk groups
with/without
the surgeon
knowing
90 ]
[
imaging
fi ndings
Radiotherapy 13.5
and high-risk
groups
35 Laparoscopic Intermediate-
97 ]
Meinhardt
et al. [
15 Radioguided Sentinel Lymph Node Biopsy and Lymphatic Mapping in Urogenital Malignancies
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lymphoceles
3 (0.6 %) ureteral
1 external iliac
vein injury
1 neuropraxia 1
deep venous
thrombosis
3 lymphoceles
injuries
237
(continued)
91 15 0 NR 0 NR
108 Open All risk groups RRP 13.4
(mean)
LRP 4 95.3 13.5 NR 55.7 5.7 2 prostatitis
140 Laparoscopic Low- and
intermediate-
risk groups
7 76 12 0 69.3 4.1 NR
RRP
100 Open All risk groups 87 patients
13 patients
radiotherapy
Radiotherapy 4.3 (mean) 98 33 NR NR 35 NR
46 Laparoscopic Intermediate-
NR 3 100 43.1 NR NR 6.2 NR
risk group
16 Laparoscopic Intermediate-
91 ] 2020 Open All risk groups RRP 9 98 16.7 5.8 NR NR NR
3 89.3 6.1 2.1 76.7 NR 18 (3.9 %)
RRP (418
patients) and
All risk groups
and high-risk
for open PLND
groups
laparoscopic
463 Open and
laparoscopic
PLND (45
patients) for
staging
and high-risk
group for
laparoscopic
PLND
3 100 50 NR 80 NR NR
procedure
Salvage
treatment and
with recurrent
80 Laparoscopic 10 patients
radiotherapy
prostate cancer
70 patients
with
intermediate-
risk group
95 ]
et al. [
eschke et al.
99 ]
[
Hautmann
120 ]
Brenot-Rossi
et al. [
130 ]
Vermeeren
et al. [
Holl et al. [
131 ]
Vermeeren
et al. [
132 ]
Schilling et al.
[
107 ]
Vermeeren
et al. [
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