Timing of lymphadenectomy during robot-assisted radical cystectomy: before or after cystectomy? Fifteen cases with totally intracorporeal urinary diversions

Introduction
Many publications detail the level and number of lymphadenectomies, whereas the timing of pelvic lymph node dissection (PLND) is infrequently discussed in the robot-assisted radical cystectomy (RARC) series.

Aim
To determine the effects of performing PLND before or after cystectomy in totally intracorporeal RARC on operative outcomes.

Material and methods
A total of 15 patients included in the study underwent RARC and intracorporeal orthotopic neobladder. Of these, 8 patients underwent PLND before cystectomy (group 1), whereas 7 underwent PLND after cystectomy (group 2). Demographic information, intraoperative data, and post-operative outcomes were recorded for each patient.

Results
The mean ± SD age was 61.87 ±6.76 years. Overall mean operation time (OT) was 537.33 ±63.07 min. The mean EBL and hospitalization time were 322.33 ±69.92 ml and 13.87 ±5.2 days. The number of LN removed was 23.75 ±3.454) for group 1 and 13.71 ±6.873 for group 2 (p = 0.007). The postoperative pathological stages were: pT2(5), pT3(2), pT4(1) for group 1, pT2(4), pT3(2), pT4(1) for group 2. Surgical margins were negative in all patient. Overall complications occurred in 7 (46.6%) patients. Only the number of LN removed was statistically significant in favor of group 1 (p = 0.007). Mean follow-up was 15.87 months.

Conclusions
Our initial experience with performing extended PLND (ePLND) before or after cystectomy in totally intracorporeal RARC appears to be favorable, with similar oncological results and acceptable complication rates. However, although the number of cases is too low for statistical evaluation, it seems to be advantageous to perform ePLND before cystectomy in terms of LN number and operation time.