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Kumar et al. Mini-invasive Surg 2018;2:19 I http://dx.doi.org/10.20517/2574-1225.2018.26 Page 7 of 15

Pubic symphysis

Bladder

Left external iliac vein
Obturator nerve

Figure 5. Robotic lateral pelvic lymph node dissection with dissection inferior to obturator nerve

experienced laparoscopic surgeons specializing in pelvic surgery. The author emphasized that lateral pelvic
lymph node metastasis more commonly occurs around the distal internal iliac vessels located very deep in
the pelvic space . With magnified and illuminated vision of MIS and surgeons with good knowledge of
[49]
lateral pelvic anatomy and sufficient experience in MIS TME procedure, lateral pelvic lymph node dissection
can be performed meticulously with less blood loss .
[61]
Nagayoshi et al. evaluated the feasibility and oncological safety of laparoscopic lateral pelvic lymph node
[62]
dissection compared with the conventional open approach. The mean operative time was longer in the
laparoscopic group than in the open group (641.0 vs. 312.0 min, P < 0.001). The laparoscopic group had less
blood loss (252.0 vs. 815.0 mL, P < 0.001) and a shorter hospital stay (22.9 vs. 29.1 days, P = 0.04) than the
open group. The morbidity rate and OS (3-year OS: 94.7% vs. 82.9%, P = 0.25) did not differ between the two
groups. The mean number of harvested lateral pelvic lymph nodes was more in the laparoscopic group than
in the open group (19.5 vs. 15.8, P < 0.05). In lateral pelvic lymph node dissection following neo-adjuvant
chemo-radiotherapy, lymph node yield would be low and studies have shown that the number of lymph
[63]
nodes does not affect the recurrence rate and survival . Furuhata et al. confirmed the good oncological
[64]
[65]
outcomes with perioperative morbidity of 16.7% as three patients developed grade 2 urinary retention.
Robotic surgery may facilitate lateral pelvic lymph node dissection because of its advantage over laparoscopic
surgery. Initial small series have confirmed the feasibility of robotic lateral pelvic lymph node dissection [66,67] . In
our institute, we standardized the technique of robotic lateral pelvic lymph node dissection . We use standard
[57]
five-port technique followed by completion of TME, medialization of ureter, skeletonization and dissection
around external and internal iliac vessels, dissection of obliterated umbilical artery, dissection in paravesical
space, standard template dissection, identification of obturator nerve, and dissection up to pelvic floor [Figure 6].

Kagawa et al. reported short-term outcomes in 50 consecutive robotic lateral pelvic lymph node dissections. The
[68]
median operative time was 165 min (range 85-257 min) and median blood loss was 27 mL (range 5-690 mL). The
median number of harvested lymph nodes was 19 (range 5-47). There was no conversion to open or laparoscopic
approach. Clavien-Dindo classification grade III-IV complications occurred in only one patient (2.0%).

Yamaguchi et al. compared short-term outcomes of robotic-assisted laparoscopic lateral pelvic lymph node
[69]
dissection with open approach. Operative time was significantly longer in the robotic surgery (P = 0.007). The
blood loss and perioperative complications were significantly less in the robotic group.

Kim et al. have compared robotic lateral pelvic lymph node dissection with laparoscopic approach. There was
[70]
no significant difference in operative time between the two groups (robotic vs. laparoscopic, 41.0 ± 15.8 min vs.