General indications for pelvic lymph node dissection in routine urologic practices include intermediate- and high-risk prostate cancer patients undergoing radical prostatectomy and bladder cancer patients undergoing partial/radical cystectomy [6]. The primary role of pelvic lymph node dissection for prostate and bladder cancers is in the staging procedure that provides information on prognosis (e.g., the number of lymph nodes involved). Besides this staging procedure, a number of studies support its therapeutic role; pelvic lymph node dissection can be curative in a subset of patients with limited lymph node metastases for both prostate and bladder cancers [7–11]. Extents of pelvic lymph node dissection in our practice include obturator, external, and internal iliac regions for intermediate- and high-risk prostate cancer and obturator, external, internal, and distal common iliac and presacral regions for muscle-invasive bladder cancer.

This procedure is usually performed at the time of radical prostatectomy and radical/partial cystectomy. Preoperative preparation and patient positioning of pelvic lymph node dissection conforms to those of radical prostatectomy (see Chap. 6), radical cystectomy (see Chap. 7), and partial cystectomy (see Chap. 8).

The surgical field for pelvic lymph node dissection is fixed using the Omni-Tract self-retractor system to displace the peritoneum upward and the bladder medially and to maintain the round shape of the single port (Figs. 9.7 and 9.8). All of the surgical procedures are performed under magnified stereovision on the 3D-HMD by all participants (Fig. 9.9). For right pelvic lymph node dissection, a right-handed lead surgeon stands on the left side of the patient and an assistant and an endoscopist stand on the opposite side (Fig. 9.9). When an endoscope is inserted from the opposite side of the lead surgeon, the surgeon rotates the images on the 3D-HMD 180° to obtain the orthoscopic images.

The size of the single port necessary for pelvic lymph node dissection is 2–3 cm in diameter. However, this procedure is usually performed simultaneously with radical prostatectomy and radical/partial cystectomy. In our practice, the diameters of the single ports for radical prostatectomy, partial cystectomy, and radical cystectomy are usually 4 cm, 3–4 cm, and 5–6 cm, respectively. To create a single port, a lower abdominal vertical skin incision of corresponding length (e.g., 4.5 cm for radical prostatectomy) is made. The Retzius space is opened by dissecting the peritoneum upward using a long retractor (PLES retractor^®, Innomedics Medical Instruments, Inc.). Once the Retzius space is opened bilaterally, a wound retractor (Alexis wound retractor^®, Applied Medical Resources, Corp.) is positioned so as to make a single port (Fig. 9.8).

The sheath of the external iliac vein is incised along the vein from the femoral canal to the bifurcation of the common iliac artery (Fig. 9.10). The external iliac vein is then lifted up with a vessel retractor to facilitate the incision of the connective tissue covering the obturator internus muscle (Fig. 9.11). The connective tissue is dissected from the fascia of the obturator internus muscle to the bottom of the obturator fossa to create the lateral border of the obturator lymph node packet (Fig. 9.12). Following identification of the obturator nerve, a right-angle clamp is passed through the obturator lymph node packet just above the obturator nerve, and the lymph node packet is ligated with a 1–0 silk to facilitate the obturator lymph node dissection (Fig. 9.13). The obturator lymph node packet is dissected distally to the femoral canal to doubly clip and divide the distal end of the lymphatic chain with a sealing device (Fig. 9.14). The obturator lymph node packet is dissected cranially along the obturator nerve (Fig. 9.15) to the internal iliac artery (Fig. 9.16) and vein (Fig. 9.17) near its cranial border. Finally, the cranial end of the lymphatic chain is dissected and divided dorsally to the common iliac vein using a sealing device (Fig. 9.18).