Optimisation of Fluorescence Guidance During Robot-assisted Laparoscopic Sentinel Node Biopsy for Prostate Cancer

• Published in: European urology 2014-12, Vol.66 (6), p.991-998
• Main Authors: KleinJan, Gijs H, van den Berg, Nynke S, Brouwer, Oscar R, de Jong, Jeroen, Acar, Cenk, Wit, Esther M, Vegt, Erik, van der Noort, Vincent, Valdés Olmos, Renato A, van Leeuwen, Fijs W.B, van der Poel, Henk G
• Format: Article
• Language: English
• Subjects: Aged; Biological and medical sciences; Coloring Agents; Fluorescence; Fluorescence-guided surgery; Gynecology. Andrology. Obstetrics; Humans; Hybrid approach; Hybrid tracer; Image-Guided Biopsy - methods; Image-guided surgery; Indocyanine Green; Lymph Nodes - diagnostic imaging; Lymphoscintigraphy; Male; Male genital diseases; Medical sciences; Middle Aged; Multimodal Imaging; Nephrology. Urinary tract diseases; Optical Imaging - instrumentation; Optical Imaging - methods; Pelvis; Prostate cancer; Prostatic Neoplasms - pathology; Prostatic Neoplasms - surgery; Radio-guided surgery; Radiopharmaceuticals; Robotic Surgical Procedures; Sentinel (lymph) node; Sentinel Lymph Node Biopsy - methods; Technetium Tc 99m Aggregated Albumin; Tomography, Emission-Computed, Single-Photon; Tomography, X-Ray Computed; Tumors; Tumors of the urinary system; Urinary tract. Prostate gland; Urology
• ISSN: 0302-2838; 1873-7560
• DOI: 10.1016/j.eururo.2014.07.014

Abstract Background The hybrid tracer was introduced to complement intraoperative radiotracing towards the sentinel nodes (SNs) with fluorescence guidance. Objective Improve in vivo fluorescence-based SN identification for prostate cancer by optimising hybrid tracer preparation, injection technique, and fluorescence imaging hardware. Design, setting, and participants Forty patients with a Briganti nomogram–based risk >10% of lymph node (LN) metastases were included. After intraprostatic tracer injection, SN mapping was performed (lymphoscintigraphy and single-photon emission computed tomography with computed tomography (SPECT-CT)). In groups 1 and 2, SNs were pursued intraoperatively using a laparoscopic gamma probe followed by fluorescence imaging (FI). In group 3, SNs were initially located via FI. Compared with group 1, in groups 2 and 3, a new tracer formulation was introduced that had a reduced total injected volume (2.0 ml vs 3.2 ml) but increased particle concentration. For groups 1 and 2, the Tricam SLII with D-Light C laparoscopic FI (LFI) system was used. In group 3, the LFI system was upgraded to an Image 1 HUB HD with D-Light P system. Intervention Hybrid tracer-based SN biopsy, extended pelvic lymph node dissection, and robot-assisted radical prostatectomy. Outcome measurements and statistical analysis Number and location of the preoperatively identified SNs, in vivo fluorescence-based SN identification rate, tumour status of SNs and LNs, postoperative complications, and biochemical recurrence (BCR). Results and limitations Mean fluorescence-based SN identification improved from 63.7% (group 1) to 85.2% and 93.5% for groups 2 and 3, respectively ( p = 0.012). No differences in postoperative complications were found. BCR occurred in three pN0 patients. Conclusions Stepwise optimisation of the hybrid tracer formulation and the LFI system led to a significant improvement in fluorescence-assisted SN identification. Preoperative SPECT-CT remained essential for guiding intraoperative SN localisation. Patient summary Intraoperative fluorescence-based SN visualisation can be improved by enhancing the hybrid tracer formulation and laparoscopic fluorescence imaging system.