Diagnostic and therapeutic value of pelvic lymph node dissection in the fossa of Marcille in patients with clinically localized high‐risk prostate cancer: Histopathological and molecular analyses

Abstract

Background: The optimal extent of lymph node dissection in radical prostatectomy has not been determined. Lymph nodes in the fossa of Marcille, which is an important pelvic lymphatic pathway and candidate for additional dissection, have not been evaluated at the molecular level. Here, we assessed by molecular analysis the presence of occult positive lymph nodes in the fossa of Marcille in patients with clinically localized high-risk prostate cancer.Methods: Fifty-two patients with clinically localized high-risk prostate cancer underwent pelvic lymph node dissection accompanied by robot-assisted radical prostatectomy. All nodal packets were dissected separately and grouped into right and left obturator, external and internal iliac regions (including common iliac region to ureter crossing), and fossa of Marcille. All lymph nodes were bisected and evaluated by histopathological or molecular analysis using a quantitative reverse transcription-polymerase chain reaction. The number of positive lymph nodes in the fossa of Marcille and the difference in detection rate were investigated using histopathological and molecular analyses. Perioperative complication rate and predictive factors for biochemical recurrence were evaluated.Results: In the molecular analysis, there were seven positive lymph nodes in the fossa of Marcille in three patients, which were coexistent with positive nodes in other regions. The detection rate of positive lymph nodes was significantly higher using molecular than histopathological analysis (P < .01). Perioperative complication rate within 90 days after the operation was 25.0% and no Clavien-Dindo grade ≥3 complication was confirmed.Detection of metastasis by histopathological and molecular analysis was a significant factor related to biochemical recurrence in the Cox proportional hazards regression model. Conclusions: No case of positive lymph nodes in the fossa of Marcille that had skipped over other regions was confirmed. Additional lymph node dissection of fossa of Marcille did not lead to complete resection of molecularly positive lymph nodes. K E Y W O R D S lymph node dissection, prostatectomy, reverse transcription-polymerase chain reaction

Standardization of robot‐assisted pelvic lymph node dissection—Development of a common understanding of regional anatomy and surgical technique based on cross‐disciplinary discussion among colorectal surgery, urology, and gynecology

“…[21][22][23][24] It has been reported that the isolated metastasis to this area is less likely, and that metastasis is frequently confirmed when multiple lymph node metastasis is found elsewhere. 22 On the other hand, many urologists dissect the fossa of Marcille for prostate and bladder cancer because it facilitates en bloc dissection of the obturator lymph nodes around the obturator nerve. In bladder cancer, the treatment significance of lymph node dissection extending to the para-aortic lymph nodes has also been discussed, but at present, opinions generally recommend dissection distal to the common iliac bifurcation.…”

“…In addition to the internal iliac, obturator, and external iliac regions, extended PLND including the common iliac and sacral regions is recommended for bladder cancer 11,20,21 . The area called “the fossa of Marcille,” located lateral to the common iliac vessels, medial to the psoas muscle, anterior to the sciatic nerve, and cephalic to the obturator lymph nodes, is considered an important lymphatic route from the prostate and bladder and has long been considered by urologists to be an area that needs to be dissected 21–24 . It has been reported that the isolated metastasis to this area is less likely, and that metastasis is frequently confirmed when multiple lymph node metastasis is found elsewhere 22 .…”

“…The area called “the fossa of Marcille,” located lateral to the common iliac vessels, medial to the psoas muscle, anterior to the sciatic nerve, and cephalic to the obturator lymph nodes, is considered an important lymphatic route from the prostate and bladder and has long been considered by urologists to be an area that needs to be dissected 21–24 . It has been reported that the isolated metastasis to this area is less likely, and that metastasis is frequently confirmed when multiple lymph node metastasis is found elsewhere 22 . On the other hand, many urologists dissect the fossa of Marcille for prostate and bladder cancer because it facilitates en bloc dissection of the obturator lymph nodes around the obturator nerve.…”

Embryological Development and Topographic Anatomy of Pelvic Compartments—Surgical Relevance for Pelvic Lymphonodectomy

“…Marcille's triangle or fossa has been given special attention in the creation of adequate anatomical templates for lymph node dissection. Lymph nodes located in this region are covered by the iliac vessels and therefore less obvious, but are considered relevant for achieving optimal lymph node clearance [31][32][33].…”

“…A rather neglected lymph node region extends behind the proximal iliac vessels and corresponds to the triangle or fossa of Marcille, which is explored surgically by some surgeons during extended or salvage lymphonodectomy [31][32][33]. Marcille's triangle is limited by the anterolateral aspect of the fifth lumbar vertebra, the medial border of the psoas muscle, and the ala of the sacrum (see Figure 6B).…”