Extending the indications and anatomical limits of pelvic lymph node dissection for prostate cancer: improved staging or increased morbidity?

Limited versus Extended Pelvic Lymph Node Dissection for Prostate Cancer: A Randomized Clinical Trial

BACKGROUND

Pelvic lymph node dissection (PLND) is the most reliable procedure for lymph node staging. However, the therapeutic benefit remains unproven; although most radical prostatectomies at academic centers are accompanied by PLND, there is no consensus regarding the optimal anatomical extent of PLND.

OBJECTIVE

To evaluate whether extended PLND results in a lower biochemical recurrence rate.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a single-center randomized trial. Patients, enrolled between October 2011 and March 2017, were scheduled to undergo radical prostatectomy and PLND. Patients were assigned to limited or extended PLND by cluster randomization. Specifically, surgeons were randomized to perform limited or extended PLND for 3-mo periods.

INTERVENTION

Randomization to limited (external iliac nodes) or extended (external iliac, obturator fossa and hypogastric nodes) PLND.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was the rate of biochemical recurrence.

RESULTS AND LIMITATIONS

Of 1440 patients included in the final analysis, 700 were randomized to limited PLND and 740 to extended PLND. The median number of nodes retrieved was 12 (interquartile range [IQR] 8-17) for limited PLND and 14 (IQR 10-20) extended PLND; the corresponding rate of positive nodes was 12% and 14% (difference -1.9%, 95% confidence interval [CI] -5.4% to 1.5%; p = 0.3). With median follow-up of 3.1 yr, there was no significant difference in the rate of biochemical recurrence between the groups (hazard ratio 1.04, 95% CI 0.93-1.15; p = 0.5). Rates for grade 2 and 3 complications were similar at 7.3% for limited versus 6.4% for extended PLND; there were no grade 4 or 5 complications.

CONCLUSIONS

Extended PLND did not improve freedom from biochemical recurrence over limited PLND for men with clinically localized prostate cancer. However, there were smaller than expected differences in nodal count and the rate of positive nodes between the two templates. A randomized trial comparing PLND to no node dissection is warranted.

PATIENT SUMMARY

In this clinical trial we did not find a difference in the rate of biochemical recurrence of prostate cancer between limited and extended dissection of lymph nodes in the pelvis. This study is registered on ClinicalTrials.gov as NCT01407263.

Association of lymph node yield with overall survival in patients with pathologically node negative prostate cancer

We investigated the association between lymph node yield (LNY) with overall survival (OS) and post-radical prostatectomy (RP) secondary treatments among men with pathologically node negative (pN0) prostate cancer. We reviewed the National Cancer Database for men with Gleason Grade Group 2 or higher prostate cancer treated with RP and had pathologically node-negative disease. LNY was modeled as a continuous and categorical variable grouped by quartiles of LNY. Secondary treatment was defined as the use of radiation or systemic therapy post-RP. Multivariable Cox proportional hazards and logistic regression models were used to test for an association of LNY with OS and secondary treatments, respectively. We identified 89,416 men with pN0 prostate cancer treated with RP from 2010-2015. LNY was associated with improved OS when modeled as a categorical and continuous variable. The third (6-9 nodes) and fourth (≥10 nodes) quartiles of LNY were associated with improved OS (HR 0.87, 95% CI 0.79-0.96, P = 0.006 and HR 0.88, 95% CI 0.79-0.98, P= 0.017, respectively) when compared with the lowest quartile of LNY (≤3 nodes) and the hazard of death decreased by 1% for each benign lymph node removed (HR 0.99, 95% CI 0.98-0.99, P= 0.022). Additionally, categorical and continuous LNY was associated with significantly less use of post-RP secondary treatments. Removal of additional negative lymph nodes was associated with improved OS and less secondary treatments in patients with pN0 prostate cancer. These data suggest that removing a higher quantity of lymph nodes provides more accurate staging and prognosis.

Impact of Pelvic Lymph Node Dissection and Its Extent on Perioperative Morbidity in Patients Undergoing Radical Prostatectomy for Prostate Cancer: A Comprehensive Systematic Review and Meta-analysis

CONTEXT

Pelvic lymph node dissection (PLND) yields the most accurate staging in patients undergoing radical prostatectomy (RP) for prostate cancer (PCa), although it can be associated with morbidity.

OBJECTIVE

To systematically evaluate the impact of PLND extent on perioperative morbidity in patients undergoing RP. A new PLND-related complication assessment tool is proposed.

EVIDENCE ACQUISITION

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) was conducted. MEDLINE/PubMed, Scopus, Embase and Web of Science databases were searched to yield studies discussing perioperative complications following RP and PLND. The extent of PLND was classified according to the European Association of Urology PCa guidelines. Studies were categorized according to the extent of PLND. Intra- and postoperative complications were classified as "strongly," "likely," or "unlikely" related to PLND. Anatomical site of perioperative complications was recorded. A cumulative meta-analysis of comparative studies was conducted using Review Manager 5.3 (Cochrane Collaboration, Oxford, UK).

EVIDENCE SYNTHESIS

Our search generated 3645 papers, with 176 studies meeting the inclusion criteria. Details of 77 303 patients were analyzed. Of these studies, 84 (47.7%), combining data on 28 428 patients, described intraoperative complications as an outcome of interest. Overall, 534 (1.8%) patients reported one or more intraoperative complications. Postoperative complications were reported in 151 (85.7%) studies, combining data on 73 629 patients. Overall, 10 401 (14.1%) patients reported one or more postoperative complication. The most reported postoperative complication strongly related to PLND was lymphocele (90.6%). The pooled meta-analysis revealed that RP + limited PLND/standard PLND had a significantly decreased risk of experiencing any intraoperative complication (risk ratio [RR]: 0.55; p =  0.01) and postoperative complication strongly related to PLND (RR: 0.46; p =  <0.00001), particularly for lymphocele formation (RR: 0.52; p =  0.0003) and thromboembolic events (RR: 0.59; p =  0.008), when compared with extended/superextended PLND. The extent of PLND was confirmed to be an independent predictor of lymphocele formation (RR: 1.77; p <  0.00001).

CONCLUSIONS

The perioperative morbidity of PLND in patients undergoing RP and PLND for PCa significantly correlates with the extent of PLND. More standardized reporting of intra- and postoperative complications is needed to better estimate the direct impact of PLND extent on perioperative morbidity.

PATIENT SUMMARY

Pelvic lymph node dissection (PLND) is the most accurate method for staging in patients undergoing radical prostatectomy for prostate cancer, although it can be associated with complications. This study aims to systematically evaluate the impact of PLND extent on perioperative complications in these patients. We found that intra- and postoperative complications correlate significantly with the extent of PLND. A more rigorous assessment and thorough reporting of perioperative complications are recommended.

Hospital readmissions after limited vs. extended lymph node dissection during open and robot-assisted radical prostatectomy

PURPOSE

Differences exist concerning when and how to perform lymph node dissection (LND) during radical prostatectomy due to lack of high-grade evidence to its safety and efficacy. We aimed to compare readmission rates between limited and extended LND during open radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP).

MATERIALS AND METHODS

We conducted a prospective trial of 3,706 eligible patients comparing ORP vs. RARP (LAPPRO). Six hundred and twenty-seven underwent concomitant LND. Data were retrieved for readmissions within 90 days from surgery from the Swedish Patient Registry. Causes for readmissions were classified according to the modified Clavien-Dindo classification system. We estimated risks for readmission stratified by type of LND and surgical approach.

RESULTS

We recorded 107 readmissions in 90 patients. The overall readmission rate was 14% (90/627). In the open group, extended LND had a higher, but not statistically significant readmission rate of 18% compared to 11% after limited LND (95%CI 0.87-3.01). In the robot-assisted group, readmissions after extended LND did not differ from limited LND (15% vs. 18%, 95%CI 0.49-1.61). RARP with limited LND showed a higher risk for any (RR 1.98, 95%CI [1.02-3.81]) as well as Clavien-Dindo grade 1 to 2 readmissions (RR 2.49, 95%CI [1.10-5.63]) compared to open approach with limited LND. Robot-assisted extended LND reduced the risk for Clavien-Dindo grade 3 to 5 complications leading to readmissions compared to the open approach by 59% (RR 0.41, 95%CI [0.19-0.87]).

CONCLUSIONS

The risk for hospital readmission was similar when performing limited or extended LND during a radical prostatectomy. Robot-assisted technique for performing extended LND may decrease the risk for severe complications.

Difference in Frequency and Distribution of Nodal Metastases Between Intermediate and High Risk Prostate Cancer Patients: Results of a Superextended Pelvic Lymph Node Dissection

Objectives: To evaluate the frequency and distribution of pelvic nodes metastases, in intermediate-high risk prostate cancer (PCa) patients (pts), who underwent open radical prostatectomy (ORP) and superextended pelvic lymph node dissection (sePLND). Patients and Methods: We retrospectively evaluated 630 consecutive pts with clinically localized, intermediate-high risk PCa, treated with ORP and sePLND from 2009 to 2016 at a single institution. The sePLND always removed all nodal/fibro-fatty tissue of the internal iliac, external iliac, obturator, common iliac, and presacral regions. Results: Positive lymph nodes (LN+) were found in 133 pts (21.1%). The median number of removed nodes and LN+ was 25 and 1, respectively. LN+ were found in 64 (48.1%), 58 (43.6%), 53 (39.8%), 16 (12%), and 20 (15%) pts and were present as a single site in 27 (20.3%), 22 (16.5%), 20 (15%), 0, and 6 (4.5%) cases in the internal iliac, external iliac, obturator, common iliac, and presacral chain, respectively. An ePLND would have correctly staged 127 (95%) pts but removed all LN+ in only 97 (73%) pts. Presacral nodes harbored LN+ in 20 patients. Among them, 18 were high-risk patients. Moreover, all but 1 pts with common iliac LN+ were in high risk group. Conclusions: These results suggest that removal of presacral and common iliac nodes could be omitted in intermediate risk pts. However, a PLND limited to external iliac, obturator, and internal iliac region may be adequate for nodal staging purpose, but not enough accurate if we aim to remove all possible site of LN+ in high risk pts.

Robot-assisted extended lymphadenectomy in prostate cancer

INTRODUCTION

The extent of lymph node dissection (LND) and its potential survival benefit are still a matter of debate. Aim of our review was to summarize the latest literature data regarding the surgical templates, the potential oncological benefits, the functional outcomes and the complications of extended lymph node dissection (eLND) during robot-assisted radical prostatectomy (RARP).

EVIDENCE ACQUISITION

We systematically reviewed all relevant studies using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) guidelines.

EVIDENCE SYNTHESIS

A narrative synthesis of all relevant publications on surgical templates, complications, oncological and functional outcomes of robot assisted eLND was undertaken.

CONCLUSIONS

A great deal of evidence supports that an extended template of LND is not only technically feasible but also safe in the context of RARP. It is really promising that in the era of minimally invasive surgery, parameters like the lymph node yield and the detection rates of positive lymph nodes during LND have become highly comparable with open series. The extended approach has already proved its benefits in terms of proper patient staging but more studies are needed with regard to functional outcomes and oncological benefits of this procedure.

The Benefits and Harms of Different Extents of Lymph Node Dissection During Radical Prostatectomy for Prostate Cancer: A Systematic Review

CONTEXT

There is controversy regarding the therapeutic role of pelvic lymph node dissection (PLND) in patients undergoing radical prostatectomy for prostate cancer (PCa).

OBJECTIVE

To systematically review the relevant literature assessing the relative benefits and harms of PLND for oncological and non-oncological outcomes in patients undergoing radical prostatectomy for PCa.

EVIDENCE ACQUISITION

MEDLINE, MEDLINE In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched up to December 2015. Comparative studies evaluating no PLND, limited, standard, and (super)-extended PLND that reported oncological and non-oncological outcomes were included. Risk-of-bias and confounding assessments were performed. A narrative synthesis was undertaken.

EVIDENCE SYNTHESIS

Overall, 66 studies recruiting a total of 275,269 patients were included (44 full-text articles and 22 conference abstracts). Oncological outcomes were addressed by 29 studies, one of which was a randomized clinical trial (RCT). Non-oncological outcomes were addressed by 43 studies, three of which were RCTs. There were high risks of bias and confounding in most studies. Conflicting results emerged when comparing biochemical and clinical recurrence, while no significant differences were observed among groups for survival. Conversely, the majority of studies showed that the more extensive the PLND, the greater the adverse outcomes in terms of operating time, blood loss, length of stay, and postoperative complications. No significant differences were observed in terms of urinary continence and erectile function recovery.

CONCLUSIONS

Although representing the most accurate staging procedure, PLND and its extension are associated with worse intraoperative and perioperative outcomes, whereas a direct therapeutic effect is still not evident from the current literature. The current poor quality of evidence indicates the need for robust and adequately powered clinical trials.

PATIENT SUMMARY

Based on a comprehensive review of the literature, this article summarizes the benefits and harms of removing lymph nodes during surgery to remove the prostate because of PCa. Although the quality of the data from the studies was poor, the review suggests that lymph node removal may not have any direct benefit on cancer outcomes and may instead result in more complications. Nevertheless, the procedure remains justified because it enables accurate assessment of cancer spread.

Diagnostic yield and complications of extended lymphadenectomy versus limited lymphadenectomy combined with radical prostatectomy

BACKGROUND

Lymphadenectomy for prostate cancer (PC) is the most reliable procedure for detecting lymphatic metastases. The optimal extension of this procedure is still a topic of debate.

OBJECTIVE

To analyse the diagnostic performance and complications of extended lymphadenectomy (ELD) and limited lymphadenectomy (LLD) in a series of patients with high-risk PC who underwent radical prostatectomy (RP).

MATERIAL AND METHODS

A retrospective study was conducted on patients with high d'Amico risk who underwent RP with lymphadenectomy between 1999 and 2014. A comparative analysis was performed of the diagnostic capacity of lymphatic metastases of ELD and LLD and of postoperative complications at 90 days.

RESULTS

Ninety-three patients were analysed, 20 (21.5%) and 73 (78.5%) of whom underwent ELD and LLD, respectively. The mean age of the series was 65.26 years (SD, 5.51). The median follow-up was 1.51 (0.61-2.29) years in the ELD group and 5.94 (3.61-9.10) in the LLD group. The median number of nodes obtained was 13 (9-23) in the ELD group compared with 5 (2-8) in the LLD group (p <.001). The percentages of patients with positive nodes in the ELD and LLD groups were 35% and 5.47%, respectively (p <.001). The overall complication rate at 90 days was 35.5% (33 patients). In the ELD group, 12 patients (60%) had complications, compared with 21 patients (28.8%) in the LLD group (p=.016), with no significant differences in severity according to the Clavien scale (p=.73).

CONCLUSIONS

In our series, the detection of metastatic nodes was significantly greater with ELD. ELD increases the number of complications, with no differences compared with LLD in severity according to the modified Clavien scale.

Predictive factors for lymph node positivity in patients undergoing extended pelvic lymphadenectomy during robot assisted radical prostatectomy

Introduction:

Pelvic lymphadenectomy during radical prostatectomy (RP) improves staging and may provide a therapeutic benefit. However, there is no clear consensus on the selection criteria for subjecting patients to this additional procedure. With a growing adoption of robot assisted radical prostatectomy (RARP) in India, it has become imperative to study the incidence and predictive factors for lymph node involvement in our patients.

Materials and Methods:

From February 2010 to February 2014, 452 RARP procedures were performed at our institution. A total of 100 consecutive patients from July 2011 to August 2012 were additionally subjected to a robotic extended pelvic lymphadenectomy (EPLND). Lymph node positivity rates and lymph node density were analyzed on the basis of preoperative prostate specific antigen (PSA), Gleason score, clinical stage, D’Amico risk category and magnetic resonance imaging (MRI) findings. Multivariate analysis was performed to ascertain factors associated with lymph node positivity in our cohort.

Results:

The mean age of the patients was 65.5 (47–77) years and the body mass index was 26.3 (16.3–38.7) kg/m². The mean console time for EPLND was 45 (32–68) min. A median of 17 (two to 40) lymph nodes were retrieved. Seventeen patients (17%) had positive lymph nodes (median of 1, range 1–6). Median lymph node density in these patients was 10%. When stratified by PSA, Gleason score, clinical stage, D’Amico risk category and features of locally advanced disease on MRI, a trend towards increasing incidence of lymph node positivity was observed, with an increase in adverse factors. However, on multivariate analysis, clinical stage > T2a was the only significant factor impacting lymph node positivity in our cohort.

Conclusions:

A significant proportion of men undergoing RARP in India have positive lymph nodes on EPLND. While other variables may also have a potential impact, a higher clinical stage predisposes to an increased incidence of lymph node metastases.

Thromboembolic complications in 3,544 patients undergoing radical prostatectomy with or without lymph node dissection

PURPOSE

Lymph node dissection in patients with prostate cancer may increase complications. An association of lymph node dissection with thromboembolic events was suggested. We compared the incidence and investigated predictors of deep venous thrombosis and pulmonary embolism among other complications in patients who did or did not undergo lymph node dissection during open and robot-assisted laparoscopic radical prostatectomy.

MATERIALS AND METHODS

Included in study were 3,544 patients between 2008 and 2011. The cohort was derived from LAPPRO, a multicenter, prospective, controlled trial. Data on adverse events were extracted from patient completed questionnaires. Our primary study outcome was the prevalence of deep venous thrombosis and/or pulmonary embolism. Secondary outcomes were other types of 90-day adverse events and causes of hospital readmission.

RESULTS

Lymph node dissection was performed in 547 patients (15.4%). It was associated with eightfold and sixfold greater risk of deep venous thrombosis and pulmonary embolism events compared to that in patients without lymph node dissection (RR 7.80, 95% CI 3.51-17.32 and 6.29, 95% CI 2.11-18.73, respectively). Factors predictive of thromboembolic events included a history of thrombosis, pT4 stage and Gleason score 8 or greater. Open radical prostatectomy and lymph node dissection carried a higher risk of deep venous thrombosis and/or pulmonary embolism than robot-assisted laparoscopic radical prostatectomy (RR 12.67, 95% CI 5.05-31.77 vs 7.52, 95% CI 2.84-19.88). In patients without lymph node dissection open radical prostatectomy increased the thromboembolic risk 3.8-fold (95% CI 1.42-9.99) compared to robot-assisted laparoscopic radical prostatectomy. Lymph node dissection induced more wound, respiratory, cardiovascular and neuromusculoskeletal events. It also caused more readmissions than no lymph node dissection (14.6% vs 6.3%).

CONCLUSIONS

Among other adverse events we found that lymph node dissection during radical prostatectomy increased the incidence of deep venous thrombosis and pulmonary embolism. Open surgery increased the risks more than robot-assisted surgery. This was most prominent in patients who were not treated with lymph node dissection.

Surgical management of prostate cancer

Surgery remains a mainstay in the management of localized prostate cancer. This article addresses surgical aspects germane to the management of men with prostate cancer, including patient selection for surgery, nerve-sparing approaches, minimization of positive surgical margins, and indications for pelvic lymph node dissection. Outcomes for men with high-risk prostate cancer following surgery are reviewed, and the present role of neoadjuvant therapy before radical prostatectomy is discussed. In addition, there is a review of the published literature on surgical ablative therapies for prostate cancer.

Implications of laparoscopic inguinal hernia repair on open, laparoscopic, and robotic radical prostatectomy

Purpose:

There have been anecdotal reports of surgeons having to abandon radical prostatectomy (RP) after laparoscopic inguinal hernia repair (LIHR) due to obliteration of tissue planes by mesh. Nodal dissection may also be compromised. We prospectively collected data from four experienced prostate surgeons from separate institutions. Our objective was to evaluate the success rate of performing open RP (ORP), laparoscopic RP (LRP) and robotic assisted RP (RALRP) and pelvic lymph node dissection (PLND) after LIHR, and the frequency of complications.

Methods:

A retrospective analysis of prospectively maintained databases of men who underwent RP after LIHR between 2004 and 2010 at four institutions was undertaken. The data recorded included age, preoperative prostate-specific antigen, preoperative Gleason score, and clinical stage. The operative approach, success or failure to perform RP, success or failure to perform PLND, pathological stage, and complications were also recorded.

Results:

A total of 1,181 men underwent RP between 2004 and 2010. Fifty-seven patients (4.8%) underwent RP after LIHR. An ORP was attempted in 19 patients, LRP in 33, and RALRP in 5. All 57 cases were able to be successfully completed. Ten of the 18 open PLND were able to be completed (55.6%). Four of the 22 laparoscopic LND were able to be completed (18.2%). Robotic LND was possible in 5 of 5 cases (100%). Therefore, it was not possible to complete a LND 56.8% of patients. Complications were limited to ten patients. These complications included one LRP converted to ORP due to failure to progress, and one rectourethral fistula in a salvage procedure post failed high intensity focused ultrasound.

Conclusions:

LIHR is an increasingly common method of treating inguinal hernias. LIHR is not a contra-indication to RP. However PLND may not be possible in over 50% of patients who have had LIHR. Therefore, these patients may be under-staged and under treated.

Is there a relationship between the number of lymph nodes and disease parameters in patients who underwent retropubic prostatectomy

PURPOSE

We aimed to establish the relationship between lymph nodes (LNs) counts that were removed with standard pelvic lymph node dissection (sPLND) and different disease parameters in patients who underwent radical prostatectomy (RP).

MATERIALS AND METHODS

A total of 70 patients who underwent sPLND during RP were scanned retrospectively. The scanned parameters were levels of serum PSA, the total weight of the removed prostate, the amount as a percentage of the tumor in the prostate tissue, the stage of the tumor, the total Gleason score (GS) and the number of standard pelvic lymph nodes that were removed from both right and left sides.

RESULTS

The average age of the patients was 59 years. A positive correlation was found between the total GS and the number of lymph nodes; while this correlation was significant (p = 0.0038), there was no significant difference between lymph nodes counts and other scanned parameters. The average pelvic lymph node numbers of patients with GS of 6-7 and 8 were 10.4-11.5 and 13.2, respectively. Lymph nodes metastases were found in 3 (4.2 %) patients whose average pelvic lymph node number was 17.3.

CONCLUSION

The chance of cure or decreased recurrence is much more possible in patients who had received extended PLND or at least standard one, because of the removal of much more lymph node tissues that have a high probability of disseminating cancer cells. This position can especially be considered in patients with high GS.

[Comparison of ventral and dorsal lymph node metastases of obturator nerve in radical prostatectomy]

OBJECTIVE

In this study, we assessed the significance of complete dissection of the dorsal lymph node of the obturator nerve during radical prostatectomy.

PATIENTS AND METHODS

Fifty-six patients undergoing open radical prostatectomy and pelvic lymph node dissection for treatment of prostate cancer were included in this study. Neoadjuvant hormonal therapy and radiation therapy were not performed in any of the patients. First, pelvic lymph node dissection was performed between the external iliac vein and obturator nerve and classified as "ventral lymph node of the obturator nerve". Then, the tissue located in the area between the obturator nerve and the surface of the obturator internus muscle was removed and classified as "dorsal lymph node of the obturator nerve". Both lymph nodes were meticulously examined by identical pathologist. Lymph node yields, lymph node positive rate, and the factors associated with lymph node metastasis were studied.

RESULTS

Eight of the 56 patients had pelvic lymph node metastases (6 were high risk and 2 were intermediate risk according to the D'Amico's criteria). In the 8 node-positive patients, only 1 patient had positive lymph node in "ventral lymph node of the obturator nerve" exclusively. Four patients had positive lymph node exclusively in "dorsal lymph node of the obturator nerve" and 3 patients had in both "ventral and dorsal lymph nodes of the obturator nerve". The total lymph node yields from "ventral lymph node of the obturator nerve" and "dorsal lymph node of the obturator nerve" were 459 (8.2 per patient) and 117 (2.1 per patient), respectively. The total numbers of positive lymph nodes from "ventral lymph node of the obturator nerve" and "dorsal lymph node of the obturator nerve" were 6 and 12, respectively. Lymph node positive rate was significantly higher in "dorsal lymph node of the obturator nerve" (10%) than "ventral lymph node of the obturator nerve" (1.3%) (P < 0.0001). The level of prostate-specific antigen (> or = 20 ng ml), Gleason score sum at prostate biopsy (> or = 9), and lymph node yield (> or = 16) were associated with lymph node status on univariate analysis. In multivariate analysis, only lymph node yield was associated with lymph node status.

CONCLUSIONS

Dorsal lymph nodes of the obturator nerve should be dissected completely during radical prostatectomy.

Long-term outcomes of patients with lymph node metastasis treated with radical prostatectomy without adjuvant androgen-deprivation therapy

BACKGROUND

The presence of lymph node metastasis (LNM) at radical prostatectomy (RP) is associated with poor outcome, and optimal treatment remains undefined. An understanding of the natural history of node-positive prostate cancer (PCa) and identifying prognostic factors is needed.

OBJECTIVE

To assess outcomes for patients with LNM treated with RP and lymph node dissection (LND) alone.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed data from a consecutive cohort of 369 men with LNM treated at a single institution from 1988 to 2010.

INTERVENTION

RP and extended LND.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Our primary aim was to model overall survival, PCa-specific survival, metastasis-free progression, and freedom from biochemical recurrence (BCR). We used univariate Cox proportional hazard regression models for survival outcomes. Multivariable Cox proportional hazard regression models were used for freedom from metastasis and freedom from BCR, with prostate-specific antigen, Gleason score, extraprostatic extension, seminal vesical invasion, surgical margin status, and number of positive nodes as predictors.

RESULTS AND LIMITATIONS

Sixty-four patients with LNM died, 37 from disease. Seventy patients developed metastasis, and 201 experienced BCR. The predicted 10-yr overall survival and cancer-specific survival were 60% (95% confidence interval [CI], 49-69) and 72% (95% CI, 61-80), respectively. The 10-yr probability of freedom from distant metastasis and freedom from BCR were 65% (95% CI, 56-73) and 28% (95% CI, 21-36), respectively. Higher pathologic Gleason score (>7 compared with ≤ 7; hazard ratio [HR]: 2.23; 95% CI, 1.64-3.04; p < 0.0001) and three or more positive lymph nodes (HR: 2.61; 95% CI, 1.81-3.76; p < 0.0001) were significantly associated with increased risk of BCR on multivariable analysis. The retrospective nature and single-center source of data are study limitations.

CONCLUSIONS

A considerable subset of men with LNM remained free of disease 10 yr after RP and extended LND alone. Patients with pathologic Gleason score <8 and low nodal metastatic burden represent a favorable group. Our data confirm prior findings and support a plea for risk subclassification for patients with LNM.

Pelvic lymph node dissection during robot-assisted radical prostatectomy: efficacy, limitations, and complications-a systematic review of the literature

CONTEXT

Pelvic lymph node dissection (PLND) in prostate cancer is the most effective method for detecting lymph node metastases. However, a decline in the rate of PLND during radical prostatectomy (RP) has been noted. This is likely the result of prostate cancer stage migration in the prostate-specific antigen-screening era, and the introduction of minimally invasive approaches such as robot-assisted radical prostatectomy (RARP).

OBJECTIVE

To assess the efficacy, limitations, and complications of PLND during RARP.

EVIDENCE ACQUISITION

A review of the literature was performed using the Medline, Scopus, and Web of Science databases with no restriction of language from January 1990 to December 2012. The literature search used the following terms: prostate cancer, radical prostatectomy, robot-assisted, and lymph node dissection.

EVIDENCE SYNTHESIS

The median value of nodal yield at PLND during RARP ranged from 3 to 24 nodes. As seen in open and laparoscopic RP series, the lymph node positivity rate increased with the extent of dissection during RARP. Overall, PLND-only related complications are rare. The most frequent complication after PLND is symptomatic pelvic lymphocele, with occurrence ranging from 0% to 8% of cases. The rate of PLND-associated grade 3-4 complications ranged from 0% to 5%. PLND is associated with increased operative time. Available data suggest equivalence of PLND between RARP and other surgical approaches in terms of nodal yield, node positivity, and intraoperative and postoperative complications.

CONCLUSIONS

PLND during RARP can be performed effectively and safely. The overall number of nodes removed, the likelihood of node positivity, and the types and rates of complications of PLND are similar to pure laparoscopic and open retropubic procedures.