Comparison of semi-extended and standard lymph node dissection in radical prostatectomy: A single-institute experience

Abstract

Standard lymphadenectomy for prostate cancer is limited to the obturator lymph nodes (LNs), although the internal and external iliac LNs represent the primary landing zone for prostatic lymphatic drainage. We performed anatomically semi-extended pelvic lymph node dissection (PLND) to assess the incidence of LN metastasis in cases of clinically localized prostate cancer. A total of 730 consecutive patients underwent radical prostatectomy with either semi-extended PLND, comprising 6 selective fields, namely the external iliac, internal iliac and obturator LNs bilaterally, or standard LND (obturator LNs alone). A total of 131 patients undergoing semi-extended PLND were compared with 599 patients undergoing standard LND. The patients were stratified into high-risk [prostate-specific antigen (PSA)>20 ng/ml, Gleason score (GS)≥8], intermediate-risk (PSA 10-20 ng/ml, GS=4+3) and low-risk (PSA<10 ng/ml, GS≤3+4) subgroups. Following semi-extended LND, positive LNs were detected in 12/61 (20%) of the high-risk, 1/30 (3%) of the intermediate-risk and 0/40 (0%) of the low-risk cases. Following standard LND, positive LNs were detected in 13/182 (7%) of the high-risk, 1/164 (0.6%) of the intermediate-risk and 0/253 (0%) of the low-risk cases. In high-risk patients, the detection rate of LN metastasis was significantly higher following extended LND compared with standard LND (P<0.01). In 9 of 13 patients (69%), metastases were identified in the internal and external iliac regions, despite negative obturator LNs. There were no significant differences regarding intraoperative and postoperative complications or blood loss in the two groups. There was no lymphocele formation in patients undergoing either standard or semi-extended LND. Extended pelvic LND (PLND) is associated with a high rate of LN metastasis detection outside the fields of standard LND in cases with clinically localized prostate cancer. Therefore, LND including the internal and external iliac LNs should be performed in all patients with high-risk prostate cancer; however, in the low-risk group, PLND may be omitted.

The benefits and harms of different extents of lymph node dissection during radical prostatectomy for prostate cancer: A systematic review

“…Similarly, the rate of lymphocele was significantly higher in the ePLND group in four studies [40,70,73,74], while no significant differences were observed in four others [42,64,66,67].…”

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

“…When considering data from 15 retrospective studies, conflicting results were observed. Five studies showed significantly higher intra-operative and post-operative complications in the ePLND group compared with lPLND / sPLND [14,40,[70][71][72], while five studies did not show any statistically significant differences [42,64,[66][67][68].…”

Head-to-Head Comparison of Two Nomograms Predicting Probability of Lymph Node Invasion in Prostate Cancer and the Therapeutic Impact of Higher Nomogram Threshold

“…The characteristics of the 807 patients are listed in the Table 1 . The median (interquartile) number of removed lymph nodes was 7 [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 ]. The overall rate of LNI in the entire cohort was 12% (97/807).…”

“…PLND represents the important staging procedure in identifying patients with lymph node invasion (LNI); therefore, it is related to poor prognosis after RP. The rate of LNI increases linearly with the number of removed LN, which is why more extended pelvic lymph node dissection (ePLND) is recommended [ 4 ]. However, ePLND is associated with increased morbidity, longer operating time and higher costs; for these reasons, it should be done with high precaution [ 5 ].…”