Editorial Comment to Contemporary minimally‐invasive extended pelvic lymph node dissection for prostate cancer before curative radiotherapy: Prospective standardized analysis of complications

Abstract

Editorial Comment to Contemporary minimally-invasive extended pelvic lymph node dissection for prostate cancer before curative radiotherapy: Prospective standardized analysis of complicationsAlthough there are many controversies regarding the current role of pelvic lymph node dissection (PLND) for prostate cancer (PCa), there is clear evidence that a well carried out extended PLND is the most reliable means of detecting lymph node invasion (LNI), and thus providing accuracy in staging PCa. (RT). A total of 45 patients (31%) were found to have LNI out of a total of 154 patients that were prospectively included in both arms of the study.2 Thus, more than two-thirds of the study population (69%) safely avoided potential overtreatment and the subsequent side-effects accompanying whole pelvis RT. In contrast, as mentioned in the manuscript, complications were noted in both arms, whereas the additional cost and the physiological stress of surgery for the patient should be considered, especially when in some cases surgery could have achieved definitive therapy.As far as the lymphoceles are concerned, there was no difference in formation of symptomatic and large lymphoceles between groups, leading the authors to conclude that MI-PLND was associated with increased development of small (<40 mL) asymptomatic lymphoceles. Although, extended PLND was carried out in 33% and 95% of open and minimally-invasive cases, respectively, in multivariate regression analysis MI-PLND remained an independent risk factor for lymphocele development. As mentioned by the authors, one of the limitations of their study was the fact that MI-PLND and O-PLND were carried out by different surgeons, which by itself could explain the difference in lymphocele development. Furthermore, one could easily assume that as both surgeons in the MI-PLND arm were in their learning curve and as PLND is an operation with no reconstruction, it could have served in building up laparoscopic confidence without the burden of extending the operation for definitive therapy.Another key point of the study was the fact that both robotic (n = 14) and laparoscopic (n = 86) PLND were grouped as MI-PLND, with a definite predominance of laparoscopic cases.The ergonomic advantage of the robotic platform combined with the wristed instrumentation offers superior angles of dissection, giving the surgeon the ability to carry out elegant maneuvers and use pinpoint coagulation along the major vessels, which could potentially reduce lymphorrhea.By overcoming the learning curve and including more robotic cases, the study of Van Praet et al. could converge with the findings of the literature.3 It remains to be seen whether one of the future roles of minimally-invasive urology could be to stratify PCa patients for curative radiotherapy and whether the health systems can support such a cost.