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

Abstract

Context. Controversy exists regarding the therapeutic role of pelvic lymph node dissection (PLND) in patients undergoing radical prostatectomy for prostate cancer. Objective. To systematically review the relevant literature assessing the relative benefits and harms of PLND on oncological and non-oncological outcomes in patients undergoing radical prostatectomy for prostate cancer. 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 and reporting on 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 across 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. Conclusion. Although representing the most accurate staging procedure, PLND and its extension are associated with worse intra-operative and peri-operative 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 summarises the benefits and harms of removing lymph nodes during surgery to remove the prostate for cancer. Although the quality of the data from studies was poor, the review suggests lymph node removal may not have any direct benefit on cancer outcomes and may instead result in more complications. Nevertheless, the procedure is still justified because it enables accurate assessment of cancer spread.

Gleason grade patterns in nodal metastasis and corresponding prostatectomy specimens: impact on patient outcome

“…The limitations of this study include its retrospective nature and the use of material from only two institutions. The extent of nodal dissection has been demonstrated to impact the final pN status; [34][35][36] however, it was unclear from some operative reports whether a standard or extended pelvic node dissection had been performed, thus this variable could not be assessed in this study. The length of clinical follow-up (median 60 months) is also reasonably short when considering cancer-specific survival as an endpoint.…”

Retzius‐sparing robot‐assisted radical prostatectomy using the Revo‐i robotic surgical system: surgical technique and results of the first human trial

“…We fully discussed this issue with patients before surgery and informed them that surgery might miss some microscopic nodal involvement, if present, and that they would need very strict follow-up to detect early BCR and/or local recurrence that would be treated with adjuvant therapy. Interestingly, a recent systematic review did not show additional benefit of performing any type of PLND during radical prostatectomy for any oncological outcomes including BCR and survival [18]; however, PLND may be curative for certain patients with limited lymph node involvement that is completely removed at the time of surgery (direct effect) or may represent an accurate tool for identification of patients with pN1 disease, who might benefit from early adjuvant treatments that improve survival outcomes (indirect effect) [18].…”

Declining use of radical prostatectomy and pelvic lymphadenectomy despite more robotics: National population data over 15 years

“…Indeed, PLND was performed on protocol during a Queensland-based randomized trial of open RP versus RALP in 36% (PLND:noPLND ratio 0.57) of cases (positive in 3% overall) among a contemporary cohort (61% organ confined disease) with a higher lymph node yield observed in favor of RALP 21. Thus, we conclude that significant factors contributing to the reduced use PLND may include surgeon preference, the introduction of laparoscopic RP and RALP to Australian urological practice in the early 2000s, the absence of consensus on which patients should undergo PLND at time of RP 23 and the uncertainty regarding the long-term oncological benefit of a PLND in the majority of men 9.…”

“…9,10 A recent systematic review did not show any oncologic benefit of performing any PLND during RP at the expense of longer operating times, more blood loss, increased length of stay and postoperative complications. 9 Limited descriptions of patterns of PCa care in Australia have been described to date. [5][6][7][8]11 Detailed considerations of surgical patterns of care, specifically relating to age groups treated, geographic locations of treatment and use of PLND, as well as the uptake of robotic-assisted laparoscopic prostatectomy (RALP), are yet to be described.…”