The underestimated posterior lymphatic drainage of the prostate: An historical overview and preliminary anatomical study on cadaver

Abstract

BackgroundThe evidence of pelvic lymph node metastases after radical prostatectomy (RP) with pelvic lymph node dissection (PLND) is one of the strongest prognostic factors for poor oncologic outcome. The extent of PLND, although representing a crucial step in RP, is still controversial. Currently, there is a critical drawback in clinical practice due to the lack of congruence between the known lymphatic drainage and cancer dissemination despite defined management by a surgical approach. We hypothesized the existence of alternative pathways for the lymphatic drainage of the prostate currently not considered in clinical daily practice.MethodsWe carried out a literature review of the anatomic description of nodal drainage of prostate reported by online databases (MEDLINE/PubMed, EBSCO, Web of Science, Ovid, and Scopus) and the original texts since the 18th century, with an additional anatomical dissection on a human cadaver to confirm theoretical data.ResultsThe anatomical dissection study converged with the historical anatomical treatises in describing three groups of lymphatics devoted to carrying out prostatic nodal drainage. Apart from the ascending ducts from the cranial gland leading to the external iliac nodes; the lateral ducts leading to the hypogastric nodes; small lymphatic vessels from the posterior surface of the prostate, directed to the pararectal lymphatic plexus, in the direction of the lateral sacral lymph nodes and those at the sacral promontory (ie, pararectal and presacral lymph nodes) were observed.ConclusionsOur preliminary findings demonstrate that lymphatic drainage of the prostate extends beyond standard nodal templates actually considered in surgical daily practice, despite the knowledge reported by historical anatomical treatises. Further anatomical and experimental evidence are needed to investigate anatomical variability in humans, as well as to add more topographical details.

M1a prostate cancer: Results of a Dutch multidisciplinary consensus meeting

“…Based on TNM, inguinal and pararectal LNs should be considered as M1a and N1 disease, respectively 1 . This is also confirmed by studies investigating the pattern of lymphatic drainage of the prostate 20,21 . Adequately defining the extent of nodal disease is critical for correct completion of registries.…”

“…1 This is also confirmed by studies investigating the pattern of lymphatic drainage of the prostate. 20 , 21 Adequately defining the extent of nodal disease is critical for correct completion of registries.…”

68Ga-PSMA ligand PET/CT integrating indocyanine green-guided salvage lymph node dissection for lymph node metastasis after radical prostatectomy

“… 22 Boscolo-Berto et al . 12 reviewed the literature and experimentally dissected a human corpse with prostatic lymphatic drainage. Based on their study, there is a pararectal lymphatic plexus relating to the prostate in the direction of the lateral sacral lymph nodes, finally arriving at the common iliac and aortic lymphatic plexuses.…”

“…Moreover, Boscolo-Berto et al . 12 described that apart from the ascending ducts from the cranial gland leading to the external iliac nodes and the lateral ducts leading to the hypogastric nodes, lymphatic ducts from the posterior surface of the prostate were directed to the pararectal lymphatic plexus, leading to the lymphatic network around the common iliac artery and aorta. Notably, we previously performed a comparative study between ePLND and ICG-guided PLND and confirmed that ICG-guided PLND was able to provide a two-year metastasis-free survival rate of 100%, whereas conventional ePLND was able to provide a rate of 86%.…”

Predictors of complications occurring after open and robot-assisted prostate cancer surgery: a retrospective evaluation of 1062 consecutive patients treated in a tertiary referral high volume center

“…When PLND is performed during RP, especially when an extended template is adopted, complications may occur not only because of uncontrolled clamping of the lymphatic vessels but also because of small bleeding vessels originating from the muscular pelvic wall of the obturator fossa. Anatomic human variability of the vessels and the lymphatic pelvic system is also a factor that should considered during ePLND, as shown by anatomical studies investigating this subject [ 28 ]. As such, an ePLND may result in complicated lymphoceles or pelvic hematomas requiring subsequent invasive procedures.…”