Editorial Comment

Abstract

In a provocative article of data culled from the Surveillance, Epidemiology, and End Results (SEER) database, 68% of Medicare patients undergoing radical prostatectomy (RP) from 2003 to 2005 underwent pelvic lymph node dissection (PLND). The major finding was that the rates varied by surgical approach (only 17% for minimally invasive RP compared with 83% for open RP). Other risk factors for the nonperformance of PLND were low-volume surgeons and older men with multiple comorbidities. High-volume surgeons performed PLND more frequently than did low-volume surgeons; however, even high-volume surgeons using minimal invasive approaches performed PLND in only 28% of their patients. The reasons suggested for this discrepancy in performing PLND during an era in which minimal invasive procedures blossomed were that surgeons were learning new approaches and wished to shorten the operating times, reduce complications, and lessen costs. Another overriding factor suggested was that most patients undergoing surgery in the present era have low-risk cancer predicted to have a low rate of nodal metastases, persuading many surgeons to adopt the attitude that PLND is simply unnecessary. The issues raised by this disturbing report made me pause and ponder how we think about and treat our patients with prostate cancer. Variations in Surgeon Volume and Use of Pelvic Lymph Node Dissection with Open and Minimally Invasive Radical ProstatectomyUrologyVol. 72Issue 3PreviewAlthough pelvic lymph node dissection (PLND) during radical prostatectomy (RP) improves staging, controversy remains concerning its indications and benefits on cancer control. We examined the factors associated with PLND use among men undergoing open RP (ORP) and minimally invasive RP (MIRP). Full-Text PDF ReplyUrologyVol. 72Issue 3PreviewWe appreciate Dr. Herr's thoughtful comments and agree that the striking disparity in the use of PLND during MIRP vs ORP is provocative. Furthermore, we agree that for high-risk patients undergoing RP, PLND is appropriate. Subsequent staging of prostate cancer may guide follow-up therapy, because immediate antiandrogen therapy for patients with lymph node metastases has been shown to affect survival.1 However, the appropriate role of PLND during RP in the prostate-specific antigen era, particularly for low-risk disease, independent of surgical approach, remains controversial. Full-Text PDF