Should all men having a radical prostatectomy have a pelvic lymph node dissection? No

Abstract

For decades, pelvic lymph node dissection (PLND) has been performed at the time of radical prostatectomy (RP) as a lymph node (LN) staging procedure in prostate cancer (PCa) patients. However, growing evidence suggests that PLND might not be an accurate tool for predicting lymph node invasion (LNI). Recently, Mattei and colleagues examined the primary prostate lymphatic drainage sites in PCa patients.1 In their report, they defined “limited PLND” as the removal of LNs along the external iliac vein and obturator nerve; they reported that this dissection missed up to 62% of the primary LNs. Similarly, the extended PLND area, which also included LNs medial and lateral to the internal iliac vein, missed up to 37% of the primary LNs. The authors suggested a new “super extended” PLND area, which additionally includes the LNs along the common iliac vessels up to the ureteric crossing. However, the authors found that even this “super extended” PLND missed 25% of the primary LNs.1 Consequently, the authors concluded that the removal of all primary LNs is not feasible in all or even most patients because of cost, time, extent of surgery and risk of complications. It is noteworthy that the complication rate after PLND may be up to 51%;2 the complication rate appears to be associated with increasing the extent of the dissection.3,4 These findings question the usefulness of PLND as a staging procedure in PCa patients. Moreover, these findings indicate the need to develop more accurate and, possibly less invasive, staging tools.