Why all prostate cancer surgery should include an adequate lymph node dissection

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The role of a lymph node dissection in most cancer sites portends a benefit from accurate staging and assignment of adjuvant therapy or, possibly, a direct therapeutic effect by local/regional control. The adequacy of this regional dissection has become an important quality of care indicator (i.e., colon, rectal, testes and bladder). The adoption of recommendations to limit lymphadenectomy in other sites has generally followed prospective studies (i.e., uterine) or established predictive tools (i.e., sentinel biopsy in melanoma, breast cancer). This issue is controversial for prostate cancer management given the lack of prospective data and ambiguous retrospective studies1 and is illustrated in the variation in our clinical practice guidelines (Table 1).2–5 Table 1. Overview of clinical practice guidelines on prostate cancer management Coincident with the decrease of lymph node involvement (LNI) in most prostatectomy series6,7 there has been remarkable decline in pelvic lymph node dissection (PLND) for low-risk disease,8 although this trend may be less apparent in Canada.9 A risk-adapted approach to PLND remains controversial; it has been suggested that other complicating elements are involved in its decline, including changes in surgical approach as well as reimbursement issues.10 But what is the evidence to abandon this concept of regional control for prostate cancer in patients with perceived low-risk disease? Without prospective randomized data the argument to omit PLND generally revolves around the following three issues: staging, therapeutic benefit and side effects.