Extent Of Pelvic Lymph Node Dissection Research Articles

Comparison of peritoneal interposition flaps and sealants for prevention of lymphocele after robotic radical prostatectomy and pelvic lymph node dissection: a systematic review, meta-analysis, Bayesian network meta-analysis, and meta-regression.

Lymphocele is one of the most common complications after radical prostatectomy. Multiple authors have proposed the use of vessel sealants or peritoneal interposition techniques as preventive interventions. This study aimed to aggregate and analyze the available literature on different interventions which seek to prevent lymphocele through a Bayesian Network. A systematic review was performed to identify prospective studies evaluating strategies for lymphocele prevention after robot assisted laparoscopic prostatectomy + pelvic lymph node dissection. Data was inputted into Review Manager 5.4 for pairwise meta-analysis. Data was then used to build a network in R Studio. These networks were used to model 200,000 Markov Chains via MonteCarlo sampling. The results are expressed as odds ratios (OR) with 95% credible intervals (CrI). Meta-regression was used to determine coefficient of change and adjust for pelvic lymph node dissection extent. Ten studies providing data from 2211 patients were included. 1097 patients received an intervention and 1114 patients served as controls. Interposition with fenestration had the lowest risk of developing a lymphocele (OR 0.14 [0.04, 0.50], p = 0.003). All interventions, except sealants or patches, had significant decreased odds of lymphocele rates. Meta-analysis of all the included studies showed a decreased risk of developing a lymphocele (OR 0.42 [0.33, 0.53], p < 0.00001) for the intervention group. Perivesical fixation and interposition with fenestration appear to be effective interventions for reducing the overall incidence of lymphocele.

The relationship between biochemical recurrence and number of lymph nodes removed during surgery for localized prostate cancer

PurposeTo assess whether completeness of pelvic lymph node dissection (PLND) as measured by lymph node yield reduces biochemical recurrence (BCR) in men undergoing radical prostatectomy (RP) for prostate cancer (PCa), stratified according to Briganti nomogram-derived risk (≥5% vs. < 5%) of lymph node invasion (LNI).MethodsRetrospective study of 3724 men who underwent RP between January 1995 and January 2015 from our prospectively collected institutional database. All men included had minimum five years follow-up and were not given androgen deprivation therapy or radiotherapy prior to BCR. Primary endpoint was time to BCR as defined by PSA > 0.2ng/ml. Patients were analysed according to Briganti Nomogram derived risk of ‘low-risk’ (< 5%) vs. ‘high-risk’ (≥ 5%). Extent of PLND was analysed using number of nodes yielded at dissection as a continuous variable as well as a categorical variable: Group 1 (limited, 1–4 nodes), Group 2 (intermediate, 5–8 nodes) and Group 3(extensive, ≥9 nodes).ResultsMedian follow-up in the overall cohort was 79.7 months and 65% of the total cohort underwent PLND. There were 2402 patients with Briganti risk of LNI < 5% and 1322 with a Briganti risk of LNI ≥5%. At multivariate analysis, only PSA (HR1.01, p < 0.001), extracapsular extension at RP (HR 1.86, p < 0.001), positive surgical margin (HR 1.61, p < 0.001) and positive lymph node on pathology (HR 1.52, p = 0.02) were independently associated with BCR. In the high-risk group, increased nodal yield at PLND was associated with reduction in risk of BCR (HR 0.97, 95%CI 0.95-1.00 p = 0.05, Cochran Mantel Haenszel test, p < 0.05: respectively). In the low-risk group increased number of nodes at PLND did not reduce risk of BCR.ConclusionsIn this study of extent of PLND at RP, higher nodal yield did not reduce risk of BCR in low-risk men (Briganti risk < 5%), however there was a weak benefit in terms of reduced long-term risk of BCR in high-risk men (Briganti risk ≥5%).

Extended pelvic lymph node dissection in muscle invasive bladder cancer.

Bilateral pelvic lymph node dissection (PLND) at the time of radical cystectomy (RC) provides important staging information and oncologic benefit in patients with bladder cancer. The optimal extent of the PLND remains controversial. Our aim is to highlight nodal mapping studies and the data that guides optimization of both staging and oncologic outcomes. We then review contemporary randomized trials studying the extent of PLND. A recent randomized trial (RCT) powered for a 15% improvement in recurrence-free survival (RFS) of extended (e) over limited (l)PLND was completed but failed to identify this large difference in outcome. Concerns over study design limit the ability to interpret the oncologic results. Importantly, ePLND minimally changed surgical morbidity. An ongoing, similar RCT (SWOG S1011) powered to detect a 10% difference in RFS has completed accrual, but no published outcomes are available. RC and ePLND can provide cure in 33% of LN positive bladder cancer patients. Current data support a 5% improvement in RFS if ePLND is routinely used in MIBC patients. Two randomized trials powered to identify much larger (15 and 10%) improvements in RFS are unlikely to identify such an ambitious benefit by extending the PLND.

Comparison of therapeutic features and oncologic outcome in patients with pN1 prostate cancer among robot-assisted, laparoscopic, or open radical prostatectomy.

To compare the therapeutic features and oncological outcomes of robot-assisted radical prostatectomy (RARP) with those of open radical prostatectomy (ORP) or laparoscopic radical prostatectomy (LRP) in lymph node (LN) positive prostate cancer patients in a retrospective observational multi-institutional study. We evaluated the clinical results of 561 patients across 33 institutions who underwent RARP, LRP, or ORP and who were diagnosed with LN-positive prostate cancer during RP with pelvic LN dissection (PLND). We determined the following survival outcomes: metastasis-free survival, overall survival, cancer-specific survival, and biochemical recurrence-free survival. The Kaplan-Meier method, log-rank test, and Cox proportional hazards regression model were used to evaluate the effect of treatment on oncological outcomes. Statistical significance was set atP < 0.05. There was no significant difference for any of the survival outcomes between the three surgical groups. However, RARP achieved a greater LN yield compared to that of ORP or LRP. When the extent of PLND was limited to the obturator LNs, the number of removed LNs (RLNs) was comparable between the three surgical groups. However, higher numbers of RLNs were achieved with RARP compared to the number of RLNs with ORP (P < 0.001) when PLND was extended to the external and/or internal iliac LNs. RARP, LRP, and ORP provided equal surgical outcomes for pN1 prostate cancer, and the prognosis was relatively good for all procedures. Increased numbers of RLNs may not necessarily affect the oncological outcome.

MP57-16 IMPACT OF EXTENT OF LYMPHADENECTOMY ON ALL CAUSE MORTALITY IN PATIENTS WITH INTERMEDIATE AND HIGH-RISK PROSTATE CANCER MANAGED WITH RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 May 2022MP57-16 IMPACT OF EXTENT OF LYMPHADENECTOMY ON ALL CAUSE MORTALITY IN PATIENTS WITH INTERMEDIATE AND HIGH-RISK PROSTATE CANCER MANAGED WITH RADICAL PROSTATECTOMY Furkan Dursun, Ahmed Elshabrawy, Hanzhang Wang, Michael A. Liss, Ronald Rodriguez, Dharam Kaushik, and Ahmed M. Mansour Furkan DursunFurkan Dursun More articles by this author , Ahmed ElshabrawyAhmed Elshabrawy More articles by this author , Hanzhang WangHanzhang Wang More articles by this author , Michael A. LissMichael A. Liss More articles by this author , Ronald RodriguezRonald Rodriguez More articles by this author , Dharam KaushikDharam Kaushik More articles by this author , and Ahmed M. MansourAhmed M. Mansour More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002640.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The role of limited versus extended pelvic lymph node dissection (PLND) in the surgical management of prostate cancer (PCa) remains controversial. We sought to evaluate the impact of the extent of PNLD on survival outcomes for patients with intermediate and high-risk PCa. METHODS: The NCDB was queried for patients with intermediate and high-risk PCa (according to AUA guidelines risk stratification), who were treated by radical prostatectomy (RP) and PLND from 2004 to 2013. We limited our cohort to men <70 years of age with a CCI=0. Patients were divided into 3 groups according to the number of excised LN as a surrogate for the extent of PLND (Group 1:1–9, Group 2:10–19, and Group 3:≥20 nodes). Primary outcome was overall survival (OS). All-cause mortality was evaluated using propensity score weighted Kaplan-Meir (KM) Curves and Cox regression models. RESULTS: 103,250 men had a new diagnosis of PCa, and 25.8% of those had high-risk PCa. The number of LN excised was <10 for 80.5%, 10-19 for 15.9%, and ≥20 for 3.6% of the patients. Figure 1 illustrates the KM curves in the propensity score-weighted cohorts. In intermediate-risk PCa patients, propensity score adjusted cox regression analysis showed OS benefit for group 2 compared to group 1 (HR0.86, CI0.79-0.93, p <0.001). Similarly, in high-risk patients, group 3 had better OS compared to group 1 (HR0.61, CI 0.47-0.78, p <0.001) (Table 1). pN+ disease rates were significantly higher in group 3 compared to group 1 and 2 in both intermediate and high-risk diseases. (Intermediate risk 9.3% vs. 1.5% and 4.5%, p <0.001; high risk 25.3% vs. 5.7% and 15.5%, p <0.001, respectively). CONCLUSIONS: Removal of ≥20 LNs during RP was associated with better OS for men with high-risk PCa. Similar survival benefit was noted in the intermediate-risk group with removal of 10-19 lymph nodes. Increased number of removed nodes was associated with increased likelihood of lymph node positivity and more accurate pathologic staging. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e988 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Furkan Dursun More articles by this author Ahmed Elshabrawy More articles by this author Hanzhang Wang More articles by this author Michael A. Liss More articles by this author Ronald Rodriguez More articles by this author Dharam Kaushik More articles by this author Ahmed M. Mansour More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP42-15 UROTHELIAL CARCINOMA OF THE BLADDER WITH ISOLATED LYMPH NODE METASTASIS: NATURAL HISTORY AND OUTCOMES FOLLOWING SURGICAL RESECTION

You have accessJournal of UrologyCME1 May 2022MP42-15 UROTHELIAL CARCINOMA OF THE BLADDER WITH ISOLATED LYMPH NODE METASTASIS: NATURAL HISTORY AND OUTCOMES FOLLOWING SURGICAL RESECTION Ernest Morton, Sumedh Kaul, Aaron Fleishman, Ruslan Korets, Peter Chang, Andrew Wagner, Simon Kim, Joaquim Bellmunt, Irving Kaplan, Aria Olumi, and Boris Gershman Ernest MortonErnest Morton More articles by this author , Sumedh KaulSumedh Kaul More articles by this author , Aaron FleishmanAaron Fleishman More articles by this author , Ruslan KoretsRuslan Korets More articles by this author , Peter ChangPeter Chang More articles by this author , Andrew WagnerAndrew Wagner More articles by this author , Simon KimSimon Kim More articles by this author , Joaquim BellmuntJoaquim Bellmunt More articles by this author , Irving KaplanIrving Kaplan More articles by this author , Aria OlumiAria Olumi More articles by this author , and Boris GershmanBoris Gershman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002608.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pathologic lymph node involvement (cN0 pN+) carries a poor prognosis in patients with urothelial carcinoma of the bladder (UCB), and there are limited contemporary data describing the natural history of UCB in such patients following radical cystectomy (RC) with pelvic lymph node dissection (PLND). We therefore utilized a nationwide oncology dataset to examine the natural history and outcomes of cN0 pN+ UCB after RC and PLND. METHODS: We identified patients in the National Cancer Database (NCDB) with cN0 pN+ cM0 UCB from 2006-2015 treated with RC and PLND. The associations of baseline characteristics with all-cause mortality (ACM) were evaluated using Cox regression. RESULTS: The study cohort consisted of 2,884 patients, including 42% with pN1 and 58% with pN2-3 disease. Of these, 606 (21%) received multiagent neoadjuvant chemotherapy, while 1,172 (41%) received post-operative adjuvant chemotherapy. A median of 15 (IQR 9-23) LNs were removed during PLND. The 5- and 8-year overall survival (OS) for the entire cohort were 20% and 17%, respectively (Fig. 1). Compared to the overall cohort, patients surviving >5 years had lower pN stage (59% vs 42% pN1) and pT stage (41% vs 22% ≤pT2). On multivariable analysis, higher pT stage (HR 2.84, 95% CI 1.15-5.33 for pT3, HR 3.33, 95% CI 1.76-6.29 for pT4 vs pT0) and pN stage (HR 1.27, 95% CI 1.14-1.42 for pN2-3 vs pN1) were associated with worse ACM, while greater number of LNs removed (HR 0.99, 95% CI 0.98-0.99) and receipt of adjuvant chemotherapy (HR 0.62, 95% CI 0.56-0.69) were associated with improved ACM (Table 1). CONCLUSIONS: While OS for cN0 pN+ M0 UCB is poor, a subset of patients demonstrates durable long-term survival with 5- and 8-year OS of 20% and 17%, respectively. Higher pT and pN stage represent adverse prognostic characteristics, while greater extent of PLND and administration of adjuvant chemotherapy represent potential interventions associated with improved OS. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e737 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ernest Morton More articles by this author Sumedh Kaul More articles by this author Aaron Fleishman More articles by this author Ruslan Korets More articles by this author Peter Chang More articles by this author Andrew Wagner More articles by this author Simon Kim More articles by this author Joaquim Bellmunt More articles by this author Irving Kaplan More articles by this author Aria Olumi More articles by this author Boris Gershman More articles by this author Expand All Advertisement PDF DownloadLoading ...

Contemporary Trends and Efficacy of Pelvic Lymph Node Dissection at Radical Cystectomy for Urothelial and Variant Histology Carcinoma of the Urinary Bladder.

To test 1) contemporary pelvic lymph node dissection (PLND) trends at radical cystectomy (RC) in variant histology bladder cancer (VHBC) patients and urothelial carcinoma of the urinary bladder (UCUB), as well as 2) to test the effect of PLND extent on cancer specific mortality (CSM) after RC. Within the Surveillance, Epidemiology and End Results Registry (SEER, 2004-2016), we identified non-metastatic stage T1-2 or T3-4 VHBC and UCUB patients, who underwent RC. CSM and lymph node invasion (LNI) rates were stratified according to PLND extent, as well as coded continuously in multivariate Cox and logistic regression models. Of 19,020 patients, 1736 (9.1%) were coded as having VHBC (46.9% squamous cell carcinoma, 22.5% adenocarcinoma, 18.9% neuroendocrine carcinoma, 11.7% not otherwise specified) vs 17,284 (90.9%) UCUB. PLND was performed in 80.1 of VHBC vs. 83.5% UCUB patients. In both histological groups, PLND rates increased over time (70.9-89.6% and 76.2%-90.1%, both P < .01). PLND extent did not significantly affect CSM in stage T1-2 or T3-4 VHBC patients. Conversely, PLND extent was associated with lower CSM in T1-2, as well as in T3-4 UCUB patients, which was confirmed in multivariate Cox analyses (Hazard ratio [HR] 0.99, P < .001). Rates of LNI increased with extent of PLND in logistic regression analyses in stage T3-4 VHBC (Odds ratio [OR] 1.01, P=.001), stage T1-2 UCUB (OR 1.01, P < .001) and T3-4 UCUB (OR 1.01, P < .001), but not in stage T1-2 VHBC (OR 1.01, P = .3). PLND rates do not differ between VHBC and UCUB patients. A potential survival benefit related to more extensive PLND is operational in UCUB patients, but not in VHBC patients.

Effect of pelvic lymph node dissection and its extent on oncological outcomes in intermediate-risk prostate cancer patients: A multicenter study of the Turkish Uro-oncology Association.

Pelvic lymph node dissection (PLND) is the gold standard method for lymph node staging in prostate cancer. We aimed to evaluate the effect of PLND combined with radical prostatectomy (RP) on oncological outcomes in D'Amico intermediate-risk prostate cancer (IRPC) patients. Patients with D'Amico IRPC were included in the study. In the overall cohort and subgroups (biopsy International Society of Urological Pathology [ISUP]grade group 2 and 3), patients were divided into two groups as PLND and no-PLND. More extensive PLND, defined as a number of removed nodes (NRN) ≥ 75th percentile. After exclusion, a total of 631 patients were included: 351 (55.6%) had PLND and 280 (44.4%) had no-PLND. The mean age was 63.1 ± 3.60 years. The median NRN was 8.0 (1.0-40.0). The mean follow-up period was 47.7 ± 37.5 months. The lymph node involvement (LNI) rate was 5.7% in the overall cohort, 3.9% in ISUP grade 2, and 10.8% in ISUP grade 3. Patients with PLND were associated with more aggressive clinicopathologic characteristics but no significant difference in biochemical recurrence-free survival (BCRFS) was found between patients with PLND and no-PLND (p = 0.642). In the subgroup analysis for ISUP grades 2 and 3, no significant difference in BCRFS outcomes was found in patients with PLND and No-PLND (p = 0.680 and p = 0.922). Also, PLND extent had no effect on BCRFS (p = 0.569). The multivariable Cox regression model adjusted for preoperative tumor characteristics revealed that prostate specific antigen (PSA) (HR: 1.18, 95% CI: 1.01-1.25; p = 0.048) was an independent predictor of biochemical recurrence (BCR). The optimum cut-off value for PSA, which can predict BCRFS, was assigned to be 7.81 ng/ml, with an AUC of 0.63 (95% CI: 0.571-0.688). The highest sensitivity and specificity were 0.667 and 0.549. Overall and cancer-specific survival analyzes were not evaluated because not enough events were observed. Neither PLND nor its extent improved BCRFS outcomes in IRPC. The LNI rate is low in patients with biopsy ISUP grade 2 and the BCR rate is low in those with PSA < 7.81 ng/dl so PLND can be omitted in these IRPC patients.

The Influence of Lymph Node Count on Oncological Outcome of Radical Cystectomy in Chemotherapy Pre-Treated and Chemotherapy-Naïve Patients with Muscle Invasive Bladder Cancer.

Radical cystectomy (RC) with pelvic lymph node dissection (PLND) remains the mainstay of treatment for muscle-invasive bladder cancer (MIBC). The extent of PLND and number of removed lymph nodes (LNs) have been associated with improved staging and survival outcomes in several series of RC patients. Neoadjuvant chemotherapy (NAC) has become standard of care for cisplatin-eligible patients qualified to RC, yet few studies on PLND stratified cases according to the receipt of NAC. We aimed to address this issue and reevaluate the prognostic value of PLND nodal yields in series of patients who underwent RC on the verge of the NAC era. This single-center, retrospective, clinical follow-up study enrolled 439 consecutive patients, out of whom 83 received NAC. We analyzed survival outcome of RC according to the number of removed nodes between NAC and non-NAC subgroups. We found PLND thresholds of 10 and 15 LNs prognostically meaningful in our study cohort, and this association was particularly pronounced in the non-NAC subgroup. Higher numbers of LNs provided a 25% reduction in risk of all-cause mortality and correspondingly correlated with up to a 14% increase in 3-year overall survival. The receipt of NAC diminished the benefit of adequate PLND, as the number of retrieved LNs was not associated with survival in the NAC-RC cohort. Given the limitations of our study, additional research is needed to verify these findings.

MP15-07 ANALYSIS OF PERIOPERATIVE COMPLICATIONS IN PATIENTS WITH PROSTATE CANCER BASED ON EXTENSION OF PELVIC LYMPH NODE DISSECTION

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I (MP15)1 Sep 2021MP15-07 ANALYSIS OF PERIOPERATIVE COMPLICATIONS IN PATIENTS WITH PROSTATE CANCER BASED ON EXTENSION OF PELVIC LYMPH NODE DISSECTION Marissa Maas, Nima Nassiri, Paolo Dell’Oglio, George Thalmann, Axel Heidenreich, James Eastham, Christopher Evans, Jeffrey Karnes, Andre Abreu, Alberto Briganti, Walter Artibani, Inderbir Gill, Francesco Montorsi, and Giovanni Cacciamani Marissa MaasMarissa Maas More articles by this author , Nima NassiriNima Nassiri More articles by this author , Paolo Dell’OglioPaolo Dell’Oglio More articles by this author , George ThalmannGeorge Thalmann More articles by this author , Axel HeidenreichAxel Heidenreich More articles by this author , James EasthamJames Eastham More articles by this author , Christopher EvansChristopher Evans More articles by this author , Jeffrey KarnesJeffrey Karnes More articles by this author , Andre AbreuAndre Abreu More articles by this author , Alberto BrigantiAlberto Briganti More articles by this author , Walter ArtibaniWalter Artibani More articles by this author , Inderbir GillInderbir Gill More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , and Giovanni CacciamaniGiovanni Cacciamani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001996.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While there is consensus on the importance of pelvic lymph node dissection (PLND) in the staging and management of clinically localized prostate cancer, there is controversy regarding the optimal extent of PLND. The European Association of Urology (EAU) currently recommends an extended PLND (ePLND) for high-risk patients. In this study, we evaluated the difference in non-oncologic complication rates following standard PLND (sPLND) vs. ePLND. METHODS: A systematic review and metanalysis in accordance with the Preferred Reporting Items for Systematic Review and Metanalysis guidelines was conducted. Our team queried Medline, Web of Science, Scopus, and Embase for all papers reporting intra- or postoperative outcomes of radical prostatectomy and PLND. We defined sPLND and ePLND according to EAU guidelines. Data was collected for patient demographics, quality of complication reporting, intraoperative, and postoperative complications. RESULTS: 3,645 papers were collected and 176 met inclusion criteria. 84 described intraoperative complications with a total of 28,428 patients. 534 (1.8%) patients suffered at least one intraoperative complication and rectal injury was most common. The rate of intraoperative complications strongly related to PLND was 11.6%, including obturator nerve and iliac vessel injury. 151 papers with a total of 73,629 patients analyzed postoperative complications. 19 papers reported the complication rates following sPLND vs. ePLND. 10,401 (14.1%) patients reported at least one postoperative complication. Lymphatic system morbidities were most common. The most frequently reported complication strongly related to PLND was lymphocele (90.6%). According to metanalysis, there was a statistically significant decreased risk of intraoperative (RR:0.55; p=0.01) and PLND-related postoperative complications (RR:0.55; p=0.01) with standard/limited PLND compared to extended/super-extended. Extent of PLND is an independent predictor of lymphocele (RR:1.77, p>0.0001). CONCLUSIONS: While there may be an oncologic benefit conferred by ePLND, it is associated with increased risk of intraoperative and postoperative complications, especially lymphocele formation. It is imperative that shared decision is undertaken when deciding extent of PLND. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e266-e266 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marissa Maas More articles by this author Nima Nassiri More articles by this author Paolo Dell’Oglio More articles by this author George Thalmann More articles by this author Axel Heidenreich More articles by this author James Eastham More articles by this author Christopher Evans More articles by this author Jeffrey Karnes More articles by this author Andre Abreu More articles by this author Alberto Briganti More articles by this author Walter Artibani More articles by this author Inderbir Gill More articles by this author Francesco Montorsi More articles by this author Giovanni Cacciamani More articles by this author Expand All Advertisement Loading ...

The Adequacy of Pelvic Lymphadenectomy During Radical Cystectomy for Carcinoma Urinary Bladder: A Narrative Review of Literature.

An adequate pelvic lymph node dissection (PLND) is an essential part of radical cystectomy for muscle invasive bladder cancer. However, the definition of what constitutes an adequate PLND is often shrouded in controversy. Various authors have defined different anatomic templates of PLND based on levels of pelvic lymph nodes. Some have suggested other surrogate markers of the adequacy of PLND, namely lymph node count and lymph node density. While individual studies have shown the efficacy and reliability of some of the above markers, none of them have been recommended forthright due to the absence of robust prospective data. The use of non-standardized nomenclature while referring to the above variables has made this matter more complex. Most of older data seems to favor use of extended template of PLND over the standard template. On the other hand, one recent randomized controlled trial (RCT) did not show any benefit of one template over the other in terms of survival benefit, but the study design allowed for a large margin of bias. Therefore, we conducted a systematic search of literature using EMBASE, Medline, and PubMed using PRISMA-P checklist for articles in English Language published over last 20 years. Out of 132 relevant articles, 47 articles were included in the final review. We have reviewed existing literature and guidelines and have attempted to provide a few suggestions toward a uniform nomenclature for the various anatomical descriptions and the extent of PLND done while doing a radical cystectomy. The results of another large RCT (SWOG S1011) are awaited and until we have a definitive evidence, we should adhere to these suggestions as much as possible and deal with each patient on a case to case basis.

Eliminating microscopic lymph node metastasis by performing pelvic lymph node dissection during radical prostatectomy for prostate cancer.

The oncological benefit of pelvic lymph node dissection (PLND) for prostate cancer (PCa) remains unclear. The therapeutic effect of PLND on the elimination of microscopic metastases during radical prostatectomy (RP) for PCa was examined in the current study. A total of 348 Japanese patients with high- or intermediate-risk PCa without lymph node metastasis, who underwent antegrade RP at the Kyushu Cancer Center (Fukuoka, Japan) between August 1998 and May 2013 were retrospectively analyzed. The patients were divided into the standard (obturator + internal iliac nodes) group and the expanded (standard + additional nodes) group according to the extent of PLND. Preoperative and postoperative characteristics were also analyzed to determine the factors associated with prostate-specific antigen (PSA) failure. Standard and expanded PLND were performed in 70.9% (247/348) and 29.1% (101/348) of cases, respectively. The results revealed that preoperative PSA levels were the only marked difference between the two groups. No differences were observed in the other preoperative and postoperative characteristics. Furthermore, the rate of PSA recurrence in each group did not differ to a statistically significant extent (P=0.3622). Reducing the area of dissection from expanded PLND to standard PLND significantly reduced the number of dissected lymph nodes (P<0.0001). Additionally, the PSA level, clinical tumor stage, Gleason score of the biopsy specimen, pathological tumor stage and extent of PLND were all associated with PSA recurrence, as determined via multivariate Cox hazards regression analysis (P=0.0177, P=0.0023, P=0.0027, P<0.0001 and P=0.0164, respectively). In high- and intermediate-risk patients without lymph node metastasis, a greater number of lymph nodes were dissected when the extent of dissection was greater. Furthermore, the extent of PLND was a significantly associated with PSA failure. The results indicated that PLND exerted a therapeutic effect by eliminating microscopic pelvic lymph node metastases that were not detected by routine pathological examinations.

Pelvic lymph node dissection and its extent on survival benefit in prostate cancer patients with a risk of lymph node invasion >5%: a propensity score matching analysis from SEER database

Pelvic lymph node dissection (PLND) represents the gold standard for nodal staging in PCa and is recommended for patients with a probability of lymph node invasion (LNI) >5%. However, the therapeutic role of PLND and its extent remains a debate. In this study, data of 20,668 patients treated with radical prostatectomy (RP) with and without PLND from SEER database between 2010 and 2015 were retrospectively analyzed. All patients had a risk of LNI >5% according to 2012-Briganti nomogram. Propensity score matching (PSM) was performed to balance baseline characteristics between patients with and without PLND. Kaplan-Meier curves and Cox regression were used to evaluate the impacts of the PLND and its extent on cancer-specific survival (CSS) and overall survival (OS). In overall cohort, patients with PLND were associated with more aggressive clinicopathologic characteristics and had poorer survival compared to those without PLND (5-year CSS rate: 98.4% vs. 99.7%, p < 0.001; 5-year OS rate: 96.3% vs. 97.8%, p < 0.001). In the post-PSM cohort, no significant difference in survival was found between patients with and without PLND (5-year CSS rate: 99.4% vs. 99.7%, p = 0.479; 5-year OS rate: 97.3% vs. 97.8%, p = 0.204). In addition, the extent of PLND had no impact on prognosis (all p > 0.05). Subgroup analyses reported similar negative findings. In conclusion, neither PLND nor its extent was associated with survival in North American patients with a risk of LNI >5%. The cut-off point of 5% probability of LNI might be too low to show benefits in survival in patients underwent PLND.

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

The 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. We 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. The 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. Our 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.

866P - Pelvic lymph node dissection and its extent on survival benefit in prostate cancer patients with a risk of lymph node invasion>5%: A propensity score matching analysis from SEER database

BackgroundThe aim of the study was to evaluate the therapeutic role of pelvic lymph node dissection (PLND) and its extent in North American patients with a risk of lymph node invasion (LNI)>5%. MethodsData of 20,668 patients treated with radical prostatectomy (RP) with and without PLND from SEER database between 2010 and 2015 were retrospectively analyzed. All patients had a risk of LNI>5% according to 2012-Briganti nomogram. Propensity score matching (PSM) was performed to balance baseline characteristics between patients with and without PLND. Kaplan-Meier curves and Cox regression were used to evaluate the impacts of the PLND and its extent on cancer-specific survival (CSS) and overall survival (OS). ResultsThe median follow-up was 32 months. In overall cohort, patients with PLND were associated with more aggressive clinicopathologic characteristics and had poorer survival compared to those without PLND (5-year CSS rate: 98.4% vs. 99.7%, p<0.001; 5-year OS rate: 96.3% vs. 97.8%, p<0.001). PSM resulted in 4,267 patients in each group. In the post-PSM cohort, no significant difference in survival was found between patients with and without PLND (5-year CSS rate: 99.4% vs. 99.7%, p=0.479; 5-year OS rate: 97.3% vs. 97.8%, p=0.204). In addition, the extent of PLND had no impact on prognosis (all p<0.05). Subgroup analyses reported similar negative findings. ConclusionsNeither PLND nor its extent was associated with survival in North American patients with a risk of LNI>5%. Legal entity responsible for the studyHao Zeng. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Increasing rate of lymph node invasion in patients with prostate cancer treated with radical prostatectomy and lymph node dissection

ObjectivesTo investigate lymph node invasion (LNI) rates in prostate cancer (PCa) patients. Recent studies demonstrated an inverse stage migration in PCa patients toward more advanced and unfavorable diseases. We hypothesized that this trend is also evident in LNI rates, in PCa patients treated with radical prostatectomy (RP) and pelvic lymph node dissection (PLND). Patients and methodsWithin the Surveillance, Epidemiology, and End Results database (2004–2014), we identified patients who underwent RP and PLND. Annual trends of LNI rates and PLND extent were plotted. Univariable and multivariable logistic regression models tested the hypothesis that LNI rates are increasing annually, even after adjustment for clinical or pathological characteristics. ResultsOf 96,874 patients treated with RP and PLND, 4.1% (n = 4,002) exhibited LNI. The rate of LNI (2.5%–6.6%.), the mean (6.5–8.4) and median (5–6) number of removed lymph nodes increased during the study period. In multivariable logistic regression models, more contemporary year of diagnosis was associated with higher LNI rate, when year of diagnosis was modeled as a continuous, categorized or cubic spline variable, with adjustment for either clinical (prostate specific antigen, clinical tumor stage, and biopsy Gleason group) or pathological characteristics (pathologic tumor stage and Gleason group), as well as PLND extent (number of removed lymph nodes). ConclusionWe confirmed the hypothesis about increasing LNI rate over time in RP patients. This observation implies an increasing rate of unfavorable PCa defined as LNI. This finding is novel for contemporary epidemiological North American or European databases.

Gallium 68 PSMA-11 PET/MR Imaging in Patients with Intermediate- or High-Risk Prostate Cancer.

Purpose To report the results of dual-time-point gallium 68 (68Ga) prostate-specific membrane antigen (PSMA)-11 positron emission tomography (PET)/magnetic resonance (MR) imaging prior to prostatectomy in patients with intermediate- or high-risk cancer. Materials and Methods Thirty-three men who underwent conventional imaging as clinically indicated and who were scheduled for radical prostatectomy with pelvic lymph node dissection were recruited for this study. A mean dose of 4.1 mCi ± 0.7 (151.7 MBq ± 25.9) of 68Ga-PSMA-11 was administered. Whole-body images were acquired starting 41-61 minutes after injection by using a GE SIGNA PET/MR imaging unit, followed by an additional pelvic PET/MR imaging acquisition at 87-125 minutes after injection. PET/MR imaging findings were compared with findings at multiparametric MR imaging (including diffusion-weighted imaging, T2-weighted imaging, and dynamic contrast material-enhanced imaging) and were correlated with results of final whole-mount pathologic examination and pelvic nodal dissection to yield sensitivity and specificity. Dual-time-point metabolic parameters (eg, maximum standardized uptake value [SUVmax]) were compared by using a paired t test and were correlated with clinical and histopathologic variables including prostate-specific antigen level, Gleason score, and tumor volume. Results Prostate cancer was seen at 68Ga-PSMA-11 PET in all 33 patients, whereas multiparametric MR imaging depicted Prostate Imaging Reporting and Data System (PI-RADS) 4 or 5 lesions in 26 patients and PI-RADS 3 lesions in four patients. Focal uptake was seen in the pelvic lymph nodes in five patients. Pathologic examination confirmed prostate cancer in all patients, as well as nodal metastasis in three. All patients with normal pelvic nodes in PET/MR imaging had no metastases at pathologic examination. The accumulation of 68Ga-PSMA-11 increased at later acquisition times, with higher mean SUVmax (15.3 vs 12.3, P < .001). One additional prostate cancer was identified only at delayed imaging. Conclusion This study found that 68Ga-PSMA-11 PET can be used to identify prostate cancer, while MR imaging provides detailed anatomic guidance. Hence, 68Ga-PSMA-11 PET/MR imaging provides valuable diagnostic information and may inform the need for and extent of pelvic node dissection.

Evolution of cystectomy care over an 11-year period in a high-volume tertiary referral centre.

To describe the evolution in radical cystectomy (RC) care over 11 years at a referral centre. The clinical data of patients undergoing either open RC (ORC) or robot-assisted RC (RARC) for cT1-4aN0M0 bladder cancer (BCa) at our centre between January 2006 and December 2016 were retrospectively evaluated. Crude and propensity score-weighted log-binomial regression analyses were conducted to assess the association between pre- and peri-operative variables and the risk of reoperation, intensive care unit (ICU) admission and death <90 days after RC. A total of 814 patients were considered. The percentage of RARCs performed increased (from 10% to 100%) between 2006 and 2013. Overall, 29% of the patients received neoadjuvant chemotherapy (12-37% from 2006 to 2016). Despite no differences in terms of operating time, pelvic lymph node dissection (PLND) was more commonly attempted during RARC and extended PLND was more frequently performed in the RARC group (72% vs 19%; P < 0.001). Ileal conduit was the preferred urinary diversion in both groups, and more patients in the RARC group underwent neobladder construction (34% vs 14%; P < 0.001). The overall rates of re-intervention, ICU admission and death within 90 days of RC were 8.9%, 5.4% and 2.9%, respectively. On crude analysis, RARC was associated with a reduced risk of ICU admission (relative risk [RR] 0.42, 95% confidence interval [CI] 0.23-0.77; P = 0.005), reintervention (RR 0.58, 95% CI 0.37-0.90; P = 0.015) and death (RR 0.37, 95% CI 0.16-0.85; P = 0.020); however, these risk reductions were not statistically significant on weighted analyses. The introduction of RARC has coincided with a reduction in the rate of ICU admission, reoperation and death within 90 days of surgery, without compromising operating time, PLND extent or neobladder utilization.

Rate and Extent of Pelvic Lymph Node Dissection in the US Prostate Cancer Patients Treated With Radical Prostatectomy.

To evaluate the utilization of pelvic lymph node dissection (PLND) and its extent in contemporary US patients, and to correlate it to the detection of pN1 disease. A total of 328,710 individuals who received radical prostatectomy between the years 2004 and 2013 were identified within the National Cancer Data Base. The Cochran-Armitage test was used to assess the statistical significance of temporal trends. Logistic regression analysis tested the relationship between the number of lymph nodes removed (LNR) and pN1 rate. Most patients had T2 disease (76.7%) and a Gleason score of 7 (55.9%). Overall, 63.5% of the patients received PLND; this ranged between 58.9% and 72.1% over the study period (P= .8). In patients receiving PLND, mean LNR increased from 6.1 nodes in 2004 to 7.2 nodes in 2013 (P< .001). When stratified by tumor risk, utilization and extent of PLND increased in intermediate- and high-risk tumors, while it decreased in low-risk tumors. Overall pN1 rate was 3.73%, and it increased from 2.9% to 5.3% between 2004 and 2013 (P< .001). In multivariable analysis, LNR was an independent predictor of pN1 (P< .001). The utilization patterns of PLND in the United States have improved, with an increased focus on patients with intermediate- and high-risk disease. Likewise, the extent of PLND has improved to include more lymph nodes. This seems to translate into more accurate tumor, node, metastasis classification system staging, as more patients are being appropriately diagnosed with pN1 disease.

Determination of adequate pelvic lymph node dissection range for Japanese males undergoing radical prostatectomy.

The present study aimed to determine the adequate pelvic lymph node dissection (PLND) range for Japanese males undergoing radical prostatectomy. A total of 467 Japanese patients who underwent antegrade radical prostatectomy at the National Kyushu Cancer Center (Fukuoka, Japan) were retrospectively reviewed. The patients were divided into two groups according to the PLND extent: The standard (obturator + internal iliac nodes) group and the expanded (standard + additional nodes) group, which accounted for 64.5% (301/467) and 35.5% (166/467) of the patients, respectively. No differences were observed in the preoperative and postoperative characteristics of the two groups. In addition, there was no difference in PSA recurrence between the two groups. There were no differences between the standard and expanded groups in the low-, intermediate- and high-risk groups (P=0.1456, P=0.1581, P=0.2125, respectively). The median number of lymph node dissection was 13 and 19, in the standard and expanded groups respectively (P<0.0001). However, regarding the number of lymph node metastases and the rate of patients with lymph node metastasis, no significant difference was observed between the standard and expanded groups (P=0.4219 and P=0.4257, respectively). According to multivariate analysis, a significant difference in the presence of lymph node metastasis (hazard ratio 3.547; P=0.0247), but not in the PLND extent, was detected in patients with prostate specific antigen failure (P=0.0655). When expanding the dissection extent, the number of dissected lymph nodes increases, but is not associated with the number or rate of positive lymph nodes. Thus, the current dissection range is considered to be appropriate for Japanese men undergoing radical prostatectomy.