Pelvic Lymph Node Dissection Group Research Articles

Pelvic Lymphadenectomy May Not Improve Biochemical Recurrence-Free Survival in Patients with Prostate Cancer Treated with Robot-Assisted Radical Prostatectomy in Japan (The MSUG94 Group)

In this multicenter retrospective cohort study, we aimed to evaluate whether pelvic lymph node dissection (PLND) improved biochemical recurrence (BCR) in patients with prostate cancer (PCa) who underwent robot-assisted radical prostatectomy (RARP) in Japan. A multicenter retrospective cohort study of 3195 PCa patients undergoing RARP at nine institutions in Japan was conducted. Enrolled patients were divided into two groups: those who underwent RARP without PLND (non-PLND group) and those who underwent PLND (PLND group). The primary endpoint was biochemical recurrence-free survival (BRFS) in PCa patients who underwent PLND. We developed a propensity score analysis to reduce the effects of selection bias and potential confounding factors. Propensity score matching resulted in 1210 patients being enrolled in the study. The 2-year BRFS rate was 95.0% for all patients, 95.8% for the non-PLND group, and 94.3% for the PLND group (p = 0.855). For the all-risk group according to the National Comprehensive Cancer Network risk stratification, there were no significant differences between patients who did and did not undergo PLND. Based on the results of the log-rank study, PLND may be unnecessary for patients with PCa undergoing RARP.

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 ...

Therapeutic value of pelvic lymph node dissection in high-grade prostate cancer

Objective: This study aimed to assess the therapeutic value of pelvic lymph node dissection (PLND) in high-grade margin-negative prostate cancer without and with lymph node metastases. Methods: We retrospectively reviewed cases in the Western Australian radical prostatectomy (RP) database between January 1, 2010, and December 31, 2017. We identified men who had RP only (no PLND) and those had RP with PLND. Further, a subset of high-grade (Gleason score (GS) ⩾8) margin-negative cancers were identified. We assessed the therapeutic impact of PLND in this high-risk but potentially curable subset. Results: A total of 5648 prostatectomies were performed, and 1209 of these had concurrent PLND, negative surgical margins, and follow-up prostate-specific antigen (PSA) data. Of 558 men with high-grade margin-negative prostate cancer, 395 men had PLND, while 163 did not. There were significantly more patients with T3/T4 disease in the PLND group compared to those without PLND. Preoperative PSA did not differ significantly between the two groups. However, when stage matched, PLND had no impact on the numbers of men who were cured compared to those who failed surgical intervention. Conclusion: PLND has value in staging high-grade prostate cancer but has limited impact on producing a durable PSA cure or avoiding adjuvant therapy. Level of evidence: Not applicable for this multicenter audit.

Therapeutic Consequences of Omitting a Pelvic Lymph Node Dissection at Radical Prostatectomy when Grade and/or Stage Increase

To analyze the effect on biochemical recurrence (BCR) of omitting PLND in subsequently upgraded/upstaged patients (pNx regret). Using nomograms, patients with low to intermediate-risk prostate cancer can be selected to omit a pelvic lymph node dissection (PLND) at the time of a radical prostatectomy (RP). However, some patients will experience upgraded pathology and/or stage. We searched a prospectively maintained single institution/multi-surgeon cohort of patients treated by RP and >5-year follow-up. From 2006-2012, 1026 (521 pNx and 505 pN0/1) eligible patients with biopsy Gleason Score ≤3+4 and cT1c-cT2 undergoing RARP were included in the study. Gleason upgrading from ≤3+4 to >3+4 and/or pT3-4 occurred in 17% of pNx and 32% of pN0/N1 (p<0.001). BCR occurred in 5% of the pNx, and 7% of the PLND group. Five-year BCR free survival was higher in the pNx group (94.7% vs. 91%, P = .048). BCR occurred in 3% in the non-pNx regret and 18% in the pNx regret patients. However, with propensity score matching with pNx regret and pN0/N1 patients, 5-year BCR free survival rates were similar (81% vs 77%, P = .466). Low to favorable intermediate-risk patients who PLND was omitted and experienced upgrading or upstaging (pNx regret), have a higher predicted BCR. However, when matched to a similar cohort with pN0/N1, the BCR did not differ. Omission of a PLND does not appear to alter the rates of BCR compared to PLND inclusion.

MP67-13 COMPARISON OF MORBIDITY BETWEEN LIMITED AND EXTENDED PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER: RESULTS FROM A LARGE, CLINICALLY-INTEGRATED, RANDOMIZED TRIAL

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy III (MP67)1 Apr 2020MP67-13 COMPARISON OF MORBIDITY BETWEEN LIMITED AND EXTENDED PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER: RESULTS FROM A LARGE, CLINICALLY-INTEGRATED, RANDOMIZED TRIAL Karim Touijer, Daniel D. Sjoberg, Nicole Benfante, Claudia Mercader Barrull*, Natalia Picola Brau, Inés Rivero Belenchón, Vincent Laudone, Behfar Ehdaie, James A. Eastham, Peter T. Scardino, and Andrew Vickers Karim TouijerKarim Touijer More articles by this author , Daniel D. SjobergDaniel D. Sjoberg More articles by this author , Nicole BenfanteNicole Benfante More articles by this author , Claudia Mercader Barrull*Claudia Mercader Barrull* More articles by this author , Natalia Picola BrauNatalia Picola Brau More articles by this author , Inés Rivero BelenchónInés Rivero Belenchón More articles by this author , Vincent LaudoneVincent Laudone More articles by this author , Behfar EhdaieBehfar Ehdaie More articles by this author , James A. EasthamJames A. Eastham More articles by this author , Peter T. ScardinoPeter T. Scardino More articles by this author , and Andrew VickersAndrew Vickers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000947.013AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pelvic lymph node dissection (PLND) in prostate cancer is controversial. Although it represents the most reliable procedure for lymph node staging, the extended PLND was reported to be associated with increased morbidity. METHODS: Between October 2011 and March 2017, men were consented to the trial and underwent radical prostatectomy at Memorial Sloan Kettering Cancer Center. The study design was a cluster randomization with crossover. Each surgeon was randomized to use a limited (external iliac nodal packet) vs. extended (external iliac, obturator fossa and hypogastric nodal packets) PLND template for a 3-month period. At the end of the 3-month period, surgeons were once again randomized. Morbidity data within 30 days of surgery was prospectively graded and collected in the clinical research database. RESULTS: A total of 1574 patients were randomized: 811 randomized to the extended and 763 to the limited template. Overall the rate of complication was 10.5% in the limited PLND group vs. 8.5% in the extended PLND group. There were no grade IV or V complications. Rates for grade II and III complications were similar (7.2% in limited vs. 6.3% in extended). CONCLUSIONS: In this large randomized trial the overall rate of grade II and III complications was low. There was no significant difference in complication rates between the limited and extended PLND. Source of Funding: None. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1030-e1030 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Karim Touijer More articles by this author Daniel D. Sjoberg More articles by this author Nicole Benfante More articles by this author Claudia Mercader Barrull* More articles by this author Natalia Picola Brau More articles by this author Inés Rivero Belenchón More articles by this author Vincent Laudone More articles by this author Behfar Ehdaie More articles by this author James A. Eastham More articles by this author Peter T. Scardino More articles by this author Andrew Vickers More articles by this author Expand All Advertisement PDF downloadLoading ...

Standard versus extended pelvic lymphadenectomy in the patients with clinically localized prostate cancer

Background/Aim. Pelvic lymph node dissection (PLND) is the most accurate staging procedure in the diagnosis of lymph node involvement by prostate cancer. However, the therapeutic value of this procedure is still unclear. The objective of the study was to compare diagnostic and therapeutic values of extended and standard PLND as an adjunct of radical prostatectomy. Methods. The patients who underwent surgical treatment for clinically localized prostate cancer (n = 157) were enrolled in this open nonrandomized prospective study. In the standard PLND (sPLND) group 109 patients were enrolled while the extended PLND (ePLND) group involved 48 patients. Both groups were compared regarding age, prostate-specific antigen (PSA) level, a percentage of positive biopsies, preoperative and postoperative Gleason score, number of retrieved and positive lymph nodes, duration of surgery, blood loss, amount of lymphorrhea and biochemical recurrence-free survival. Results. The average number of retrieved lymph nodes was 17.27 and 24.46 in the sPLND and ePLND group, respectively (p = 0.001). The rate of positive lymph nodes was 9/109 (8.3%) and 8/48 (16.7%) in the sPLND and ePLND groups, respectively. Biochemical recurrence was noted in 38/109 (31.2%) and 7/48 (14.6%) patients in the sPLND and ePLND group, respectively (p = 0.003). Conclusion. Comparison of sPLND to ePLND led to the following conclusions: nodal yield was significantly higher in the ePLND group; the ePLND template was associated with a much higher rate of lymph node metastases; the biochemical recurrence-free survival rate was significantly more favorable in the ePLND group comparing to the sPLND group.

Prognostic outcome and complications of sentinel lymph node navigation surgery for early-stage cervical cancer.

To evaluate the prognostic outcome and surgical complications in patients with early-stage cervical cancer who underwent sentinel node navigation surgery (SNNS) for hysterectomy or trachelectomy. A total of 139 patients who underwent SNNS using 99mTc phytate between 2009 and 2015 were evaluated. No further lymph node dissection was performed when intraoperative analysis of the sentinel lymph nodes (SLNs) was negative for metastasis. We compared the surgical complications between the SNNS group and 67 matched patients who underwent pelvic lymph node dissection (PLND) after SLN mapping between 2003 and 2008. We also examined the clinical outcomes in the SNNS group. The mean number of detected SLNs was 2.5 per patient. Fourteen of the 139 patients in the SNNS group underwent PLND based on the intraoperative SLN results. The amount of blood loss, the operative time, and the number of perioperative complications were significantly less in the SNNS group than in the matched PLND group. There was no recurrence during a follow-up period ranging from 2 to 88months (median 40months) in the SNNS group. Using SNNS for early-stage cervical cancer is safe and effective and does not increase the recurrence rate. A future multicenter trial is warranted.

S&T-18 PREOPERATIVE MEMBRANOUS URETHRAL LENGTH BECOMES PREDICT FACTOR FOR THE EARLY URINARY INCONTINENCE AFTER ROBOT ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY

INTRODUCTION AND OBJECTIVES: Lymphoceles are common complications after pelvic lymph node dissection (PLND). Lymphatic vessels from the femoral canal are usually ligated or sealed with clips to avoid lymphoceles. However, data about the efficiency of this measure are lacking. Hence, we prospectively randomized patients (pts) undergoing extended PLND and robot-assisted radical prostatectomy (RARP) to compare the use of titan clips versus bipolar coagulation. METHODS: From July 2012 to July 2015, 220 consecutive pts undergoing PLND and RARP at our institution were enrolled in the study. Pts were prospectively randomized in two groups; In 110 pts titan clips were used to seal the lymphatic vessels during PLND (group A); in 110 pts only bipolar coagulation was used (group B). All pts underwent ultrasound examination 10 and 90 days after PLND. Lymphoceles were defined as any clear definable fluid collections in the pelvis. Pts with anastomotic insufficiency at cystography, routinely performed at postoperative day 4, were excluded from the trial. Lymphoceles were considered clinically relevant when causing pelvic pain, leg oedema, hydronephrosis, deep vein thrombosis, or infection/sepsis requiring any medical or surgical treatment. Groups A and B were compared using the Mann-Whitney and chi-square tests or Fisher’s exact test. RESULTS: Groups A and B were comparable regarding baseline data and intraand post-operative characteristics. There were no statistically significant differences between the two groups regarding mean operative time [241 43 min vs. 245 37 min; p1⁄40.211], median number of resected lymph nodes (LN) (19 vs. 18; p1⁄40.355), positive LN rates (16% vs. 19%; p1⁄40.596), positive surgical margins (13% vs. 16%; p1⁄40.233), complication rates (27% vs. 31%; p1⁄40.187) and mean length of stay [6 2 days vs. 7 3 days; p1⁄40.075]. Lymphoceles were detected in 105 of the total 220 pts (47%). 11/ 220 (5%) pts were symptomatic and required treatment. Groups A and B showed no significant difference regarding the overall incidence of lymphoceles [48% vs. 47%; p1⁄40.893], and in terms of clinically significant lymphoceles [5% vs. 4%; p1⁄40.725]. Both groups were also comparable regarding mean lymphocele volume [30 32 ml vs. 35 39; p1⁄40.566], lymphocele location (mono or bilateral) (p1⁄40.781), and detection at postoperative day 10 (95% vs. 98%; p1⁄40.499). CONCLUSIONS: Clipping or coagulating the lymphatic vessels do not to affect the incidence of postoperative lymphoceles as well as the risk of developing clinically significant lymphoceles after PLND and RARP.

Is pelvic lymph node dissection required at radical prostatectomy for low‐risk prostate cancer?

To determine the necessity of pelvic lymph node dissection for low-risk prostate cancer, we analyzed the incidence of lymph node invasion and the therapeutic value of pelvic lymph node dissection in low-risk prostate cancer patients. Medical records for 1268 patients undergoing open radical prostatectomy between January 2000 and December 2009 who had not undergone neoadjuvant therapy were retrospectively reviewed. Patients with low-risk disease (n = 222; prostate-specific antigen <10 ng/mL, biopsy Gleason score ≤6, clinical T1c or T2a) were classified according to whether they underwent pelvic lymph node dissection (pelvic lymph node dissection group, n = 147) or did not (no pelvic lymph node dissection group, n = 75). Pelvic lymph node dissection was carried out in a limited style, which included the external iliac vein and the obturator fossa. The incidence of lymph node invasion was determined and referred to the preoperative nomogram developed for Japanese patients (Japanese nomogram), Partin and Kattan nomograms. The 5-year biochemical recurrence-free survivals in both groups were analyzed. Lymph node invasion in low-, intermediate- and high-risk disease was 0.7% (1/147), 1.2% (7/595) and 6.1% (23/374). The 5-year biochemical recurrence-free survival rates for patients with low-risk disease were 87.6% in the pelvic lymph node dissection group and 87.1% in the no pelvic lymph node dissection group (P = 0.65, log-rank). No patients in the pelvic lymph node dissection group exceeded 2% of lymph node invasion risk with Japanese and Partin nomograms. With the Kattan nomogram, 22.4% (33/147) of the pelvic lymph node dissection group exceeded 2% of lymph node invasion risk, and one patient had documented lymph node invasion, but none exceeded 2.5%. Pelvic lymph node dissection can be spared at radical prostatectomy for low-risk disease, as its diagnostic and therapeutic value is poor.

WITHDRAWN: Is the impact of the extent of lymphadenectomy in radical prostatectomy related to the disease risk? A single center prospective study

Controversy exists regarding the extent of pelvic lymph node dissection (PLND) in radical prostatectomy (RP) for prostate cancer. Impact of the extent of PLND may be determined by the disease risk. The aim of our study was to find the association between the extent of PLND on biochemical progression and disease risk. The study included 360 consecutive patients treated with RP for clinically localized prostate cancer at our department between 2000 and 2003. Patients were randomized to receive extended PLND (n = 180) and standard PLND (n = 180) at RP. Clinical and pathological data were prospectively collected. The patients did not receive any neoadjuvant or adjuvant therapy. The relation of disease risk and the extent of PLND to biochemical progression-free survival (BPFS) were examined. There were no significant differences in age, prostate-specific antigen, and other preoperative features in patients who underwent standard and extended PLND. Mean patient age was 68 y old and median follow-up was 74 mo. BPFS for the standard PLND group and the extended PLND group was 90.1% and 91.3% in low risk disease (log rank P = 0.807), 73.1% and 85.7% in intermediate risk disease (log rank P = 0.042), and 51.1% and 71.4% in high risk disease (log rank P = 0.036), respectively. In multivariate Cox proportional hazard analysis, extended PLND was an independent prognostic factor of biochemical progression-free survival when adjusting for other clinical and pathologic features. In intermediate and high risk patients, extended PLND positively affects BPFS. In low risk patients, extended PLND may be omitted to reduce operation time and complications.

592 IS PELVIC LYMPH NODE DISSECTION FOR PN2 PENILE CANCER NECESSARY?

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease1 Apr 2011592 IS PELVIC LYMPH NODE DISSECTION FOR PN2 PENILE CANCER NECESSARY? Majid Shabbir, C.J. Shukla, Evangelos Zacherakis, K.J. Ho, Raj Nigam, Peter Malone, Alex Freeman, David Ralph, Asif Muneer, and Suks Minhas Majid ShabbirMajid Shabbir London, United Kingdom More articles by this author , C.J. ShuklaC.J. Shukla London, United Kingdom More articles by this author , Evangelos ZacherakisEvangelos Zacherakis London, United Kingdom More articles by this author , K.J. HoK.J. Ho London, United Kingdom More articles by this author , Raj NigamRaj Nigam London, United Kingdom More articles by this author , Peter MalonePeter Malone London, United Kingdom More articles by this author , Alex FreemanAlex Freeman London, United Kingdom More articles by this author , David RalphDavid Ralph London, United Kingdom More articles by this author , Asif MuneerAsif Muneer London, United Kingdom More articles by this author , and Suks MinhasSuks Minhas London, United Kingdom More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1424AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES EAU guidelines state that penile cancer patients with pN2 disease should undergo a pelvic lymph node dissection (PLND). The aim of this study was to assess the detection rate, outcome and histopathological trends of patients who underwent PLND for pN2 disease. METHODS We reviewed all penile cancer cases treated in our institution between 2000 and 2010. Histological grade, tumour subtype, stage, presence of lymphovascular invasion (LVI), number of positive inguinal lymph nodes (ILN) and presence of extra nodal spread (ENS) were assessed and correlated with PLN status and outcome data. Fisher's exact test and unpaired t tests were used for analysis, and p values < 0.05 were taken as statistically significant. RESULTS 34 patients were identified with pN2 disease. 14 (41%) had no PLND as they were either unfit for surgery (4/14–28%) or had advanced metastatic disease treated with palliative chemo/radiotherapy (8/14–58%). 2/14 patients (14%) opted for surveillance. 9/14 patients (65%) in this group died after a median of 218 days (33–1110 days). 20 patients (59%) underwent PLND; 4/20 (20%) were found to have metastatic disease in the pelvic lymph nodes. All positive PLN's occurred on the same side as the positive ILN's. 2/4 (50%) of these patients died after a median of 1233 days (335–2132 days). 16/20 patients (80%) had no metastatic disease in the pelvic lymph nodes. 6/16 patients in this group (38%) died after a median of 476 days (324–912 days). Histological grade, tumour subtype, LVI status, and the presence of ENS were not significantly associated with PLN status. However, patients with positive PLN did have significantly more ILN involvement (mean 5.5 vs. 2.6 nodes, p=0.03). Mortality was not significantly associated with PLN status. However, presence of ENS was a significant predictor of death independent of PLN status (p=0.02). There were no significant differences in the survival data of those undergoing PLND vs. those who did not (overall mortality and median survival; PLND group 50% and 476 days vs. 65% and 218 days, p=0.11). CONCLUSIONS PLND has a low yield in pN2 disease, detecting metastases in only 20% of cases. Despite theoretical bilateral drainage, metastatic PLN were only detected on the ipsilateral side as the positive ILN's and this may have implications for the extent of the PLND performed. Overall mortality was not associated with PLN status, but the presence of ENS on ILND was a significant independent predictor of death. PLND itself did not confer any significant survival advantage, although this may be related to the sample size in this series. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e239 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Majid Shabbir London, United Kingdom More articles by this author C.J. Shukla London, United Kingdom More articles by this author Evangelos Zacherakis London, United Kingdom More articles by this author K.J. Ho London, United Kingdom More articles by this author Raj Nigam London, United Kingdom More articles by this author Peter Malone London, United Kingdom More articles by this author Alex Freeman London, United Kingdom More articles by this author David Ralph London, United Kingdom More articles by this author Asif Muneer London, United Kingdom More articles by this author Suks Minhas London, United Kingdom More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Extending the indications and anatomical limits of pelvic lymph node dissection for prostate cancer: improved staging or increased morbidity?

• To assess, in a risk/benefit analysis, the additional risk for complications and benefits of extending the indications and anatomical limits of pelvic lymph node dissection (PLND). • In total, 971 consecutive patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy from 2003-2007. • Before 1 February 2005, patients with a nomogram probability of lymph node invasion (LNI) <2% did not undergo PLND (No PLND group), whereas those with a LNI ≥ 2% had a PLND limited to the external iliac nodal group (limited PLND group). • After 1 February 2005, all patients underwent a standard PLND including the external iliac, hypogastric and obturator fossa nodal groups (standard PLND group). • The risk parameters were PLND-related complications and operating time. Complications were graded using a modified Clavien classification. The benefit was the detection of nodal metastases. • In the subgroup of patients with a LNI ≥ 2%, standard PLND was a superior operation than the limited PLND in detecting nodal metastases (14.3% vs 4.5%, respectively; P = 0.003). • The risk/benefit of standard vs limited PLND would be one additional grade 3 complication per 20 additional patients with nodal metastases. In the subgroup of patients with LNI <2%, three patients (1.0%) had positive nodes after a standard PLND. • The risk/benefit of standard PLND vs no PLND would be one additional grade 3 complication per three or four additional patients with nodal metastasis. The no PLND group was associated with the lowest risk of grade 1, 2 and 3 complications compared to either the limited or standard PLND groups (P < 0.001). • In patients with LNI ≥ 2%, standard PLND detects more nodal metastasis. PLND is associated with higher but non-prohibitive complications rate. • The present study found no evidence that the incidence of complications would be reduced by a limited PLND.

Limited Pelvic Lymph Node Dissection Does Not Improve Biochemical Relapse-Free Survival at 10 Years After Radical Prostatectomy in Patients with Low-Risk Prostate Cancer

To compare the long-term differences in actuarial biochemical relapse-free survival rates from a contemporary series of patients who underwent radical prostatectomy with and without pelvic lymph node dissection (PLND). The records of 806 consecutive radical prostatectomy cases performed from January 1995 to June 1999 were reviewed. The entire subset of patients (n = 336) with low-risk disease, defined by a prostate-specific antigen level of 10 ng/mL or less, biopsy Gleason score of 6 or less, and clinical Stage T1 or T2a, who had not received adjuvant or neoadjuvant therapy were divided into two groups according to whether PLND was performed (PLND group, n = 140) or omitted (no-PLND group, n = 196). A Cox proportional hazards model was used to analyze the effect of demographic, pretreatment, surgical, and pathologic factors on the likelihood of biochemical failure. Biochemical relapse-free survival for each group was estimated by Kaplan-Meier analysis. The median prostate-specific antigen follow-up time for the entire group was 89.0 months, with a similar follow-up for both cohorts (PLND group 94.5 months and no-PLND group 88.0 months, Mann-Whitney U test, P = 0.14). The long-term biochemical relapse-free survival rate for the entire cohort was 86.1% at 10 years. The 10-year actuarial biochemical relapse-free rate for the PLND and no-PLND groups was 83.8% and 87.9%, respectively (log-rank, P = 0.33). On univariate analysis, PLND was not an independent predictor of outcome (Wald, P = 0.33). The results of our study have shown that the omission of limited PLND in patients with favorable tumor characteristics does not adversely affect biochemical relapse-free survival at 10 years. Such patients can be spared the morbidity and cost of PLND without affecting their chance for cure.

Limited Pelvic Lymph Node Dissection at the Time of Radical Prostatectomy Does Not Affect 5-Year Failure Rates for Low, Intermediate and High Risk Prostate Cancer: Results From CaPSURE™

Limited bilateral pelvic lymph node dissection performed at radical prostatectomy provides staging information that is used to guide further disease management. Given the effects of widespread prostate specific antigen testing and stage migration, most procedures in the United States are performed for low risk disease, which has a low probability (less than 1%) of lymph node metastasis. We compared 5-year treatment failure rates in patients with low, intermediate and high risk disease who underwent radical prostatectomy with or without pelvic lymph node dissection. We compared treatment failure rates for radical prostatectomy in 4,693 patients enrolled in the CaPSURE database who underwent radical prostatectomy with or without limited pelvic lymph node dissection. Secondary analysis was performed as a function of pelvic lymph node dissection and risk group based on pretreatment stage, grade and prostate specific antigen. Treatment failure rates were estimated by Kaplan-Meier analysis. The 5-year failure-free survival rate was 70% in the no pelvic lymph node dissection group and 74% in the limited pelvic lymph node dissection group (p = 0.11), while the rates in the low, intermediate and high risk groups were 81% and 82% (p = 0.83), 71% and 63% (p = 0.21), and 42% and 48% (p = 0.45) in the no vs limited pelvic lymph node dissection groups, respectively. Multivariate analysis demonstrated that pelvic lymph node dissection status was not a predictor of treatment failure (p = 0.93). This study demonstrates in a large cohort of patients that limited pelvic lymph node dissection at radical prostatectomy has no effect on treatment failure rates at 5 years in those at low, intermediate and high risk.

PROSPECTIVELY PACKAGED LYMPH NODE DISSECTIONS WITH RADICAL CYSTECTOMY: EVALUATION OF NODE COUNT VARIABILITY AND NODE MAPPING

Accumulating evidence supports the relationship between an increased number of lymph nodes (LNs) reported following radical cystectomy (RC) and overall outcome. We prospectively evaluated RC cases with transitional cell carcinoma of the bladder to determine which factors may contribute to the variability in the number of reported LNs. We conducted a prospective evaluation in which 144 patients undergoing RC and pelvic lymph node dissection (PLND) between June 2001 and April 2003 were included. Lymph nodes were processed as individual packets. A standard method of evaluating nodal submissions was used. A mixed statistical model was used with neoadjuvant chemotherapy, node status, pathological stage, bacillus Calmette-Guerin exposure, age and number of days from transurethral resection as the fixed effects. Surgeon and pathologist were treated as random effects. The extended PLND group had a significantly greater lymph node yield (median 22.5 nodes) compared to standard PLND (median 8), however, no staging advantage was observed in the extended dissection group. Only the type of PLND performed was associated with node yield (p <0.001). Subset analysis of patients with unexpected microscopic nodal involvement revealed that 33% had involvement of the common iliac nodes. In our series only the extent of the lymph node dissection was found to influence node yield significantly after radical cystectomy. Additionally, the observed risk of involvement of the common iliac chain in microscopically node positive cases suggests a need to include this region as part of the PLND for bladder cancer for cases without grossly involved LNs.

No difference in six-year biochemical failure rates with or without pelvic lymph node dissection during radical prostatectomy in low-risk patients with localized prostate cancer

Objectives To compare differences in the actuarial biochemical relapse-free survival rates at 6 years in a contemporary series of patients who underwent radical prostatectomy with and without pelvic lymph node dissection (PLND). Biochemical failure was defined as a serum prostate-specific antigen level greater than 0.2 ng/mL confirmed at least 1 week later. Methods The records of 806 consecutive radical prostatectomy cases performed between January 1995 and June 1999 were reviewed. A total of 336 patients with favorable tumor characteristics (prostate-specific antigen 10 ng/mL or less, biopsy Gleason score 6 or less, and clinical Stage T1 or T2) not receiving adjuvant or neoadjuvant therapy were divided into two groups according to whether PLND was performed (PLND group, n = 140) or omitted (no-PLND group, n = 196). A Cox proportional hazards model was used to analyze the effect of age, race, family history, initial prostate-specific antigen level, tumor stage, biopsy Gleason score, PLND, extracapsular extension, and seminal vesicle invasion on the likelihood of biochemical failure. Biochemical relapse-free survival for each group was estimated by Kaplan-Meier analysis. The mean follow-up time for the entire group was 60.0 months, with a similar follow-up for both cohorts (mean 61.8 and 58.2 months, respectively, P value not statistically significant). Follow-up information was obtained through an institutional review board-approved prospective patient registry. Results The 6-year biochemical relapse-free rate for the PLND versus no-PLND group was 86% and 88%, respectively ( P = 0.28). On multivariate analysis, PLND was not an independent predictor of outcome ( P = 0.33). Conclusions Our study results demonstrated that the omission of PLND in patients with favorable tumor characteristics does not adversely affect biochemical relapse rates at 6 years after surgery. Such patients can be spared the morbidity and cost of PLND without affecting the chance for cure.

High incidence of inguinal hernia after radical retropubic prostatectomy

Objectives To assess the incidence of, and risk factors for, inguinal hernia after retropubic radical prostatectomy compared with after pelvic lymph node dissection and total cystectomy. Methods A total of 155 radical prostatectomies, 35 pelvic lymph node dissections, and 56 total cystectomies were included in this study. We reviewed the charts retrospectively and evaluated the incidence of, and risk factors for, inguinal hernia after surgery using Kaplan-Meier plots and a Cox proportional hazard model. Results Of 155 patients in the radical prostatectomy group, 35 patients in the pelvic lymph node dissection group, and 56 patients in the cystectomy group, 33 (21.3%), 4 (11.4%), and 3 (5.4%), respectively, developed inguinal hernias during follow-up. In the radical prostatectomy group, 27 (81.8%) of the 33 patients developed inguinal hernia within 2 years postoperatively. Multivariate Cox proportional hazard analysis revealed that prostatectomy group, past history of inguinal hernia, and body mass index of less than 23 were significant risk factors for postoperative inguinal hernia. Conclusions The incidence of inguinal hernia after radical prostatectomy is not low. Urologists should realize that inguinal hernia is one of the major complications of radical prostatectomy and examine the groin preoperatively and postoperatively.

No difference in biochemical failure rates with or without pelvic lymph node dissection during radical prostatectomy in low-risk patients

Objectives. To detect the short-term differences in biochemical relapse-free rates between patients with and without pelvic lymph node dissection (PLND). Recently, a trend has begun to omit PLND in patients undergoing radical prostatectomy considered at low risk of pelvic lymph node metastases. Methods. The records of 1152 consecutive radical prostatectomy cases were reviewed. A total of 575 patients with favorable tumor characteristics (prostate-specific antigen [PSA] 10 ng/mL or less, Gleason score 6 or less, and clinical Stage T1 or T2) who were not receiving adjuvant or neoadjuvant therapy were divided into two groups according to whether PLND was performed (PLND group, n = 372) or omitted (no PLND group, n = 203). Proportional hazards were used to analyze the effect of age, race, family history, stage, biopsy Gleason score, initial PSA, PLND, and pathologic findings on the likelihood of biochemical failure. Biochemical failure-free survival for each group was estimated by Kaplan-Meier analysis. The mean follow-up was 38 months (range 1 to 141). Results. The actuarial 4-year biochemical relapse-free rate for the PLND versus no PLND groups was 91% and 97%, respectively ( P = 0.16). On multivariate analysis, PLND was not an independent predictor of outcome ( P = 0.24). Conclusions. The results of our study indicate that the omission of PLND in patients with favorable tumor characteristics does not adversely affect biochemical relapse rates.

Radical hysterectomy for cervical cancer: hysterectomy before pelvic lymphadenectomy or vice versa?

The technique for radical abdominal hysterectomy (RAH) and lymphadenectomy (LND) for patients with cervical cancer has been well described. Whether RAH should be performed before or after pelvic lymph node dissection (PLND) is a controversial issue. This study compared the two procedures performed at the same institution. Patients treated with type III RAH for cervical cancer stage IB-IIA at our institution between 1987 and 1995 were included in this study. Only patients who underwent para-aortic lymph node dissection (PALND) first, followed by PLND and then RAH (Group A) or RAH and then PLND (Group B) were included. Clinical and surgical information including intraoperative and postoperative complications was collected. Operative reports were used to identify the patients who had RAH performed before PLND or vice versa. Data analysis was obtained using unpaired t-test with significance set at P < 0.05. Complete information was obtained for 314 patients. The results of Group A (157 patients) and Group B (157 patients) were as follows: mean age = 45.3 and 44.8 (P = 0.73); mean weight = 149 and 149 lb.; mean length of stay = 10 and 8 days (P < 0.0001); mean operative time = 230 and 172 mins (P = 0.004); mean estimated blood loss (EBL) = 1,238 and 1098 cc (P = 0.21); mean number of PALN removed = 7 and 6 (P = 0.06); mean number of PLN removed = 28 and 26 (P = 0.24). No statistical difference in major intraoperative and postoperative complications was observed. The most common complication was postoperative fever (53/157 in Group A and 49/157 in Group B). Radical hysterectomy can be safely performed either before or after PLND. The number of pelvic lymph nodes removed, as well as the EBL and the intraoperative complications are similar and are not affected by the operative time. The surgeon should decide the sequence of the procedures accordingly to his/her personal preference.

Staging Pelvic Lymphadenectomy for Localized Carcinoma of the Prostate: A Comparison of 3 Surgical Techniques

Pelvic lymph node dissection continues to be the most effective method of staging extracapsular adenocarcinoma of the prostate. Three principal methods of pelvic lymph node dissection are currently available: intraperitoneal laparoscopic, minilaparotomy and the standard open modified pelvic lymph node dissection. In the hope of determining some of the relative advantages and disadvantages associated with each technique a comparison of these approaches was made. Of 68 patients with histologically proved clinical stage T3N0M0 adenocarcinoma of the prostate who underwent staging pelvic lymph node dissection 38 underwent modified open, 19 laparoscopic and 11 minilaparotomy procedures. The efficacy of node sampling, resource expenditure and complication rates were compared among the 3 groups. No statistically significant difference was observed in terms of the number of nodes harvested with each technique. Resource expenditure analysis revealed significantly increased operative and procedural time requirements for laparoscopic pelvic lymph node dissection compared to modified open and minilaparotomy procedures. Total hospital stay was significantly longer for the modified open pelvic lymph node dissection (mean plus or minus standard deviation 6.5 +/- 0.9 days) compared to the laparoscopic (mean 2.7 +/- 1.1 days) and minilaparotomy (mean 3.3 +/- 0.2 days) groups. Multiple complications, such as ileus, lymphocele and urinary retention, were observed in the modified open pelvic lymph node dissection group. No complications were noted in the other 2 groups. Comparison of laparoscopic and minilaparotomy procedures to modified open pelvic lymph node dissection revealed similar staging efficacy, and decreased total hospital stay and complications. Laparoscopic pelvic lymph node dissection required increased operative time. Minilaparotomy should become the open surgical procedure of choice for pelvic lymph node dissection, particularly at institutions where the laparoscopy learning curve, equipment expense and time disadvantages cannot be overcome.