Standard Pelvic Lymph Node Dissection Research Articles

Is solo indocyanine green-guided lymphadenectomy a feasible alternative to standard pelvic lymph node dissection?

Is solo indocyanine green-guided lymphadenectomy a feasible alternative to standard pelvic lymph node dissection?

Extended versus standard pelvic lymph node dissection yields no difference in 3-year biochemical recurrence rates.

extended pelvic lymph node dissection (ePLND) increases the detection rate of lymph node positive prostate cancer compared to a standard pelvic lymph node dissection (sPLND). However, improvement of patient outcomes remains questionable. Here we report and compare 3-year postoperative PSA recurrence rates between patients that underwent sPLND versus ePLND at the time of prostatectomy. 162 patients received a sPLND (which involvedremoval of periprostatic, external iliac, and obturator lymph nodes bilaterally), and 142 patients received an ePLND (which involved removal of periprostatic, external iliac, obturator, hypogastric, and common iliac nodes bilaterally). Decision to undergo ePLND versus sPLND at our institution was changed in 2016 based on the National Comprehensive Cancer Network guideline. The median follow-up time was 7 and 3years for sPLND and ePLND patients, respectively. All node-positive patients were offered adjuvant radiotherapy. Kaplan-Meier analysis was carried out to assess the impact of a PLND on early postoperative PSA progression-free survival. Subgroup analyses were done for node-negative and node-positive patients, as well as Gleason score. Gleason score and T stage were not significantly different between patients who received an ePLND and sPLND. The pN1 rate for ePLND and sPLND were 20% (28/142) and 6% (10/162), respectively. There was no difference in the use of adjuvant treatments in the pN0 patients. Significantly, more ePLND pN1 patients received adjuvant androgen deprivation therapy (25/28 vs. 5/10 P=0.012) and radiation (27/28 vs. 4/10 P=0.002). Yet, no difference in biochemical recurrence between ePLND and sPLND was observed (P=0.44). This remained true in subgroup analyses of node-positive (P=0.26), node-negative (P=0.78), Gleason Score 6-7 (P=0.51), and Gleason Score 8-10 (P=0.77). PLND provided no additional therapeutic benefit, even though ePLND patients were significantly more likely to have node-positive disease and undergo adjuvant treatment, compared to a sPLND.

Practice change: No benefit of extended lymphadenectomy at radical cystectomy in patients with muscle invasive bladder cancer

For many decades, extended pelvic lymph node dissection has been an integral part during radical cystectomy for patients with muscle invasive bladder cancer. This practice was based on large retrospective meta-analyses suggesting an oncologic benefit to an extended dissection. This mini review and meta-analysis includes the two available randomized trials in the current literature. Therefore, it can be considered as the strongest level of evidence regarding the prognostic benefit of an extended pelvic lymphadenectomy. Based on current randomized data, standard pelvic lymph node dissection up to the level of iliac bifurcation is sufficient, and extension of the dissection above this level does not provide any additional oncologic benefit.

The Hunt for Lymph Nodes: Is Total Submission of Standard-Template and Extended-Template Pelvic Lymph Node Dissections Necessary for Detecting Metastatic Prostate Cancer?

There are no consensus guidelines on submission of pelvic lymph node dissection (PLND) specimens for radical prostatectomies. Complete submission is only performed by a minority of laboratories. Our institution has been following this practice for standard-template and extended-template PLND. To investigate the utility of total submission of PLND specimens for prostate cancer and understand its impact on patients and the laboratory. Retrospective study examining 733 cases of radical prostatectomies with PLND performed at our institution. Reports and slides with positive lymph nodes (LNs) were reviewed. Data on LN yield, cassette usage, and impact of submission of remaining fat after dissection of grossly identifiable LNs were assessed. Most cases involved submission of extra cassettes for remaining fat (97.5%, n = 697 of 715). Extended PLND yielded a higher mean number of total and positive LNs versus standard PLND (P < .001). However, extended PLND required significantly more cassettes for remaining fat (mean, 8; range, 0-44). There was poor correlation between number of cassettes submitted for PLND with total and positive LN yield and between remaining fat with LN yield. Most positive LNs were grossly identified (88.5%, n = 139 of 157) and were typically larger than those not. Only 4 cases (0.6%, n = 4 of 697) would have been understaged without complete submission of PLND. Total submission of PLND increases detection of metastasis and LN yield yet increases workload significantly with only minimal patient management impact. Hence, we recommend that meticulous gross identification and submission of all LNs be pursued without the need to submit the remaining fat of PLND.

Bilateral Peritoneal Flaps Reduce Incidence and Complications of Lymphoceles after Robotic Radical Prostatectomy with Pelvic Lymph Node Dissection-Results of the Prospective Randomized Multicenter Trial ProLy.

Purpose:The purpose of this study was to investigate the effect of a surgically constructed bilateral peritoneal flap (PIF) as an adjunct to robot-assisted radical prostatectomy (RARP) and pelvic lymph node dissection (PLND) on the incidence of lymphoceles.Materials and Methods:A total of 530 men with localized prostate cancer underwent a RARP with bilateral extended standardized PLND in a prospective randomized controlled trial. In group A, a PIF was created by suturing the margins of the bladder peritoneum to the ipsilateral endopelvic fascia at 2 points on each side. In group B, no PIF was created. The patients were followed 30 and 90 days after the surgery to assess the incidence, extent and treatment of lymphoceles.Results:Lymphoceles occurred in 22% of group A patients and 33% of group B patients (p=0.008). Symptomatic lymphoceles were observed in 3.3% of group A patients and 8.1% of group B patients (p=0.027). Lymphoceles requiring intervention occurred significantly less frequently in group A patients (1.3%) than in group B patients (6.8%, p=0.002). The median lymphocele size was 4.3 cm in group A and 5.0 cm in group B (p=0.055). No statistically significant differences were observed in minor or major complications unrelated to lymphocele, blood loss, or surgical time between groups A and B.Conclusions:Bilateral PIFs in conjunction with RARP and PLND significantly reduce the total incidence of lymphoceles, the frequency of symptomatic lymphoceles and the rate of associated secondary interventions.

Incidence and outcomes of nodal metastasis in clinically nonmuscle-invasive bladder cancer.

577 Background: Radical cystectomy (RC) is recommended in NMIBC patients with high risk of progression or persistent disease despite intravesical therapy. The role and extent of lymphadenectomy is controversial and not universally performed in this population. The objective of this study is to evaluate the incidence and pattern of nodal metastasis in patients undergoing radical cystectomy for treatment of clinically non-muscle invasive bladder cancer. Methods: Prospectively collected data of patients who underwent RC and ‘super-extended’ LND with intent-to-cure for urothelial carcinoma of the bladder between 2002 and 2019 were examined. Inclusion criteria were(a) clinical stage Ta, Tis,or T1, (b) muscle present and not involved,(c) no prior diagnosis of T2 disease, (d) no prior neoadjuvant therapy, and (e) super-extended lymphadenectomy performed to level of IMA with mapping information available. Logistic regression analysis was used to evaluate for predictors of node metastasis. Results: A total of 223 patients met inclusion criteria with a median follow up of 8.2 years (IQR 4.1-10.7). Lymph node metastasis was identified in 8.1% (18/223) of the cohort. Nodal metastasis was present in 0 patients with cTis, 0 patients with cTa, and 11.6% (18/155) of patients with cT1 disease. Of the 18 patients with LNM in cT1 disease, 61% (11/18) had positive nodes below the common ileac vessel bifurcation, 6% (1/18) had positive nodes below the level of aortic bifurcation, and 33% (6/18) had distant metastasis to lymph nodes beyond aortic bifurcation. No skip metastasis were identified. After RC, 89% of cT1 with nodal metastasis had muscle invasive disease. On logistic regression analysis, presence of LVI on TURBT specimen was a significant predictor of LNM (OR 6.8, CI 2.2-20.9). Five-year RFS was 91%, 82%, and 61% in patients with pNMIBC, cNMIBC, and pMIBC, respectively. Conclusions: Routine lymph node dissection is necessary in patients undergoing RC for cT1 disease due to risk of upstaging and LNMs. Presence of LVI in TURBT specimen of cNMIBC is a predictor of nodal metastasis. In patients with nodal disease, metastasis beyond the limits of a standard lymph node template occurred in two-thirds of patients, however a standard pelvic node dissection would have identified all patients with node positive disease.

Robotic Vessel Sealer Device for Lymphocele Prevention After Pelvic Lymphadenectomy: Results of a Randomized Trial.

Introduction: Pelvic lymph node dissection (PLND) during robotic prostatectomy is associated with potential complications. The most common complication of PLND is lymphoceles, occurring in up to 50% of patients in studies with screening imaging but usually asymptomatic. We performed a prospective randomized trial to evaluate whether using advanced bipolar energy for PLND via the robotic vessel sealer can prevent lymphoceles. Methods: A total of 120 patients were enrolled in the trial with each patient serving as their own control. Robotic PLND was randomly performed using the vessel sealer on one side and standard PLND using clips on the other side. All patients underwent screening computed tomography scan 3 months postoperatively with radiologists blinded to the assigned technique. Significant lymphoceles were defined as fluid collections ≥3 cm in any plane. Results: Of those enrolled, 114 completed the study. The mean nodal yield was 6.5 nodes, with 3.1 versus 3.4 nodes for vessel sealer side versus standard technique (P = .35), respectively. The mean operative time for PLND was 11.3 versus 11.1 minutes (P = .62), respectively. Twenty-two lymphoceles were identified. Ten occurred on the vessel sealer side versus 12 on the standard side (8.8% versus 10.5%, P = .412). All lymphoceles were asymptomatic. Conclusions: While the robotic advanced bipolar device did not appear to prevent lymphoceles, the vessel sealer also did not increase the rate of lymphoceles compared with a standard technique using clips. Both techniques were equally efficacious, efficient, and safe for PLND such that surgeons who prefer to avoid clips can reasonably use the vessel sealer, although at increased cost. Clinical Trial Registration number: NCT02035475.

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 ...

Prediction of the Need for an Extended Lymphadenectomy at the Time of Radical Cystectomy in Patients with Bladder Cancer

BackgroundA prospective randomized trial (LEA AUO AB 25/02) found no survival benefit in extended compared with limited pelvic lymph node dissection (PLND) templates in bladder cancer (BCa) patients treated with radical cystectomy (RC). However, the rate of lymph node invasion (LNI) in the standard and extended templates was lower than estimated. ObjectiveTo assess the accuracy of preoperative clinical and pathological parameters to predict LNI and to develop a model to preoperatively select candidates for the extended PLND templates. Design, setting, and participantsA total of 903 BCa patients treated at a single institution were retrospectively identified. The primary outcome was to identify preoperatively the risk of LNI to tailor the type of PLND. The extended PLND templates consisted in the removal of pelvic lymph nodes together with the common iliac, presacral, para-aortocaval, interaortocaval, and paracaval sites up to the inferior mesenteric artery. InterventionA total of 903 BCa patients were treated with RC and bilateral extended PLND templates. Outcome measurements and statistical analysisSeveral models predicting LNI were evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots and decision curve analyses. A nomogram predicting LNI in the extended pattern was developed and validated internally. Results and limitationsOverall, 55 patients (6.1%) had LNI in the extended PLND templates at RC. The median number of nodes removed was 19 (interquartile range: 13–26). A model including age, clinical T stage, clinical node stage, lymphovascular invasion, and presence of carcinoma in situ at the last transurethral resection before RC was developed. The AUC of this model is 73%. Using a cutoff of 3%, 108 extended PLNDs (12%) would be spared and only two LNIs (3%) would be missed. The main limitations of our model are the retrospective nature of the data, lack of external validation, and low rate of LNI. ConclusionsThis is the first proposed model to predict LNI in the extended PLND templates. This model might help urologists identify which patients might benefit from an extended PLND at the time of RC, reserving a standard PLND for all the others. Patient summaryWe developed the first nomogram to predict lymph node invasion (LNI) in the extended pelvic lymph node dissection templates in bladder cancer patients treated with radical cystectomy. The adoption of our model to identify candidates for the extended pelvic lymph node dissection templates could avoid up to 12% of these procedures at the cost of missing only 3% of patients with LNI.

Cutting-edge Management of Muscle-invasive Bladder Cancer in 2020 and a Glimpse into the Future

This case-based discussion describes the clinical course of a 63-yr-old patient who presented with gross hematuria and was diagnosed with a muscle-invasive bladder cancer at transurethral resection. Computed tomography revealed a locally advanced tumor, and the patient underwent neoadjuvant chemotherapy followed by open radical cystectomy with standard pelvic lymph node dissection. In a step-by-step fashion, we elaborate on diagnostic and therapeutic treatment options from two different vantage points: (1) guideline-adherent treatment with the state-of-the-art standard of care, and (2) a glimpse into the future discussing the evidence of potential additional or alternative approaches based on recent scientific advances. Patient summaryIn this case-based discussion, we follow the clinical course of a patient with advanced bladder cancer and elaborate how the state-of-the-art treatment looks like in 2020, based on the best available evidence. This is compared with potential future treatment strategies, which may change and alternate our understanding of optimal bladder cancer care.

Applied anatomy of pelvic lymph nodes and its clinical significance for prostate cancer:a single-center cadaveric study

BackgroundPelvic lymph node dissection (PLND) is one of the most important steps in radical prostatectomy (RP). Not only can PLND provide accurate clinical staging to guide treatment after prostatectomy but PLND can also improve the prognosis of patients by eradicating micro-metastases. However, reports of the number of pelvic lymph nodes have generally come from incomplete dissection during surgery, there is no anatomic study that assesses the number and variability of lymph nodes. Our objective is to assess the utility of adopting the lymph node count as a metric of surgical quality for the extent of lymph node dissection during RP for prostate cancer by conducting a dissection study of pelvic lymph nodes in adult male cadavers.MethodsAll 30 adult male cadavers underwent pelvic lymph node dissection (PLND), and the lymph nodes in each of the 9 dissection zones were enumerated and analyzed.ResultsA total of 1267 lymph nodes were obtained. The number of lymph nodes obtained by limited PLND was 4–22 (14.1 ± 4.5), the number obtained by standard PLND was 16–35 (25.9 ± 5.6), the number obtained by extended PLND was 17–44 (30.0 ± 7.0), and the number obtained by super-extended PLDN was 24–60 (42.2 ± 9.7).ConclusionsThere are substantial inter-individual differences in the number of lymph nodes in the pelvic cavity. These results have demonstrated the rationality and feasibility of adopting lymph node count as a surrogate for evaluating the utility of PLND in radical prostatectomy, but these results need to be further explored.

Complication reporting with the Bern Comprehensive Complication Index CCI after open radical prostatectomy: A longitudinal long-term single-center study

ObjectiveTo impartially optimize complication reporting in patients after open radical prostatectomy (ORP) and pelvic lymph node dissection (PLND) by adopting the modified Bern Comprehensive Complication Index (CCI). ORP and PLND are associated with relevant postoperative morbidity. The CCI—ranging from 0 (no complications) to 100 (death)—is a tool that aims to integrate all complications occuring within 90 days postoperatively weighted by severity in a single formula. MethodsIn an observational single-center cohort, 90-day postoperative complications of 1,123 consecutive patients undergoing standardized ORP and PLND between 1996 and 2017 were evaluated. Prospectively collected complications were graded according to the Clavien-Dindo Classification. Grade I to II complications were defined as minor and grade IIIa to V as major. Finally, the recently developed modified Bern CCI using an exponential function, which transforms the sum of the weights into a value between 0 and 100 and the original CCI for each patient were extracted and compared. The correlation between the modified Bern and original CCI values was depicted graphically. ResultsThe complication rate was 42%, with 18% minor and 24% major complications. With the original CCI, the threshold of 100 was exceeded in 1 patient who had a maximal index value of 101 within 90d postoperatively. The maximal value of the Bern CCI was 97.5. Mean Bern and original CCI scores and standard deviations were 6.2 (11.3) and 7.6 (12.2) at 30 days, and 9.3 (13.9) and 10.7 (14.2) at 90 days. ConclusionsThe Bern CCI provides a more precise depiction of postoperative morbidity and represents the burden in patients with >1 complication after ORP and PLND more accurately than the original CCI allowing for a more reliable evaluation of quality of care and recovery. It therefore warrants consideration for standardized reporting of complications after ORP and PLND.

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.

Standard vs extended pelvic lymph node dissection: Peri-operative complications and survival outcomes following radical cystectomy

Standard vs extended pelvic lymph node dissection: Peri-operative complications and survival outcomes following radical cystectomy

Extended versus standard lymph node dissection for urothelial carcinoma of the bladder in patients undergoing radical cystectomy.

In the treatment of urothelial carcinoma of the bladder, we are currently uncertain of the benefits and harms of standard pelvic lymph node dissection (PLND) compared to extended PLND. To assess the effects of extended versus standard PLND in patients undergoing cystectomy to treat muscle-invasive (cT2 and cT3) and treatment-refractory, non-muscle-invasive (cT1 with or without carcinoma in situ) urothelial carcinoma of the bladder. We performed a comprehensive literature search using multiple databases (PubMed, Embase, Cochrane Controlled Trials, Web of Science, and LILACS), trial registries, and conference proceedings published up to April 29, 2019, with no restrictions on the language or status of publication. We included randomized controlled trials in which participants underwent radical cystectomy (RC) for muscle-invasive or therapy-refractory non-muscle-invasive urothelial carcinoma of the bladder with either an extended PLND with a superior extent reaching as far cranially as the inferior mesenteric vein, or a standard PLND with a superior extent of the bifurcation of the internal and external iliac artery, with otherwise the same anatomical boundaries. Two review authors independently assessed the included studies and extracted data from them for the primary outcomes: time to death from any cause, time to death from bladder cancer and Clavien-Dindo classification of surgical complications grade III-V, and the secondary outcomes: time to recurrence, Clavien-Dindo I-II complications and disease-specific quality of life.We performed statistical analyses using a random-effects model and rated the certainty of evidence according to the GRADE approach. The search identified one multicenter trial based in Germany that enrolled 401 participants with histologically confirmed T1 grade 3 or muscle-invasive urothelial carcinoma. The median age was 67 years (range: 59 to 74) and the majority of participants were male (78.3%). No participant received neoadjuvant chemotherapy; a small subset received adjuvant chemotherapy (14.5%).Primary outcomesOur results indicate that extended PLND may reduce the risk of death from any cause over time as compared to standard PLND, but the confidence interval includes the possibility of no effect (hazard ratio [HR]: 0.78, 95% confidence interval [CI]: 0.57 to 1.07, 401 participants, low-certainty evidence). After five years of follow-up, this may result in 83 fewer deaths (95% CI: 174 fewer to 24 more overall deaths) per 1000 participants: 420 deaths for extended PLND compared to 503 deaths per 1000 for standard PLND. We downgraded the certainty of evidence by two levels due to study limitations and imprecision.Our results indicate that extended PLND may reduce the risk of death from bladder cancer over time as compared to standard PLND but, again, the confidence interval includes the possibility of no effect (HR: 0.70, 95% CI: 0.45 to 1.07, participants = 401, low-certainty evidence). After five years of follow-up, this corresponds to 91 fewer deaths per 1000 participants (95% CI: 176 fewer to 19 more bladder cancer deaths): 264 deaths for extended PLND compared to 355 deaths per 1000 for standard PLND. We downgraded the certainty of evidence by two levels due to study limitations and imprecision.Based on follow-up of up to 30 days, we are uncertain whether extended PLND leads to more grade III-V complications as compared to standard PLND, because of study limitations and imprecision (risk ratio [RR]: 1.13, 95% CI: 0.84 to 1.52, participants = 401, very low-certainty evidence).Secondary outcomesWe are uncertain whether extended PLND reduces the risk of recurrence over time as compared to standard PLND, because of study limitations and imprecision (HR: 0.84, 95% CI: 0.58 to 1.22, participants = 401, very low-certainty evidence).Based on follow-up of up to 30 days, we are uncertain whether extended PLND leads to similar grade I-II complications as compared to standard PLND because of study limitations and imprecision (RR: 0.94, 95% CI: 0.74 to 1.19, participants = 401, very low-certainty evidence).We found no trials that reported on disease-specific quality of life. Results from a single trial indicate that extended PLND in patients undergoing radical cystectomy for invasive urothelial carcinoma of the bladder may reduce death from any cause and death from bladder cancer over time; however, the results include the possibility of no effect. We are uncertain whether the risk of serious complications up to 30 days may be increased. We are also uncertain as to whether the risk of recurrence over time or the risk of minor complications up to 30 days changes. We were unable to conduct any of the preplanned subgroup analyses, in particular, analyses based on extended lymph node dissection templates, clinical tumor stage, and use of neoadjuvant chemotherapy that may be important effect modifiers. Important additional data is expected from a larger, ongoing trial that will also consider the role of neoadjuvant chemotherapy. Inclusion of this trial in the meta-analysis may help address the issue of imprecision which was a common reason for downgrading the certainty of the evidence.

Comparison of efficacy between extended pelvic lymph node dissection and standard pelvic lymph node dissection in open radical cystectomy

Objective To compare the efficacy of extended pelvic lymph node dissection (ePLND) and standard pelvic lymph node dissection (sPLND) in open radical cystectomy. Methods We retrospectively analyzed the clinical data of 139 patients with bladder cancer cases in our hospital from January 2007 to January 2017, who underwent open radical cystectomy and pelvic lymph node dissection performed by the same group of surgeons. There were 117 males and 22 females, aged from 20 to 84 years old, with an average of (64.6±11.7) years, 91 patients were underwent ePLND group and 48 patients were underwent sPLND group. The preoperative anemia-free patients was compared between the ePLND group and the sPLND group [24 (50.0%)] vs. 58 (54.9%), respectively], the patients with anemia were [24 (50.0%) vs. 41 (45.1%)]. The range of ePLND is: sway to the common iliac artery and the lower aortic (unreaching the inferior mesenteric artery); the lateral boundary to the reproductive femoral nerve; the distal end of the iliac artery at the groin level, the posterior border to the iliac vessels and closure, which contains the anterior tibial lymph nodes between the two sides. The range of sPLND is below the level of the common iliac artery bifurcation, and the rest of the range is the same as ePLND. The average operative time, average intraoperative blood loss, intraoperative blood transfusion, intraoperative and postoperative complications, postoperative eating time, postoperative activity time, postoperative exhaust time, postoperative hospital stay, mean gastric tube indwelling time, average pelvic drainage tube indwelling time, lymph nodes positive rate, lymph node density, and cancer-free survival were evaluated. Results All 139 patients underwent surgery successfully. The average operative time in the ePLND group and the sPLND group were [(351.2±79.5) min vs.(342.5±69.3) min], average intraoperative blood loss [(314.6±120.6) ml vs.(298.3±126.3) ml], intraoperative blood transfusion [(702.9±645.7) ml vs.(936.9±818.1) ml], no intraoperative complications, postoperative complications [29 cases (31.9%)vs.18 cases (37.5%)], postoperative eating time [(5.4±1.9)d vs.(4.8±2.1)d], postoperative activity time[(2.1±0.9)d vs.(1.9±0.8)d], postoperative exhaust time [(3.8±0.9)d vs.(3.6±1.0)d], postoperative hospital stay [(14.9±7.8) d vs.(15.5 ± 6.9) d], average gastric tube indwelling time [(4.8 ± 2.6) d vs.(4.53± 1.9) d], average pelvic drainage tube indwelling time [( 11.1±4.9)d vs.(10.9±4.9)d], the difference was not statistically significant (P>0.05). A total of 2 359 lymph nodes were dissected from the two groups. The number of lymph nodes dissected in each of the ePLND group and the sPLND group was [(20.3±3.8) vs. (10.6±3.1), P<0.01], and the average number of positive lymph nodes was [(0.6±1.3) vs.(0.3±1.0), P=0.034], the ratio of lymph node positive patients was [33 (36.3%) vs. 9 (18.8%), P=0.026], and the lymph node density was [7.9% (146/1848) vs. 4.1% (21/511)], the difference was statistically significant (P<0.05). In regard to prognosis, the disease-free survival rate (DFS) of ePLND group was 94.5%, 91.0%, 84.4%, 81.1%, 75.3% at 1, 2, 3, 4 and 5 years follow-up respectively. The other group was 70.5%, 63.5%, 57.8%, 51.4%, 41.1% respectively. DFS of ePLND group tended to be higher than that of sPLND group in lymph node positive subgroups. The difference between the two groups was statistically significant (P<0.001). Conclusions In open radical cystectomy, ePLND and sPLND have similar surgical safety, but expanded lymph node dissection can improve disease-free survival in patients and improve the prognosis by increasing the detection range of positive lymph nodes. Key words: Bladder cancer; Radical cystectomy; Lymph node dissection; Cancer-free survival; Prognosis

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.

The Value of 99mTc-PSMA SPECT/CT-Guided Surgery for Identifying and Locating Lymph Node Metastasis in Prostate Cancer Patients.

This study evaluated the effect of technetium-99m (99mTc)-labeled prostate-specific membrane antigen (PSMA)-based image-guided surgery on the oncologic outcomes for patients with primary or recurrent prostate cancer (PCa). This study retrospectively analyzed 54 consecutive patients with PCa who underwent 99mTc-labeled PSMA-based image-guided surgery between January 2016 and September 2017. These patients received a radical prostatectomy (RP) with pelvic lymph node dissection (PLND) or salvage lymph node dissection (sLND). The resected specimens were compared with findings of postoperative histologic analysis. The responses to the treatment were recorded during the follow-up period. In 31 patients, PSMA single-photon emission computerized tomography (SPECT) and computed tomography (CT) could find 52 suspicious lymph node metastases (LNMs). With the help of PSMA SPECT/CT, 12 patients with recurrence received sLND, 19 primary PCa patients received RP with extended PLND, and 23 primary PCa patients received RP with standard PLND. The findings showed that PSMA SPECT/CT could detect LNMs with high sensitivity and specificity. In six patients, PSMA SPECT/CT could find more LNMs that were not found by MRI and help to modify the extent of lymphadenectomy. At the latest follow-up evaluation, 39 patients showed a biochemical response (BR), 9 patients showed a biochemical recurrence (BCR) after BR, and 6 patients never exhibited BR. The patients who received RP with standard PLND or extended PLND had a better prostate-specific antigen (PSA) response than the patients who received sLND. The patients with pelvic LNMs also had a better PSA response than the patients with retroperitoneal LNMs. This study showed that 99mTc-PSMA SPECT/CT-guided surgery can remove more LNMs than conventional imaging with high sensitivity and specificity and delay disease progression in PCa patients.

Does preoperative neutrophil/lymphocyte rate have an effect on survival of the bladder cancer patients who received radical cystectomy?

Radical cystectomy (RC) is the standard treatment model in invasive bladder cancer patients. Risk definitions before RC is mainly based on pathological results. Neutrophil/lymphocyte (N/L) rate is one of the inflammation markers. Some other studies reported negative prognostic results with increased N/L rates. In our study, we reviewed the relationship between preoperative N/L rate and clinicopathological results following RC. Data gathered from 296 bladder cancer patients that received RC between 2002 and 2012 were retrospectively reviewed. All patients received preoperative routine hematological and biochemical tests and metastasis screening. All patients were treated with radical cystoprostatectomy and standard pelvic lymph node dissection. The cutoff value for N/L rate was calculated using a web-based "cutoff finder" software. Patient mean age was calculated as 65.7 years. Mean follow-up period was 24.5 (2-84) months. Cancer-related death was seen in 132 (44.6%) patients. Multivariate analysis showed age, lymph node metastasis, and low N/L rate as significant in cancer-specific survival. In our study, age, lymph node metastasis presence, and preoperative low N/L rates were detected as independent risk factors in RC cases. N/L rate, which is relatively easy to assess during preoperative period, could be beneficial in planning postoperative adjuvant treatments in those patients.

Reconsidering the role of pelvic lymph node dissection with radical prostatectomy for prostate cancer in an era of improving radiological staging techniques.

Performing an extended pelvic lymph node dissection (PLND) on all men with intermediate- and high-risk prostate cancer at the time of a radical prostatectomy (RP) remains controversial. The majority of patients PLND histology is benign, and the long-term cancer-free progression in men with positive lymph node metastasis is low. The objective is to investigate the probability of long-term biochemical freedom from recurrent disease (bNED) in men with lymph node metastasis identified at the time of radical prostatectomy (RP). A retrospective review of the pathology of 1184 pelvic lymph node dissections performed at the time of a radical prostatectomy by multiple surgeons referred to a single uro-pathology laboratory between 2008 and 2014 identified 61 men with node-positive prostate cancer. Of the men with positive nodes, 24 had a standard PLND and 37 an extended PLND (ePLND). bNED was defined as a post-operative serum PSA<0.2ng/ml. The median follow-up is 4years (2-8). The median lymph node count was 7 (range 2-16) for PLND and 22 (range 6-46) for the ePLND. A single lymph node metastasis was identified in 56% of the 61 men. Only 10% of men with a positive lymph node metastasis remained free of biochemical recurrence of disease, and only 5% had undetectable serum PSA. There was no difference in bNED outcome between a PLND and ePLND. The number of men needed to be treated with a PLND at the time of RP (NNT) to result in an undetectable post-operative PSA at a median follow-up of 4years is 395. In men with lymph node metastasis, the probability of long-term bNED is low and the NNT for cure is high. With emerging improved radiological imaging techniques increasing the detection of lymph node metastasis outside the extended lymph node dissection templates, more scientific investigation is required to evaluate which men will benefit from a PLND and which men can avoid an unnecessary PLND procedure.