title: Extending the indications and anatomical limits of pelvic lymph node dissection for prostate cancer: improved staging or increased morbidity?
abstract: OBJECTIVE
  • 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).
  
  
  METHODS
  • 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.
  
  
  RESULTS
  • 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).
  
  
  CONCLUSIONS
  • 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.
authors.affiliation: Department of Surgery, Service of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA. touijera@mskcc.org
authors.forename: Karim
authors.initials: K
authors.lastname: Touijer
authors.forename: Rodrigo Pinochet
authors.initials: RP
authors.lastname: Fuenzalida
authors.forename: Farhang
authors.initials: F
authors.lastname: Rabbani
authors.forename: Philippe
authors.initials: P
authors.lastname: Paparel
authors.forename: Lucas
authors.initials: L
authors.lastname: Nogueira
authors.forename: Angel M
authors.initials: AM
authors.lastname: Cronin
authors.forename: Samson W
authors.initials: SW
authors.lastname: Fine
authors.forename: Bertrand
authors.initials: B
authors.lastname: Guillonneau
mesh_terms: D006801:Humans; D007431:Intraoperative Complications / Q000209:etiology; D010535:Laparoscopy / Q000009:adverse effects* / Q000379:methods; D007902:Length of Stay; D008197:Lymph Node Excision / Q000009:adverse effects* / Q000379:methods; D008207:Lymphatic Metastasis; D008297:Male; D009367:Neoplasm Staging / Q000379:methods; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D011471:Prostatic Neoplasms / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment