title: The role of radical prostatectomy and lymph node dissection in lymph node-positive prostate cancer: a systematic review of the literature.
abstract: BACKGROUND
  Because pelvic lymph node (LN)-positive prostate cancer (PCa) is generally considered a regionally metastatic disease, surgery needs to be better defined.
  
  
  OBJECTIVE
  To review the impact of radical prostatectomy (RP) and pelvic lymph node dissection (PLND), possibly in conjunction with a multimodal approach using local radiotherapy and/or androgen-deprivation therapy (ADT), in LN-positive PCa.
  
  
  METHODS
  A systematic Medline search for studies reporting on treatment regimens and outcomes in patients with LN-positive PCa undergoing RP between 1993 and 2012 was performed.
  
  
  RESULTS
  RP can improve progression-free and overall survival in LN-positive PCa, although there is a lack of high-level evidence. Therefore, the former practice of aborting surgery in the presence of positive nodes might no longer be supported by current evidence, especially in those patients with a limited LN tumor burden. Current data demonstrate that the lymphatic spread takes an ascending pathway from the pelvis to the retroperitoneum, in which the internal and the common iliac nodes represent critical landmarks in the metastatic distribution. Sophisticated imaging technologies are still under investigation to improve the prediction of LN-positive PCa. Nonetheless, extended PLND including the common iliac arteries should be offered to intermediate- and high-risk patients to improve nodal staging with a possible benefit in prostate-specific antigen progression-free survival by removing significant metastatic load. Adjuvant ADT has the potential to improve overall survival after RP; the therapeutic role of a trimodal approach with adjuvant local radiotherapy awaits further elucidation. Age is a critical parameter for survival because cancer-specific mortality exceeds overall mortality in younger patients (<60 yr) with high-risk PCa and should be an impetus to treat as thoroughly as possible.
  
  
  CONCLUSIONS
  Increasing evidence suggests that RP and extended PLND improve survival in LN-positive PCa. Our understanding of surgery of the primary tumor in LN-positive PCa needs a conceptual change from a palliative option to the first step in a multimodal approach with a significant improvement of long-term survival and cure in selected patients.
authors.affiliation: Department of Urology, University Hospital Tübingen, Eberhard-Karls University Tübingen, Germany. Electronic address: georgios.gakis@googlemail.com.
authors.forename: Georgios
authors.initials: G
authors.lastname: Gakis
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, MN, USA.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Boorjian
authors.affiliation: Department of Urology, Urological Research Institute, University Vita-Salute San Raffaele, Milan, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Briganti
authors.affiliation: Department of Urology, University Hospital K.U. Leuven, Leuven, Belgium.
authors.forename: Steven
authors.initials: S
authors.lastname: Joniau
authors.affiliation: Clinic of Urology, SJC Modern Medical Technologies, Tbilisi, Georgia.
authors.forename: Guram
authors.initials: G
authors.lastname: Karazanashvili
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, MN, USA.
authors.forename: R Jeffrey
authors.initials: RJ
authors.lastname: Karnes
authors.affiliation: Department of Urology, Kantonsspital Lucerne, Lucerne, Switzerland.
authors.forename: Agostino
authors.initials: A
authors.lastname: Mattei
authors.affiliation: Department of Urology, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Shahrokh F
authors.initials: SF
authors.lastname: Shariat
authors.affiliation: Department of Urology, University Hospital Tübingen, Eberhard-Karls University Tübingen, Germany.
authors.forename: Arnulf
authors.initials: A
authors.lastname: Stenzl
authors.affiliation: Department of Urology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
authors.forename: Manfred
authors.initials: M
authors.lastname: Wirth
authors.affiliation: Department of Urology, Ludwig-Maximilians-University, Munich-Grosshadern, Germany.
authors.forename: Christian G
authors.initials: CG
authors.lastname: Stief
mesh_terms: D017024:Chemotherapy, Adjuvant; D018572:Disease-Free Survival; D006801:Humans; D007083:Iliac Artery; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008297:Male; D010388:Pelvis; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000188:drug therapy / Q000473:pathology* / Q000601:surgery*; D015996:Survival Rate
keywords: Androgen-deprivation therapy; Imaging; Lymph node positive metastasis; Multimodality; Pelvic lymph node dissection; Prostate cancer; Radical prostatectomy; Radiotherapy