title: Indication for and extension of pelvic lymph node dissection during robot-assisted radical prostatectomy: an analysis of five European institutions.
abstract: BACKGROUND
  Several reports have shown that patients who undergo minimally invasive radical prostatectomy have a lower chance of undergoing pelvic lymph node dissection (PLND), irrespective of the disease characteristics.
  
  
  OBJECTIVE
  We evaluated the rate and extension of PLND in patients who underwent robot-assisted radical prostatectomy (RARP). We tested the adherence of the indication for PLND to the European Association of Urology (EAU) guidelines.
  
  
  METHODS
  Our study was a multi-institutional retrospective analysis of prospectively collected data on 2985 consecutive patients who underwent RARP at five high-volume European institutions. Patients were stratified according to preoperative cancer risk group.
  
  
  METHODS
  RARP.
  
  
  METHODS
  The rate and extent of PLND across different institutions were analyzed. Univariable and multivariable logistic regression models evaluated the association between preoperative variables and the probability of receiving PLND, as well as the presence of lymph node invasion (LNI). Finally, the probability of LNI was calculated for each patient, and the indication for PLND was compared with the EAU guidelines' indications.
  
  
  CONCLUSIONS
  A lymph node dissection was performed in 1777 patients (59.7%; 34.5% of low-risk patients, 64.9% of intermediate-risk patients, and 91.2% of high-risk patients). These rates were different across institutions: 5.0-41.4% in low-risk patients (p<0.001), 31.3-81.4% in intermediate-risk patients (p<0.001), and 84.6-96.4% in high-risk patients (p=0.06). The mean and median number of nodes removed was 10.8, and 122 patients (4.1%) had nodal metastases. At multivariable analysis, the institution represented an independent predictor of PLND (p<0.001). Of patients with current indication for PLND (EAU guidelines), 77.8% actually received the procedure. Limitations were the retrospective study design with different pathologic assessment and lack of follow-up data.
  
  
  CONCLUSIONS
  PLND is performed in a high proportion of patients undergoing RARP in high-volume centers in Europe for whom the procedure is indicated by the EAU guidelines, but significant differences exist among institutions. An effort toward a more rigorous standardization of PLND is advocated.
  
  
  RESULTS
  In this paper, we investigated the indication for and extension of pelvic lymph node dissection (PLND) in different institutions in Europe. Despite PLND being widely performed, significant variations with regard to PLND do exist among different institutions. Therefore, a thrust toward more rigorous attention to PLND is advocated.
authors.affiliation: Department of Urology, Urological Research Institute, University Vita-Salute San Raffaele, Milan, Italy. Electronic address: suardi.nazareno@hsr.it.
authors.forename: Nazareno
authors.initials: N
authors.lastname: Suardi
authors.affiliation: Department of Urology, Urological Research Institute, University Vita-Salute San Raffaele, Milan, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Larcher
authors.affiliation: Department of Urology, University of Hamburg Eppendorf, Hamburg, Germany.
authors.forename: Alexander
authors.initials: A
authors.lastname: Haese
authors.affiliation: Department of Urology, University of Udine, Udine, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Ficarra
authors.affiliation: Department of Urology, Moscow State University of Medicine and Dentistry, Moscow, Russia.
authors.forename: Alexander
authors.initials: A
authors.lastname: Govorov
authors.affiliation: Department of Urology, Urological Research Institute, University Vita-Salute San Raffaele, Milan, Italy.
authors.forename: Nicolò M
authors.initials: NM
authors.lastname: Buffi
authors.affiliation: Department of Urology, Institut Paoli-Calmettes, Marseille, France.
authors.forename: Jochen
authors.initials: J
authors.lastname: Walz
authors.affiliation: Fondazione Ospedale Maggiore Policlinico, Department of Urology, University of Milan, Milan, Italy.
authors.forename: Bernardo
authors.initials: B
authors.lastname: Rocco
authors.affiliation: Department of Urology, O.L.V. Clinic, Aalst, Belgium.
authors.forename: Marco
authors.initials: M
authors.lastname: Borghesi
authors.affiliation: Department of Urology, University of Hamburg Eppendorf, Hamburg, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Steuber
authors.affiliation: Department of Urology and Kidney Transplantation Center, Martin-Luther-University, Halle Saale, Germany.
authors.forename: Giovannalberto
authors.initials: G
authors.lastname: Pini
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, O.L.V. Clinic, Aalst, Belgium.
authors.forename: Alexander M
authors.initials: AM
authors.lastname: Mottrie
authors.affiliation: Department of Urology, Urological Research Institute, University Vita-Salute San Raffaele, Milan, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Guazzoni
authors.affiliation: Department of Urology, Urological Research Institute, University Vita-Salute San Raffaele, Milan, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.affiliation: Department of Urology, Moscow State University of Medicine and Dentistry, Moscow, Russia.
authors.forename: Dmitry
authors.initials: D
authors.lastname: Pushkar
authors.affiliation: Department of Urology, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Henk
authors.initials: H
authors.lastname: Van Der Poel
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D015331:Cohort Studies; D005060:Europe; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008197:Lymph Node Excision / Q000379:methods* / Q000706:statistics & numerical data; D008198:Lymph Nodes / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D010388:Pelvis / Q000601:surgery; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment; D065287:Robotic Surgical Procedures / Q000379:methods*; D015996:Survival Rate; D016896:Treatment Outcome
keywords: Lymph nodes; Lymphadenectomy; Prostate cancer; Radical prostatectomy; Robotics