title: Extended versus limited pelvic lymph node dissection during bilateral nerve-sparing radical prostatectomy and its effect on continence and erectile function recovery: long-term results and trifecta rates of a comparative analysis.
abstract: OBJECTIVE
  To assess continence and erectile function (EF) recovery of extended pelvic lymph node dissection (ePLND) versus limited PLND (lPLND) after bilateral nerve-sparing radical prostatectomy (BNSRP).
  
  
  METHODS
  Consecutive prostate cancer (PCa) patients undergoing BNSRP were stratified according to D'Amico into two groups: low-risk-PCa lPLND (obturator) and intermediate-/high-risk-PCa ePLND (obturator, external iliac artery, internal iliac artery, common iliac artery). Continence (no pad/one safety pad) and EF (IIEF-5 ≥ 17) recovery were assessed. Patients with phosphodiesterase type 5 inhibitors, neoadjuvant/adjuvant therapy, positive lymph nodes or positive surgical margins were excluded.
  
  
  RESULTS
  From January 2007 to May 2012, a total 966 consecutive patients were included. Four hundred and sixty patients met the inclusion/exclusion criteria: 262 patients had ePLND and 198 patients had lPLND. Mean number of lymph nodes was 20.4 (range 10-65) and 4.7 (range 0-10), respectively (p < 0.001). Continence and spontaneous EF recovery after 12 months were 89.7 versus 93.4 % and 40.4 versus 47.5 %, respectively (all p > 0.05). Patient age at surgery (p = 0.001), preoperative EF (p < 0.001) and pathological tumor stage (p = 0.008), but not ePLND (p = 0.561), were independent predictors of EF recovery. No association was detected for continence recovery. Seven-year BCR-free survival for pT2 PCa was 100 and 94.8 % in lPLND and ePLND, respectively (p = 0.011). For pT3 PCa, this was 94.7 and 81.2 %, respectively (p = 0.287). At 2 years, the trifecta of continence, potency and recurrence freedom was achieved in 47.5 and 44.1 % in lPLND and ePLND, respectively (p = 0.451).
  
  
  CONCLUSIONS
  ePLND is not associated with increased risk of postoperative incontinence or erectile dysfunction. Only patient age at surgery, preoperative EF and pathological tumor stage represent predictors of EF recovery.
authors.affiliation: Department of Urology, Technical University of Munich, University Hospital Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany. georgios.hatzichristodoulou@lrz.tum.de.
authors.forename: Georgios
authors.initials: G
authors.lastname: Hatzichristodoulou
authors.affiliation: Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Hospital, Homburg/Saar, Germany.
authors.forename: Stefan
authors.initials: S
authors.lastname: Wagenpfeil
authors.affiliation: Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Hospital, Homburg/Saar, Germany.
authors.forename: Gudrun
authors.initials: G
authors.lastname: Wagenpfeil
authors.affiliation: Department of Urology, Technical University of Munich, University Hospital Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany.
authors.forename: Tobias
authors.initials: T
authors.lastname: Maurer
authors.affiliation: Department of Urology, Technical University of Munich, University Hospital Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Horn
authors.affiliation: Department of Urology, Technical University of Munich, University Hospital Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Herkommer
authors.affiliation: Department of Urology, Technical University of Munich, University Hospital Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany.
authors.forename: Marie
authors.initials: M
authors.lastname: Hegemann
authors.affiliation: Department of Urology, Technical University of Munich, University Hospital Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany.
authors.forename: Jürgen E
authors.initials: JE
authors.lastname: Gschwend
authors.affiliation: Department of Urology, Technical University of Munich, University Hospital Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany.
authors.forename: Hubert
authors.initials: H
authors.lastname: Kübler
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008297:Male; D008875:Middle Aged; D059351:Organ Sparing Treatments; D010410:Penile Erection; D011467:Prostate / Q000294:innervation* / Q000601:surgery*; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000601:surgery*; D020127:Recovery of Function; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014554:Urination
keywords: Continence; Erectile function; Extended lymph node dissection; Radical prostatectomy; Trifecta