A narrative review of pelvic lymph node dissection in prostate cancer

Abstract

Pelvic lymph node dissection (PLND) is an important component in the staging and prognostication of prostate cancer. We performed a narrative review to assess the literature surrounding PLND: (I) the current guideline recommendations and contemporary utilization, (II) the calculation of patient-specific risk to perform PLND using available nomograms, (III) to review the extent of dissection, and its associated outcomes and complications. Due to the improved lymph node yield, better staging, and theoretical improvement in the control of micro-metastatic disease, guidelines have supported the use of (extended-) PLND in patients deemed to be at intermediate or high risk of lymph node involvement (often at a threshold of 5% on modern risk nomograms). However, in practice, real-world utilization of PLND varies considerably due to multiple reasons. Conflicting evidence persists with no clear oncological benefit to PLND, and a small, but important, risk of morbidity. Complications are rare, but include lymphoceles; thromboembolic events; and more rarely, obturator nerve, vascular, and ureteric injury. Furthermore, changing disease incidence and stage migration in the context of earlier detection overall have led to a decreased risk of nodal disease. The trade-offs between the benefits, harms, and risk tolerance/threshold must be carefully considered between each patient and their clinician.

Prevalence of adverse pathology features in grade group 2 prostatectomy specimens with syn‐ or metachronous metastatic disease

“…A previous single‐institution series demonstrated synchronous regional lymph node metastatic disease at the time of surgery of GG2 prostate cancer in 0.6% of patients as compared to 5% in GG3 prostatectomy cases 2 . This compares with 1.3% of synchronous regional lymph node metastases identified in our study of GG2 prostatectomy specimens and 2.9% identified by Hollemans et al 26 This variability in the frequency of positive lymph nodes at radical prostatectomy may be attributed to several confounders, such as patient population, the selection of patients undergoing lymph node dissection, the extent of the lymph node dissection, the use of imaging tools and the processing of the lymph nodes for pathology examination 27 …”

“…2 This compares with 1.3% of synchronous regional lymph node metastases identified in our study of GG2 prostatectomy specimens and 2.9% identified by Hollemans et al 26 This variability in the frequency of positive lymph nodes at radical prostatectomy may be attributed to several confounders, such as patient population, the selection of patients undergoing lymph node dissection, the extent of the lymph node dissection, the use of imaging tools and the processing of the lymph nodes for pathology examination. 27 In this study, we identified 45 cases (2.4%) with metastatic disease at the time of prostatectomy or during follow-up. This is a somewhat smaller frequency as compared to the 22 of 420 patients (5.2%) identified by Hollemans et al 26 They also reviewed their cases for the presence of adverse pathology features, including cribriform and intraductal carcinoma and tertiary grade 5.…”

Utility of Lymphadenectomy in Prostate Cancer: Where do We Stand?

“…They are extremely common, yet unlikely to be symptomatic or cause morbidity. Patients with lymphocele presented higher rates of deep venous thrombosis and pulmonary embolism [68], [70]. When it comes to severe complications the most serious ones are pulmonary insufficiency, chylous ascites (lymphatic leak) and lymphatic cysts, lymphatic fistula or chylopelvic fistula [47], [71], [72].…”

“…When it comes to severe complications the most serious ones are pulmonary insufficiency, chylous ascites (lymphatic leak) and lymphatic cysts, lymphatic fistula or chylopelvic fistula [47], [71], [72]. Thromboembolic complications are rare enough and in the majority of cases (over 99%) do not require treatment [70]. Routine pharmacological prophylaxis is currently recommended to be considered for intermediate and high thromboembolic risk indicated for ePLND.…”

“…Routine pharmacological prophylaxis is currently recommended to be considered for intermediate and high thromboembolic risk indicated for ePLND. Mechanical prophylaxis however is recommended for all PLND patients [70]. Patients with deep venous thrombosis presented increased pulmonary embolism risk and were more likely to be reoperated [68].…”