Current Status of Pelvic Lymph Node Dissection in Disease Management

While there is no consensus in the literature, the most common pelvic lymph node dissection performed for prostate cancer is a limited obturator lymph node dissection (1,2). The obturator space is bound caudally by the pubic bone, cranially by the bifurcation of common iliac artery, laterally by the external iliac vessels and inferiorly by the obturator nerve. Although it is generally believed that the obturator space is the primary landing site of prostate cancer nodal metastasis, anatomical series have demonstrated that the primary landing site may actually be in the internal iliac lymph node chain (3,4). Studies utilizing radioisotope guided dissection have confirmed the heterogeneous nature of prostatic lymph node drainage (5,6).

Historically, prostate cancer series have included a relatively high rate (up to 29%) of patients with pelvic lymph node metastasis (7). However, with stage migration in the prostate specific antigen era, contemporary open radical prostatectomy series have positive lymph node detection rates below 6% (8-10). To further stratify patients at risk for lymph node metastases, low risk and high-risk categories have been defined. Preoperative prostate specific antigen < 10 ng/mL, Gleason Sum < 6, and clinical stage < T^ is considered low risk whereas, high risk patients have a prostate specific antigen > 10 and/or Gleason > 7 and/or clinical stage < T2 (10-12). Since the likelihood of lymph node metastases is low (<2%), pelvic lymph node dissection is often omitted in the low-risk Recently, there have been studies patients.

supporting a m0re extended pe|vic Recently, there have been studies supporting a more extended pelvic lymph node lymph n0de dissecti0ii in the manage- dissection in the management of prostate cancer (13,14). In a series of 365 patients ment 0f pr0State cancer. undergoing extended pelvic lymph node dissection, 88 (24%) of patients had positive lymph nodes (13). Interestingly, of the 88 patients with positive nodes, 51 (58%) had

Concomitant pelvic lymph node dissection can be performed during either transperitoneal or extraperitoneal laparoscopic radical prostatectomy.

In general, the efficacy of laparoscopic pelvic lymph node dissection is comparable to open pelvic lymph node dissection.

nodal metastases along the internal iliac artery. Furthermore, 17 (19%) of the patients had nodal involvement only in this location and thus, it was concluded that a standard limited obturator lymph node dissection would have missed 19% of patients with node positive disease. In a similar study, 203 consecutive patients (103 extended pelvic lymph node dissection and 100 standard lymphadenectomy) were evaluated post radical retropubic prostatectomy (14). The incidence of lymph node metastases was 26% in the extended lymphadenectomy group versus 12% in the standard group (p < 0.03). In the extended pelvic lymph node dissection group, 26 patients (42%) had nodal metastases outside the standard template and of these patients, 9 (34%) had lymph nodes positive only outside the standard template. Using a cutoff off prostate specific antigen < 10.5 ng/mL and biopsy obtained Gleason Sum < 6,139 patients (68.5%) would be classified as low risk. If this cohort had not undergone any lymphadenec-tomy, only four patients would have been missed (false negative rate 2.4%). Thus, the authors of this study concluded that extended lymph node dissection should be performed for highrisk patients only thereby increasing the detection of positive nodes by 14%. Bader et al. (15) presented follow-up data on a series of 92 patients with metastatic nodes at the time of prostatec- tomy. Over a median follow-up of 45 months, 21 patients (23%) had prostate specific antigen recurrence free survival. Whilst this report does not convincingly demonstrate improved survival over an intermediate follow-up, extended pelvic lymph node dissection may benefit a small percentage of patients.

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