1
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Hori S, Nakai Y, Tachibana A, Omori C, Nishimura N, Inoue K, Tomizawa M, Shimizu T, Morizawa Y, Gotoh D, Miyake M, Torimoto K, Yoneda T, Fujimoto K, Tanaka N. Clinical significance of limited and extended pelvic lymph node dissection during robot-assisted radical prostatectomy for patients with localized prostate cancer: A retrospective, propensity score matching analysis. Int J Urol 2023; 30:168-175. [PMID: 36305671 DOI: 10.1111/iju.15075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/28/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We investigated the diagnostic and therapeutic benefits of limited or extended pelvic lymph node dissection during a robot-assisted radical prostatectomy for localized prostate cancer. METHODS Diagnostic and therapeutic benefits were assessed according to the rates of pN1 and biochemical recurrence, respectively. The primary outcome was the biochemical recurrence-free rate, and secondary outcomes included the diagnostic and therapeutic benefits of pelvic lymph node dissection. RESULTS A total of 534 patients were analyzed. Out of the 534 patients, 207 (38.8%) received limited pelvic lymph node dissection while 134 (25.1%) received extended dissection. There were 297 patients with a Briganti index ≥5%. Extended dissections yielded significantly more resected lymph nodes (p < 0.0001), and 72.2% of cases of pN1 were located outside the obturator. The incidence rate of pN1 was 6.1%, and performance of extended lymph node dissection was an independent predictor for pN1 (odds ratio 9.0, 95% confidence interval 2.5-33.1). The rate of biochemical recurrence was 14.9%, and Cox proportional hazards regression analysis of the propensity score matched population revealed that patients with high or very-high risk tended to benefit from limited lymph node dissection (hazard ratio 8.4, 95% confidence interval 0.8-82.3) while the therapeutic benefit of extended dissection was unclear by comparison. CONCLUSIONS Extended pelvic lymph node dissection significantly improves diagnostic accuracy; however, the therapeutic benefit of pelvic lymph node dissection was not observed in this study.
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Affiliation(s)
- Shunta Hori
- Department of Urology, Nara Medical University, Nara, Japan
| | - Yasushi Nakai
- Department of Urology, Nara Medical University, Nara, Japan
| | | | - Chihiro Omori
- Department of Urology, Nara Medical University, Nara, Japan
| | | | - Kuniaki Inoue
- Department of Urology, Nara Medical University, Nara, Japan
| | | | - Takuto Shimizu
- Department of Urology, Nara Medical University, Nara, Japan
| | | | - Daisuke Gotoh
- Department of Urology, Nara Medical University, Nara, Japan
| | - Makito Miyake
- Department of Urology, Nara Medical University, Nara, Japan
| | | | - Tatsuo Yoneda
- Department of Urology, Nara Medical University, Nara, Japan
| | | | - Nobumichi Tanaka
- Department of Urology, Nara Medical University, Nara, Japan.,Department of Prostate Brachytherapy, Nara Medical University, Nara, Japan
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2
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Carlsson S, Bottai M, Lantz A, Bjartell A, Hugosson J, Steineck G, Stranne J, Wiklund P, Haglind E, Akre O. Lymph swelling after radical prostatectomy and pelvic lymph node dissection. BJU Int 2022; 129:695-698. [PMID: 35132753 PMCID: PMC9313832 DOI: 10.1111/bju.15702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/11/2022] [Accepted: 01/21/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Stefan Carlsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatistics, IMM, Karolinska Institutet, Stockholm, Sweden
| | - Anna Lantz
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden.,Division of Biostatistics, IMM, Karolinska Institutet, Stockholm, Sweden
| | - Anders Bjartell
- Department of Urology, Skåne University Hospital, Malmö, Sweden.,Department of Translational Medicine, Division of Urological Cancers, Faculty of Medicine, Lund University, Sweden
| | - Jonas Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Department of Urology Gothenburg, Sweden
| | - Gunnar Steineck
- Department of Oncology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Johan Stranne
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Department of Urology Gothenburg, Sweden
| | - Peter Wiklund
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden.,Department of Urology, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Eva Haglind
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital/Östra, Department of Surgery, Gothenburg, Sweden
| | - Olof Akre
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
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3
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Ginsburg KB, Pressprich MF, Wurst HA, Cher ML. Association of lymph node yield with overall survival in patients with pathologically node negative prostate cancer. Curr Probl Cancer 2021; 45:100740. [PMID: 33931243 DOI: 10.1016/j.currproblcancer.2021.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/11/2021] [Accepted: 03/17/2021] [Indexed: 11/16/2022]
Abstract
We investigated the association between lymph node yield (LNY) with overall survival (OS) and post-radical prostatectomy (RP) secondary treatments among men with pathologically node negative (pN0) prostate cancer. We reviewed the National Cancer Database for men with Gleason Grade Group 2 or higher prostate cancer treated with RP and had pathologically node-negative disease. LNY was modeled as a continuous and categorical variable grouped by quartiles of LNY. Secondary treatment was defined as the use of radiation or systemic therapy post-RP. Multivariable Cox proportional hazards and logistic regression models were used to test for an association of LNY with OS and secondary treatments, respectively. We identified 89,416 men with pN0 prostate cancer treated with RP from 2010-2015. LNY was associated with improved OS when modeled as a categorical and continuous variable. The third (6-9 nodes) and fourth (≥10 nodes) quartiles of LNY were associated with improved OS (HR 0.87, 95% CI 0.79-0.96, P = 0.006 and HR 0.88, 95% CI 0.79-0.98, P= 0.017, respectively) when compared with the lowest quartile of LNY (≤3 nodes) and the hazard of death decreased by 1% for each benign lymph node removed (HR 0.99, 95% CI 0.98-0.99, P= 0.022). Additionally, categorical and continuous LNY was associated with significantly less use of post-RP secondary treatments. Removal of additional negative lymph nodes was associated with improved OS and less secondary treatments in patients with pN0 prostate cancer. These data suggest that removing a higher quantity of lymph nodes provides more accurate staging and prognosis.
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Affiliation(s)
- Kevin B Ginsburg
- Department of Urology, Wayne State University, Detroit, Michigan.
| | | | - Hallie A Wurst
- Wayne State University, School of Medicine, Detroit, Michigan
| | - Michael L Cher
- Department of Urology, Wayne State University, Detroit, Michigan
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4
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Milonas D, Venclovas Z, Muilwijk T, Jievaltas M, Joniau S. External validation of Memorial Sloan Kettering Cancer Center nomogram and prediction of optimal candidate for lymph node dissection in clinically localized prostate cancer. Cent European J Urol 2020; 73:19-25. [PMID: 32395318 PMCID: PMC7203765 DOI: 10.5173/ceju.2020.0079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/20/2020] [Accepted: 02/17/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction The aim of our study was to evaluate the external validity of the online Memorial Sloan Kettering Cancer Center (MSKCC) nomogram as a predictor for pelvic lymph node invasion (LNI) in men who underwent radical prostatectomy (RP) with pelvic lymph node dissection (PLND). Material and methods The study cohort consisted of 679 men with clinically localized prostate cancer (PCa) who underwent RP with PLND between 2005 and 2017. The area under curve (AUC) of the receiver operator characteristic analysis was used to quantify the accuracy of MSKCC nomogram to predict LNI. The specificity, sensitivity and negative predictive value were calculated to assess LNI probability cut-off. Results A total of 81 of 679 patients had LNI (11.9%). The AUC of MSKCC nomogram was 79%. Using the cut-off value of 7% (sensitivity 88.9%, specificity 45.2% and NPV 96.8%) a PLND could be omitted in 41% (279/679) of men. However, 3.2% (9/279) of men with LNI would be missed. MSKCC nomogram showed good calibration characteristics and high net benefit at decision curve analysis. Conclusions MSKCC nomogram in patients with PCa undergoing PLND has 79% discriminated accuracy for prediction of LNI in our cohort. Using a 7% nomogram cut-off, roughly 40% of men would be spared PLND with minimal risk to miss LNI.
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Affiliation(s)
- Daimantas Milonas
- Department of Urology, Lithuanian University of Health Sciences, Medical Academy, Kaunas, Lithuania.,Department of Urology, Leuven University Hospital, Leuven, Belgium
| | - Zilvinas Venclovas
- Department of Urology, Lithuanian University of Health Sciences, Medical Academy, Kaunas, Lithuania
| | - Tim Muilwijk
- Department of Urology, Leuven University Hospital, Leuven, Belgium
| | - Mindaugas Jievaltas
- Department of Urology, Lithuanian University of Health Sciences, Medical Academy, Kaunas, Lithuania
| | - Steven Joniau
- Department of Urology, Leuven University Hospital, Leuven, Belgium
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5
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Friedlander DF, Krimphove MJ, Cole AP, Tully KH, Lipsitz SR, Kibel AS, Kilbridge KL, Trinh QD. Facility-Level Variation in Pelvic Lymphadenectomy During Radical Prostatectomy and Effect on Overall Survival in Men with High-Risk Prostate Cancer. Ann Surg Oncol 2019; 27:1929-1936. [PMID: 31848818 DOI: 10.1245/s10434-019-08110-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE This study was designed to examine facility-level variation in the extent of pelvic lymphadenectomy and to determine whether more extensive lymphadenectomy is associated with a survival benefit among men with localized high-risk prostate cancer. METHODS Using data from the National Cancer Data Base, we identified 13,652 men with a high predicted probability of 10-year survival (≤ 65 years of age and Charlson Comorbidity Index score of 0) who underwent radical prostatectomy at 1023 facilities for biopsy-confirmed localized high-risk prostate cancer diagnosed between January 2004 and December 2011. Multilevel, multinomial logistic regression was fitted to predict facility-level probability of receiving different extents of lymphadenectomy. Inverse probability of treatment weighting-adjusted Cox regression model with Bonferroni correction was fitted to compare risk of overall mortality. RESULTS Overall, 11,284 (82.7%), 1601 (11.7%), and 767 (5.6%) men who underwent radical prostatectomy underwent concomitant none/limited lymphadenectomy (0-9 lymph nodes), standard lymphadenectomy (10-16 lymph nodes), and extended lymphadenectomy (≥ 17 lymph nodes), respectively. Extended lymphadenectomy was not associated with a survival benefit relative to standard lymphadenectomy (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.48-1.23; p = 0.4) nor no/limited lymphadenectomy (HR 0.77, 95% CI 0.87-2.20; p = 0.29) at a median follow-up of 83.3 months. Risk-adjusted facility-level predicted probabilities of extended, standard, or no/limited lymphadenectomy ranged from 0.01 to 52.6%, 3.3-53.3%, and 17.8-96.3%, respectively. CONCLUSIONS We found significant facility-level variation in the extent of pelvic lymphadenectomy during radical prostatectomy despite no apparent survival benefit associated with more extensive lymphadenectomy. Further prospective data are needed to reevaluate the role of lymphadenectomy in the management of clinically localized prostate cancer.
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Affiliation(s)
- David F Friedlander
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marieke J Krimphove
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Alexander P Cole
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Karl H Tully
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam S Kibel
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kerry L Kilbridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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6
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Tomisaki I, Ikuta H, Higashijima K, Onishi R, Minato A, Fujimoto N. Oncological Outcome After Radical Prostatectomy without Pelvic Lymph Node Dissection for Localized Prostate Cancer: Follow-up Results in a Single Institution. Cancer Invest 2019; 37:524-530. [PMID: 31597501 DOI: 10.1080/07357907.2019.1675076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The oncological benefit of pelvic lymph node dissection (PLND) is still debatable because data on clinical outcomes of radical prostatectomy (RP) without PLND are lacking. In this study, we reported oncological outcome in consecutive 146 patients who underwent RP without PLND. Although 27% of our patients developed biochemical recurrence, the estimated 5-year overall survival rates were 100%, 96.3%, and 95.7% in the low-, intermediate-, and high-risk groups, respectively. These data in our patients were not inferior to those in previous reports that investigated the survivals in patients who received PLND during RP. The therapeutic significance of PLND should be re-evaluated.
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Affiliation(s)
- Ikko Tomisaki
- Department of Urology, University of Occupational and Environmental Health, Kitakyushu City, Japan
| | - Hirofumi Ikuta
- Department of Urology, University of Occupational and Environmental Health, Kitakyushu City, Japan
| | - Katsuyoshi Higashijima
- Department of Urology, University of Occupational and Environmental Health, Kitakyushu City, Japan
| | - Rei Onishi
- Department of Urology, University of Occupational and Environmental Health, Kitakyushu City, Japan
| | - Akinori Minato
- Department of Urology, University of Occupational and Environmental Health, Kitakyushu City, Japan
| | - Naohiro Fujimoto
- Department of Urology, University of Occupational and Environmental Health, Kitakyushu City, Japan
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7
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Preisser F, Bandini M, Marchioni M, Nazzani S, Tian Z, Pompe RS, Fossati N, Briganti A, Saad F, Shariat SF, Heinzer H, Huland H, Graefen M, Tilki D, Karakiewicz PI. Extent of lymph node dissection improves survival in prostate cancer patients treated with radical prostatectomy without lymph node invasion. Prostate 2018; 78:469-475. [PMID: 29460290 DOI: 10.1002/pros.23491] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 01/23/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE To assess the effect of pelvic lymph node dissection (PLND) extent on cancer-specific mortality (CSM) in prostate cancer (PCa) patients without lymph node invasion (LNI) treated with radical prostatectomy (RP). METHODS Within the Surveillance, Epidemiology, and End results (SEER) database (2004-2014), we identified patients with D'Amico intermediate- or high-risk characteristics who underwent RP with PLND, without evidence of LNI. First, multivariable logistic regression models tested for predictors of more extensive PLND, defined as removed lymph node count (NRN) ≥75th percentile. Second, Kaplan-Meier analyses and multivariable Cox regression models tested the effect of NRN ≥75th percentile on CSM. Finally, survival analyses were repeated using continuously coded NRN. RESULTS In 28 147 RP and PLND patients without LNI, 67.3% versus 32.7% exhibited D'Amico intermediate- or high-risk characteristics. The median NRN was 6 (IQR 3-10), the 75th percentile defined patients with NRN ≥11. Patients with NRN ≥11 had higher rate of cT2/3 stage (29.8 vs 26.1%), GS ≥8 (25.7 vs 22.4%), and respectively more frequently exhibited D'Amico high-risk characteristics (34.6 vs 32.1%). In multivariable logistic regression models predicting the probability of more extensive PLND (NRN ≥11), higher biopsy GS, higher cT stage, higher PSA, more recent year of diagnosis, and younger age at diagnosis represented independent predictors. At 72 months after RP, CSM-free rates were 99.5 versus 98.1% for NRN ≥11 and NRN ≤10, respectively and resulted in a HR of 0.50 (P = 0.01), after adjustment for all covariates. Similarly, continuously coded NRN achieved independent predictor status (HR: 0.955, P = 0.01), where each additional removed lymph node reduced CSM risk by 4.5%. CONCLUSION More extensive PLND at RP provides improved staging information and consequently is associated with lower CSM in D'Amico intermediate- and high-risk PCa patients without evidence of LNI. Hence, more extensive PLND should be recommended in such individuals.
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Affiliation(s)
- Felix Preisser
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Marco Bandini
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Marchioni
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
- Department of Urology, SS Annunziata Hospital, "G.D'Annunzio" University of Chieti, Chieti, Italy
| | - Sebastiano Nazzani
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
- Academic Department of Urology, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Raisa S Pompe
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Nicola Fossati
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Briganti
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
| | | | - Hans Heinzer
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Hartwig Huland
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
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8
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Sanda MG, Cadeddu JA, Kirkby E, Chen RC, Crispino T, Fontanarosa J, Freedland SJ, Greene K, Klotz LH, Makarov DV, Nelson JB, Rodrigues G, Sandler HM, Taplin ME, Treadwell JR. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Part II: Recommended Approaches and Details of Specific Care Options. J Urol 2018; 199:990-997. [PMID: 29331546 DOI: 10.1016/j.juro.2018.01.002] [Citation(s) in RCA: 226] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2017] [Indexed: 01/14/2023]
Abstract
PURPOSE This guideline is structured to provide a clinical framework stratified by cancer severity to facilitate care decisions and guide the specifics of implementing the selected management options. The summary presented herein represents Part II of the two-part series dedicated to Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline discussing risk stratification and care options by cancer severity. Please refer to Part I for discussion of specific care options and outcome expectations and management. MATERIALS AND METHODS The systematic review utilized in the creation of this guideline was completed by the Agency for Healthcare Research and Quality and through additional supplementation by ECRI Institute. This review included articles published between January 2007 and March 2014 with an update search conducted through August 2016. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. Additional information is provided as Clinical Principles and Expert Opinions (table 2 in supplementary unabridged guideline, http://jurology.com/). RESULTS The AUA (American Urological Association), ASTRO, and SUO (Society of Urologic Oncology) formulated an evidence-based guideline based on a risk stratified clinical framework for the management of localized prostate cancer. CONCLUSIONS This guideline attempts to improve a clinician's ability to treat patients diagnosed with localized prostate cancer, but higher quality evidence in future trials will be essential to improve the level of care for these patients. In all cases, patient preferences should be considered when choosing a management strategy.
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Affiliation(s)
- Martin G Sanda
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Jeffrey A Cadeddu
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Erin Kirkby
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Ronald C Chen
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Tony Crispino
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Joann Fontanarosa
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Stephen J Freedland
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Kirsten Greene
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Laurence H Klotz
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Danil V Makarov
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Joel B Nelson
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - George Rodrigues
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Howard M Sandler
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Mary Ellen Taplin
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
| | - Jonathan R Treadwell
- American Urological Association Education and Research, Inc., Linthicum, Maryland; ASTRO, Arlington, Virginia; Society of Urologic Oncology, Schamburg, Illinois
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9
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Is More Always Better? An Assessment of the Impact of Lymph Node Yield on Outcome for Clinically Localized Prostate Cancer with Low/Intermediate Risk Pathology (pT2-3a/pN0) Managed with Prostatectomy Alone. Pathol Oncol Res 2017; 25:209-215. [PMID: 29079967 DOI: 10.1007/s12253-017-0349-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 10/20/2017] [Indexed: 10/18/2022]
Abstract
The clinical impact of lymph node dissection extent remains undetermined in the contemporary setting, as reflected in care pattern variations. Despite some series demonstrating a direct relationship between number of lymph nodes identified and detection of nodal involvement, the correlation between lymph node yield and disease control or survival outcomes remains unclear. Patients with clinically localized prostate cancer, pre-RP PSA <30, and pT2-3a/N0 disease at RP were retrospectively identified from two databases for inclusion. Those who received pre- or post-RP radiotherapy or hormone therapy were excluded. Kaplan-Meier method was employed for survival probability estimation. Cox regression models were used to assess bRFS differences between subsets. From 2002 to 2010, 667 eligible patients were identified. The median age was 61 yrs. (range, 43-76), with median PSA 5.6 ng/dL (0.9-28.0). At RP, most patients had pT2c (64%) disease with Gleason Score (GS) ≤6 (43%) or 7 (48%); 218 (33%) patients had positive margins (M+). At median clinical and PSA follow-up of 96 and 87 months, respectively, 146 patients (22%) experienced PSA failure with an estimated bRFS of 81%/76% at 5/8 years. For patients who underwent LND, univariable analysis identified PSA (at diagnosis), higher GS (≥7, at biopsy or RP), intermediate/high risk stratification, M+ as adversely associated with bRFS (all p < 0.01). A higher number of LNs excised was not associated with improved bRFS for the entire cohort (HR = 0.97, p = 0.27), nor for any clinical risk stratum, biopsy GS, or RP GS subgroup. This study did not demonstrate an association between LN yield and bRFS in patients with clinically localized pT2-3a/pN0 prostate cancer managed with RP alone, either in the entire population or with substratification by clinical risk stratum or GS.
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10
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Fossati N, Willemse PPM, Van den Broeck T, van den Bergh RCN, Yuan CY, Briers E, Bellmunt J, Bolla M, Cornford P, De Santis M, MacPepple E, Henry AM, Mason MD, Matveev VB, van der Poel HG, van der Kwast TH, Rouvière O, Schoots IG, Wiegel T, Lam TB, Mottet N, Joniau S. The Benefits and Harms of Different Extents of Lymph Node Dissection During Radical Prostatectomy for Prostate Cancer: A Systematic Review. Eur Urol 2017; 72:84-109. [PMID: 28126351 DOI: 10.1016/j.eururo.2016.12.003] [Citation(s) in RCA: 297] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 12/01/2016] [Indexed: 12/18/2022]
Abstract
CONTEXT There is controversy regarding the therapeutic role of pelvic lymph node dissection (PLND) in patients undergoing radical prostatectomy for prostate cancer (PCa). OBJECTIVE To systematically review the relevant literature assessing the relative benefits and harms of PLND for oncological and non-oncological outcomes in patients undergoing radical prostatectomy for PCa. EVIDENCE ACQUISITION MEDLINE, MEDLINE In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched up to December 2015. Comparative studies evaluating no PLND, limited, standard, and (super)-extended PLND that reported oncological and non-oncological outcomes were included. Risk-of-bias and confounding assessments were performed. A narrative synthesis was undertaken. EVIDENCE SYNTHESIS Overall, 66 studies recruiting a total of 275,269 patients were included (44 full-text articles and 22 conference abstracts). Oncological outcomes were addressed by 29 studies, one of which was a randomized clinical trial (RCT). Non-oncological outcomes were addressed by 43 studies, three of which were RCTs. There were high risks of bias and confounding in most studies. Conflicting results emerged when comparing biochemical and clinical recurrence, while no significant differences were observed among groups for survival. Conversely, the majority of studies showed that the more extensive the PLND, the greater the adverse outcomes in terms of operating time, blood loss, length of stay, and postoperative complications. No significant differences were observed in terms of urinary continence and erectile function recovery. CONCLUSIONS Although representing the most accurate staging procedure, PLND and its extension are associated with worse intraoperative and perioperative outcomes, whereas a direct therapeutic effect is still not evident from the current literature. The current poor quality of evidence indicates the need for robust and adequately powered clinical trials. PATIENT SUMMARY Based on a comprehensive review of the literature, this article summarizes the benefits and harms of removing lymph nodes during surgery to remove the prostate because of PCa. Although the quality of the data from the studies was poor, the review suggests that lymph node removal may not have any direct benefit on cancer outcomes and may instead result in more complications. Nevertheless, the procedure remains justified because it enables accurate assessment of cancer spread.
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Affiliation(s)
- Nicola Fossati
- Division of Oncology/Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Thomas Van den Broeck
- Department of Urology, University Hospitals Leuven, and Laboratory of Molecular Endocrinology, KU Leuven, Leuven, Belgium
| | | | - Cathy Yuhong Yuan
- Division of Gastroenterology and Cochrane UGPD Group, Department of Medicine, Health Sciences Centre, McMaster University, Hamilton, Canada
| | | | - Joaquim Bellmunt
- Bladder Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Michel Bolla
- Department of Radiation Therapy, CHU Grenoble, Grenoble, France
| | - Philip Cornford
- Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | | | - Ekelechi MacPepple
- Surrey Health Economic Centre, School of Economics, University of Surrey, Guilford, UK
| | - Ann M Henry
- Leeds Cancer Centre, St. James's University Hospital and University of Leeds, Leeds, UK
| | | | | | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Olivier Rouvière
- Hospices Civils de Lyon, Radiology Department, Edouard Herriot Hospital, Lyon, France
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Thomas B Lam
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Nicolas Mottet
- Department of Urology, University Hospital, St. Etienne, France
| | - Steven Joniau
- Department of Urology, University Hospitals Leuven, and Laboratory of Molecular Endocrinology, KU Leuven, Leuven, Belgium.
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Li R, Petros FG, Kukreja JB, Williams SB, Davis JW. Current technique and results for extended pelvic lymph node dissection during robot-assisted radical prostatectomy. Investig Clin Urol 2016; 57:S155-S164. [PMID: 27995219 PMCID: PMC5161019 DOI: 10.4111/icu.2016.57.s2.s155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 10/04/2016] [Indexed: 12/05/2022] Open
Abstract
The practice of extended pelvic lymph node dissection (ePLND) remains one of the most controversial topics in the management of clinically localized prostate cancer. Although most urologists agree on its benefit for staging and prognostication, the role of the ePLND in cancer control continues to be debated. The increased perioperative morbidity makes it unpalatable, especially in patients with low likelihood of lymph node disease. With the advent of robotic assisted laparoscopic prostatectomy, many surgeons were slow to adopt ePLND in the robotic setting. In this study, we summarize the evidence for the prognostic and therapeutic roles of ePLND, review the clinical tools used for lymph node metastasis prediction and survey the numerous experiences of ePLND compiled by robotic urologic surgeons over the years.
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Affiliation(s)
- Roger Li
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Firas G Petros
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Janet B Kukreja
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen B Williams
- Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - John W Davis
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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12
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Rees T, Raison N, Sheikh MI, Jaffry Z, Madaan S, Challacombe B, Ahmed K, Dasgupta P. Is extended pelvic lymph node dissection for prostate cancer the only recommended option? A systematic over-view of the literature. Turk J Urol 2016; 42:240-246. [PMID: 27909616 DOI: 10.5152/tud.2016.52893] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Pelvic lymph node dissection (PLND) is performed alongside radical prostatectomy as the most accurate method of staging prostate cancer. Yet the potential therapeutic benefits of lymphadenectomy are yet to be confirmed. MATERIAL AND METHODS A PubMed database search was performed to identify all papers comparing techniques for PLND or none. The primary outcome measure was long term oncological outcomes. Studies looking at men with clinically localized prostate cancer at the time of radical prostatectomy who received no adjuvant treatment were included. Previous reviews and single case reports were excluded. The subsequent available papers were then systematically reviewed. RESULTS Limited PLND provides no benefit in low risk prostate cancer and is unlikely to provide a therapeutic benefit in higher risk groups either when compared with no PLND. Extended PLND may provide some therapeutic benefit, particularly in patients with occult metastases; however, the evidence base for this is not particularly strong and may be down to statistical phenomena. CONCLUSION When performed in prostate cancer patients, PLND should be extended, as it is a more accurate staging tool and may provide therapeutic benefit to some patients. However, to properly assess this, randomised controlled studies need to be performed in this area.
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Affiliation(s)
- Thomas Rees
- King's College School of Medicine, King's College London, London, UK
| | - Nicholas Raison
- MRC Centre for Transplantation, Kings College London, London, UK
| | | | - Zahra Jaffry
- Department of Urology, Guy's and St Thomas' Hospital, London, UK
| | - Sanjeev Madaan
- Department of Urology, Darent Valley Hospital, Dartford, UK
| | - Ben Challacombe
- Department of Urology, Guy's and St Thomas' Hospital, London, UK
| | - Kamran Ahmed
- King's College School of Medicine, King's College London, London, UK
| | - Prokar Dasgupta
- King's College School of Medicine, King's College London, London, UK
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13
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Mandel P, Kriegmair MC, Veleva V, Salomon G, Graefen M, Huland H, Tilki D. The Role of Pelvic Lymph Node Dissection During Radical Prostatectomy in Patients With Gleason 6 Intermediate-risk Prostate Cancer. Urology 2016; 93:141-6. [PMID: 26968487 DOI: 10.1016/j.urology.2016.02.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 02/21/2016] [Accepted: 02/27/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To analyze the benefit of pelvic lymph node dissection (PLND) in patients with biopsy Gleason grade ≤ 6, cT ≤ 2b, and prostate-specific antigen (PSA) 10-20 ng/mL (main study cohort), as the indication for PLND during radical prostatectomy remains uncertain in patients with nonhigh-risk tumors. MATERIALS AND METHODS The main study cohort included 1383 patients with low intermediate-risk cancer undergoing radical prostatectomy with or without PLND between 1994 and 2013. Positive lymph node (LN) rates were reported and compared to patients with higher (≥20 ng/mL; n = 314) and lower (<10 ng/mL; n = 6861) PSA. Oncological outcome was assessed by Cox regressions in patients with a minimum follow-up of 5years. RESULTS In the main study cohort (PSA 10-20 ng/mL), PLND was performed in 867 (62.7%) patients with a median number of removed LNs of 11 (interquartile range 16-6). Positive LNs were detected in 3.3% of these patients. Compared to the main study cohort, patients with preoperatively higher PSA ≥ 20 ng/mL (or lower PSA < 10 ng/ml) underwent PLND in 83.8% (32.7%) of the cases, with 8.0% (1.8%) showing positive LNs. Median follow-up in the main study cohort was 84.5 months. Biochemical recurrence (BCR) occurred in 20.6% of these men. The 5-year and 10-year BCR-free survival rates were 82.2% and 75.6% for those with PLND, and 83.4% and 75.8% for patients without PLND. PLND was not a significant factor influencing BCR-free, metastasis-free, or cancer-specific survival in the main study cohort. CONCLUSION Positive LNs are rare in patients with Gleason grade ≤ 6, cT ≤ 2b, and PSA 10-20 ng/mL. Performing PLND had no statistical influence on oncologic outcome and therefore should be decided upon on an individual basis.
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Affiliation(s)
- Philipp Mandel
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Valia Veleva
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Georg Salomon
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Hartwig Huland
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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14
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Pelvic lymph node dissection in prostate cancer: indications, extent and tailored approaches. Urologia 2015; 84:9-19. [PMID: 26689534 DOI: 10.5301/uro.5000139] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2015] [Indexed: 01/15/2023]
Abstract
PURPOSE The purpose of this study is to review the current literature concerning the indication of pelvic lymph node dissection (PLND), its extent and complications in prostate cancer (PCa) staging, the available tools, and the future perspectives to assess the risk of lymph node invasion (LNI). METHODS A literature review was performed using the Medline, Embase, and Web of Science databases. The search strategy included the terms pelvic lymph nodes, PLND, radical prostatectomy, prostate cancer, lymph node invasion, biochemical recurrence, staging, sentinel lymph node dissection, imaging, and molecular markers. RESULTS PLND currently represents the gold standard for nodal staging in PCa patients. Available imaging techniques are characterized by poor accuracy in the prediction of LNI before surgery. On the contrary, an extended PLND (ePLND) would result into proper staging in the majority of the cases. Several models based on preoperative disease characteristics are available to assess the risk of LNI. Although ePLND is not associated with a substantial risk of severe complications, up to 10% of the men undergoing this procedure experience lymphoceles. Concerns over potential morbidity of ePLND led many authors to investigate the role of sentinel lymph node dissection in order to prevent unnecessary ePLND. Finally, the incorporation of novel biomarkers in currently available tools would improve our ability to identify men who should receive an ePLND. CONCLUSIONS Nowadays, the most informative tools predicting LNI in PCa patients consist in preoperative clinical nomograms. Sentinel lymph node dissection still remains experimental and novel biomarkers are needed to identify patients at a higher risk of LNI.
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15
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Picardo A, Vivian J. Extended pelvic lymph node dissection for clinically localized prostate cancer: a West Australian experience. ANZ J Surg 2015; 85:936-40. [PMID: 25780994 DOI: 10.1111/ans.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The role and type of pelvic lymph node dissection for clinically localized prostate cancer is controversial in Australia. Our study aims to determine the incidence of pelvic lymph node involvement and the complication rate of extended lymphadenectomy in a group of West Australian patients who underwent a robotic assisted radical prostatectomy plus extended pelvic lymph node dissection. METHOD Forty-nine patients underwent a robotic assisted radical prostatectomy with extended pelvic lymph node dissection between 2008 and 2012 by a single private urological surgeon. The inclusion criteria for the extended lymph node dissection were clinical localized, intermediate and high-risk prostate cancer based on preoperative D'Amico classification. RESULTS Of the 49 patients, eight patients had positive nodes giving a nodal positivity rate of 16.33%. Six patients had a complication giving a total complication rate of 12.24%. Three of these complications have been attributed to the nodal dissection, thus giving an extended pelvic lymph node dissection complication rate of 6.12%. CONCLUSION Rates of nodal involvement in our West Australian cohort are in keeping with those published in the literature. Extended pelvic lymph node dissection can be performed with an acceptable complication rate. Further research is required to investigate the therapeutic role of pelvic lymph node dissection.
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Affiliation(s)
- Alarick Picardo
- Urology Department, St John of God Hospital, Perth, Western Australia, Australia
| | - Justin Vivian
- Urology Department, St John of God Hospital, Perth, Western Australia, Australia
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16
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Harbin AC, Eun DD. The role of extended pelvic lymphadenectomy with radical prostatectomy for high-risk prostate cancer. Urol Oncol 2014; 33:208-16. [PMID: 25547974 DOI: 10.1016/j.urolonc.2014.11.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 10/22/2014] [Accepted: 11/20/2014] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The role of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) for prostate cancer (PCa) is controversial. Despite extensive research in both patterns of lymphatic drainage and the clinical effect of lymph node involvement, the exact role of PLND in PCa is yet to be defined. METHODS A systematic search of the MEDLINE database was performed, and all relevant articles were reviewed in depth. RESULTS We included 84 relevant articles in our review and subdivided the information into the following categories: preoperative patient evaluation, procedure/extent of dissection, complications, and robotic surgery era. Most authors agree that the greatest benefit is seen in patients with high-risk PCa undergoing RP. Multiple imaging modalities have been evaluated for assistance in patient selection, but the use of preoperative nomograms appears to be the most helpful selection tool. The role of limited PLND vs. extended PLND (e-PLND) is yet to be defined, though many authors agree that e-PLND is preferred in the setting of high-risk PCa. Although PLND is associated with a higher incidence of complications, especially lymphocele formation, it is unclear whether e-PLND leads to more complications than limited PLND. The introduction of minimally invasive surgery may have had a negative effect on implementation of PLND in the appropriate patients undergoing RP. CONCLUSION Despite a lack of prospective, randomized trials evaluating PLND in RP, there does appear to be a consistent benefit in patients with high-risk disease.
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Affiliation(s)
- Andrew C Harbin
- Department of Urology, Temple University Hospital, Philadelphia, PA.
| | - Daniel D Eun
- Department of Urology, Temple University Hospital, Philadelphia, PA
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17
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Kim KH, Lim SK, Kim HY, Han WK, Choi YD, Chung BH, Hong SJ, Rha KH. Yonsei nomogram to predict lymph node invasion in Asian men with prostate cancer during robotic era. BJU Int 2013; 113:598-604. [DOI: 10.1111/bju.12280] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Kwang Hyun Kim
- Department of Urology; Yonsei University College of Medicine; Seoul Korea
- Department of Urology; Ewha Womans University Mokdong Hospital; Seoul Korea
| | - Sey Kiat Lim
- Department of Urology; Yonsei University College of Medicine; Seoul Korea
| | - Ha Yan Kim
- Department of Biostatistics Collaboration Unit; Yonsei University College of Medicine; Seoul Korea
| | - Woong Kyu Han
- Department of Urology; Yonsei University College of Medicine; Seoul Korea
| | - Young Deuk Choi
- Department of Urology; Yonsei University College of Medicine; Seoul Korea
| | - Byung Ha Chung
- Department of Urology; Yonsei University College of Medicine; Seoul Korea
| | - Sung Joon Hong
- Department of Urology; Yonsei University College of Medicine; Seoul Korea
| | - Koon Ho Rha
- Department of Urology; Yonsei University College of Medicine; Seoul Korea
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18
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Ploussard G, Briganti A, de la Taille A, Haese A, Heidenreich A, Menon M, Sulser T, Tewari AK, Eastham JA. Pelvic lymph node dissection during robot-assisted radical prostatectomy: efficacy, limitations, and complications-a systematic review of the literature. Eur Urol 2013; 65:7-16. [PMID: 23582879 DOI: 10.1016/j.eururo.2013.03.057] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 03/25/2013] [Indexed: 11/15/2022]
Abstract
CONTEXT Pelvic lymph node dissection (PLND) in prostate cancer is the most effective method for detecting lymph node metastases. However, a decline in the rate of PLND during radical prostatectomy (RP) has been noted. This is likely the result of prostate cancer stage migration in the prostate-specific antigen-screening era, and the introduction of minimally invasive approaches such as robot-assisted radical prostatectomy (RARP). OBJECTIVE To assess the efficacy, limitations, and complications of PLND during RARP. EVIDENCE ACQUISITION A review of the literature was performed using the Medline, Scopus, and Web of Science databases with no restriction of language from January 1990 to December 2012. The literature search used the following terms: prostate cancer, radical prostatectomy, robot-assisted, and lymph node dissection. EVIDENCE SYNTHESIS The median value of nodal yield at PLND during RARP ranged from 3 to 24 nodes. As seen in open and laparoscopic RP series, the lymph node positivity rate increased with the extent of dissection during RARP. Overall, PLND-only related complications are rare. The most frequent complication after PLND is symptomatic pelvic lymphocele, with occurrence ranging from 0% to 8% of cases. The rate of PLND-associated grade 3-4 complications ranged from 0% to 5%. PLND is associated with increased operative time. Available data suggest equivalence of PLND between RARP and other surgical approaches in terms of nodal yield, node positivity, and intraoperative and postoperative complications. CONCLUSIONS PLND during RARP can be performed effectively and safely. The overall number of nodes removed, the likelihood of node positivity, and the types and rates of complications of PLND are similar to pure laparoscopic and open retropubic procedures.
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Affiliation(s)
- Guillaume Ploussard
- Department of Urology, Saint-Louis Hospital, APHP, Paris, France; Department of Urology, Jewish General Hospital and Montreal General Hospital, McGill University, Montreal, Canada; INSERM 955, Team 7, University Paris 12, Créteil, France.
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19
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Briganti A, Suardi N, Gallina A, Abdollah F, Montorsi F. Pelvic Lymph Node Dissection in Prostate Cancer: The Mystery Is Taking Shape. Eur Urol 2013; 63:459-61. [DOI: 10.1016/j.eururo.2012.08.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Accepted: 08/16/2012] [Indexed: 10/28/2022]
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20
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Kim KH, Lim SK, Kim HY, Shin TY, Lee JY, Choi YD, Chung BH, Hong SJ, Rha KH. Extended vs standard lymph node dissection in robot-assisted radical prostatectomy for intermediate- or high-risk prostate cancer: a propensity-score-matching analysis. BJU Int 2013; 112:216-23. [PMID: 23356436 DOI: 10.1111/j.1464-410x.2012.11765.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Although lymph node dissection (LND) is known as the most accurate method of nodal staging, the therapeutic role of LND remains undetermined. This is mainly because of the lack of randomized prospective studies and the fact that retrospective analyses often result in bias and misinterpretation. To overcome the limitation of retrospective analysis, we matched preoperative variables using propensity scores and compared the outcomes between patients treated with robot-assisted eLND and sLND. In the matched cohort, robot-asssited eLND achieved an increased detection rate of lymph node metastases; however, the therapeutic benefit was not statistically significant between the two groups on short-term follow-up. OBJECTIVE To compare the pathological and biochemical outcomes between extended lymph node dissection (eLND) and standard lymph node dissection (sLND) in patients undergoing robot-assisted radical prostatectomy for intermediate- or high-risk prostate cancer. PATIENTS AND METHODS A total of 905 patients underwent robot-assisted radical prostatectomy and lymph node dissection (LND) by a single surgeon between June 2006 and January 2011. Of these, 170 patients who underwent robot-assisted eLND and 294 patients who underwent robot-assisted sLND for intermediate- or high-risk prostate cancer were included in the study. Propensity-score matching was performed using the preoperative variables which included age, body mass index, prostate-specific antigen, clinical stage, biopsy Gleason score 1 and 2, total number of biopsied cores, number of positive cores and prostate volumes. Pathological and biochemical outcomes were assessed according to the extent of LND. RESULTS The median (range) follow-up period was 36 (12-77) months and the median number of lymph nodes removed was 21 and 12 in the eLND and sLND groups, respectively. Propensity-score matching resulted in 141 patients in each group. Although patients who underwent eLND had a higher clinical stage, biopsy Gleason score and number of positive cores than those treated with sLND in the entire cohort, there were no preoperative between-group differences in the matched cohort. In the matched cohort, lymph node metastases were detected at a significantly higher rate in the eLND than in the sLND group (12.1 vs. 5.0%, P = 0.033). In the matched cohort, the 3-year biochemical recurrence-free survival rates were 77.8 and 73.5% in the eLND and sLND groups, respectively, which was not significant (hazard ratio 0.85, P = 0.497). CONCLUSION Robot-assisted eLND achieved an increased lymph node yield and higher detection rate of lymph node metastases; however, robotic eLND did not alter biochemical outcomes in a short-term follow-up.
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Affiliation(s)
- Kwang Hyun Kim
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
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21
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Choi D, Kim D, Kyung YS, Lim JH, Song SH, You D, Jeong IG, Kim CS. Clinical experience with limited lymph node dissection for prostate cancer in Korea: single center comparison of 247 open and 354 robot-assisted laparoscopic radical prostatectomy series. Korean J Urol 2012. [PMID: 23185666 PMCID: PMC3502733 DOI: 10.4111/kju.2012.53.11.755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE There are limited data on the role of limited pelvic lymph node dissection (PLND) in patients with prostate cancer in Korea. The objective of this study was to demonstrate our clinical experience with limited PLND and the difference in its yield between open retropubic radical prostatectomy (RRP) and robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer patients in Korea. MATERIALS AND METHODS We retrospectively analyzed 601 consecutive patients undergoing radical prostatectomy and bilateral limited PLND by either RRP (n=247) or RALP (n=354) in Asan Medical Center. All patients were divided into three groups according to the D'Amico's risk stratification method. Clinicopathologic data, including the yield of lymph nodes, were thoroughly reviewed and compared among the three risk groups or between the RRP and RALP subjects. RESULTS The mean patient age was 64.9 years and the mean preoperative prostate-specific antigen was 9.8 ng/ml. The median number of removed lymph nodes per patient was 5 (range, 0 to 20). The numbers of patients of each risk group were 167, 199, and 238, and the numbers of patients with tumor-positive lymph nodes were 1 (0.6%), 4 (2.0%), and 17 (7.1%) in the low-, intermediate-, and high-risk groups, respectively. In the high-risk group, the lymph node-positive ratio was higher in RRP (14.9%) than in RALP subjects (2.4%). CONCLUSIONS We speculate that limited PLND may help in prostate cancer staging in intermediate- and high-risk prostate cancer groups. RRP is a more effective surgical modality for PLND than is RALP, especially in high-risk prostate cancer groups.
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Affiliation(s)
- Daeheon Choi
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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22
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Kaneko G, Miyajima A, Yazawa S, Yuge K, Kikuchi E, Asanuma H, Nakagawa K, Oya M. What is the predictor of prolonged operative time during laparoscopic radical prostatectomy? Int J Urol 2012; 20:330-6. [DOI: 10.1111/j.1442-2042.2012.03185.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 09/06/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Gou Kaneko
- Department of Urology; Keio University School of Medicine; Tokyo; Japan
| | - Akira Miyajima
- Department of Urology; Keio University School of Medicine; Tokyo; Japan
| | - Satoshi Yazawa
- Department of Urology; Keio University School of Medicine; Tokyo; Japan
| | - Kazuyuki Yuge
- Department of Urology; Keio University School of Medicine; Tokyo; Japan
| | - Eiji Kikuchi
- Department of Urology; Keio University School of Medicine; Tokyo; Japan
| | - Hiroshi Asanuma
- Department of Urology; Keio University School of Medicine; Tokyo; Japan
| | - Ken Nakagawa
- Department of Urology; Keio University School of Medicine; Tokyo; Japan
| | - Mototsugu Oya
- Department of Urology; Keio University School of Medicine; Tokyo; Japan
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Continence rate and oncological feasibility after total transurethral resection of the prostate as an alternative therapy for the treatment of prostate cancer: a pilot study. Int Neurourol J 2012; 15:222-7. [PMID: 22259737 PMCID: PMC3256308 DOI: 10.5213/inj.2011.15.4.222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 12/06/2011] [Indexed: 11/08/2022] Open
Abstract
PURPOSE The value of total transurethral resection of prostate cancer (TURPC) as an alternative therapy was first recognized by Hans J. Reuter. Thus, we conducted the study of prospectively collected data to verify total TURPC as an alternative therapy forlocalized prostate cancer. METHODS From January 2008 to July 2011, 14 patients with a mean age of 76.1 years (range, 66 to 89 years) with clinically localized prostate cancer were treated by prostatic resection by the corresponding author with curative intention. RESULTS The mean duration of TURPC was 51.7 minutes (range, 30 to 120 minutes) and the mean amount of prostatic tissue resected was 21.2 g (range, 5 to 66 g). An intra- and/or postoperative blood transfusion was necessary in 2 cases. Hyponatremia was found in 7 patients. Six months after TURPC, 3 cases of grade 1 and 1 case of grade 2 incontinence were observed. Three patients in the high-risk group did not achieve a prostate specific antigen (PSA) nadir of ≤0.2 ng/mL. PSA recurrence occurred in one case in our series. Newly developed lymph node or distant metastases were not observed during the follow-up period. CONCLUSIONS According to our results, transurethral resection for prostate cancer can be performed with reasonable oncological results. The PSA nadir levels, and rates of biochemical failure and postoperative complications, including incontinence, were comparable with the published results for other procedures. TURPC is also inexpensive and non-invasive, and requires short hospitalization and a short surgical time without vesicourethral anastomosis.
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Abdollah F, Schmitges J, Sun M, Tian Z, Briganti A, Shariat SF, Perrotte P, Montorsi F, Karakiewicz PI. A critical assessment of the value of lymph node dissection at radical prostatectomy: A population-based study. Prostate 2011; 71:1587-94. [PMID: 21480307 DOI: 10.1002/pros.21376] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Accepted: 02/08/2011] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We tested relationship between pelvic lymph node dissection (PLND) status at the time of radical prostatectomy (RP) and survival in prostate cancer (PCa) patients. METHODS Overall, 127,824 PCa patients treated with RP between 1988 and 2006 were included. Univariable and multivariable Cox regression analyses were used to evaluate the impact of PLND status (pN0 vs. pNx vs. pN1) on cancer-specific mortality (CSM) and overall mortality (OM) rates. RESULTS In pT2 patients, the 5-, 10-, and 15-year CSM rates were: 0.4%, 1.7%, and 3.9% for pN0, 0.6%, 2.5%, and 4.7% for pNx, 2.7%, 11.9%, and 20.6% for pN1 patients (all P < 0.001). The 5-, 10-, and 15-year OM rates were: 5.4%, 16.3%, and 34.5% for pN0, 6.1%, 18.2%, and 35.3% for pNx, 11.5%, 32.7%, and 53.4% for pN1 (all P < 0.001). In multivariable analyses, pNx and pN1 stage increased CSM rate, respectively by 1.3- and 3.8-fold (both P < 0.001) relative to pN0. Similarly, pNx and pN1 increased OM rate respectively by 1.1- and 1.6-fold (both P < 0.001) relative to pN0. In pT3 patients, pNx stage did not significantly increase CSM or OM rates relative to pN0 (both P > 0.05). CONCLUSIONS Patients with localized PCa treated with RP without a PLND (pNx) have less favorable survival rate than their counterparts that do not harbor lymph node invasion at PLND. However, the difference is modest (0.8% at 10 years). In consequence, the related costs and benefits of this procedure should be weighted carefully. In addition, the survival benefit of PLND was not observed in locally advanced PCa patients.
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Affiliation(s)
- Firas Abdollah
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, Canada; Department of Urology, Vita Salute San Raffaele University, Milan, Italy.
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Joung JY, Cho IC, Lee KH. Role of pelvic lymph node dissection in prostate cancer treatment. Korean J Urol 2011; 52:437-45. [PMID: 21860762 PMCID: PMC3151629 DOI: 10.4111/kju.2011.52.7.437] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 03/07/2011] [Indexed: 11/18/2022] Open
Abstract
Pelvic lymph node dissection (PLND) is the most accurate and reliable staging procedure for detecting lymph node invasion (LNI) in prostate cancer. Recently, [(11)C]-choline positron emission tomography imaging and magnetic resonance imaging with lymphotropic superpara-magnetic nanoparticles have shown potential for detecting LNI but are still under investigation. The risk of LNI in low-risk groups could be underestimated by use of the current nomograms, which rely on data collected from patients who underwent only limited PLND. Extended PLND (ePLND) shows higher lymph node yield, which leads to the removal of more positive nodes and fewer missed positive nodes. It may be possible to refrain from performing PLND on low-risk patients with a prostate-specific antigen value <10 ng/ml and a biopsy Gleason score ≤6, but the risk of biopsy-related understaging should be kept in mind. Theoretically, meticulous ePLND may also impact prostate cancer survival by clearing low-volume diseases and occult micrometastasis even in pN0. The therapeutic role of PLND in prostate cancer patients is still an open question, especially in individuals with low-risk disease. Patients with intermediate- to high-risk disease are more likely to benefit from ePLND.
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Affiliation(s)
- Jae Young Joung
- Center for Prostate Cancer, National Cancer Center, Goyang, Korea
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Chin JL, Srigley J, Mayhew LA, Rumble RB, Crossley C, Hunter A, Fleshner N, Bora B, McLeod R, McNair S, Langer B, Evans A. Guideline for optimization of surgical and pathological quality performance for radical prostatectomy in prostate cancer management: evidentiary base. Can Urol Assoc J 2011; 4:13-25. [PMID: 20165572 DOI: 10.5489/cuaj.08105] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The objective is to provide surgical and pathological guidelines for radical prostatectomy (RP) with or without concurrent pelvic lymph node dissection (PLND) to achieve optimal benefit for patients, with minimal risk of harm. METHODS For surgical questions, a literature search of MEDLINE, EMBASE and the Cochrane database was performed. A literature search for the pathological questions was not conducted since the protocol for invasive carcinomas of the prostate gland developed by the College of American Pathologists (CAP) was endorsed. Urologists and pathologists were consulted for their assessment of the surgical and pathological recommendations. RESULTS Limited high-quality evidence from 95 primary studies was available and, therefore, the expert panel developed recommendations on the basis of a consensus of the expert opinion of the working group and through a consultation with urologists and pathologists. In addition to the CAP protocol, some technical recommendations related to the handling and processing of the specimen were made. CONCLUSION Radical prostatectomy is recommended for the surgical treatment of prostate cancer, depending on a patient's preoperative risk profile. The panel unanimously determined that the goals for RP are to attain a positive margin rate of <25% for pT2 disease, a mortality rate of <1%, rates of rectal injury of <1% and blood transfusion rates of <10% in non-anemic patients. Standard PLND should be mandatory in high-risk patients, should be recommended for intermediate-risk patients and should be optional for low-risk patients. The quality and effectiveness of this treatment and of subsequent patient care depend on good management, effective communication and reporting between surgeons and pathologists working together as part of a multidisciplinary team. The complete guideline document is posted on the Cancer Care Ontario website (www.cancercare.on.ca); search in their Toolbox, Quality Guidelines & Standards, Clinical Program category under "surgery."
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Affiliation(s)
- Joseph L Chin
- Regional Head of Surgical Oncology, London Health Sciences Centre, London, ON
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Eifler J, Levinson A, Hyndman M, Trock B, Pavlovich C. Pelvic Lymph Node Dissection is Associated With Symptomatic Venous Thromboembolism Risk During Laparoscopic Radical Prostatectomy. J Urol 2011; 185:1661-5. [DOI: 10.1016/j.juro.2010.12.044] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Indexed: 10/18/2022]
Affiliation(s)
- J.B. Eifler
- James Buchanan Brady Urological Institute and the Department of Urology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - A.W. Levinson
- James Buchanan Brady Urological Institute and the Department of Urology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - M.E. Hyndman
- James Buchanan Brady Urological Institute and the Department of Urology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - B.J. Trock
- James Buchanan Brady Urological Institute and the Department of Urology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - C.P. Pavlovich
- James Buchanan Brady Urological Institute and the Department of Urology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Sfoungaristos S, Perimenis P. PSA density versus risk stratification for lymphadenectomy-making decision in patients with prostate cancer undergoing radical prostatectomy. Int Urol Nephrol 2011; 43:1073-9. [DOI: 10.1007/s11255-011-9942-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 02/24/2011] [Indexed: 10/18/2022]
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Heidenreich A, Pfister D, Thüer D, Brehmer B. Percentage of positive biopsies predicts lymph node involvement in men with low-risk prostate cancer undergoing radical prostatectomy and extended pelvic lymphadenectomy. BJU Int 2011; 107:220-5. [DOI: 10.1111/j.1464-410x.2010.09485.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abdollah F, Sun M, Thuret R, Karakiewicz PI. Should all men having a radical prostatectomy have a pelvic lymph node dissection? No. Can Urol Assoc J 2010; 4:425-6. [PMID: 21191507 DOI: 10.5489/cuaj.964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Firas Abdollah
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada
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31
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Weizer AZ, Montgomery JS. The Role of Lymphadenectomy in Minimally Invasive Urologic Oncology. J Endourol 2010; 24:1229-40. [DOI: 10.1089/end.2009.0562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alon Z. Weizer
- Division of Urologic Oncology and Minimally Invasive Surgery, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey S. Montgomery
- Division of Urologic Oncology and Minimally Invasive Surgery, Department of Urology, University of Michigan, Ann Arbor, Michigan
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Truesdale MD, Lee DJ, Cheetham PJ, Hruby GW, Turk AT, Badani KK. Assessment of Lymph Node Yield After Pelvic Lymph Node Dissection in Men with Prostate Cancer: A Comparison Between Robot-Assisted Radical Prostatectomy and Open Radical Prostatectomy in the Modern Era. J Endourol 2010; 24:1055-60. [DOI: 10.1089/end.2010.0128] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Daniel J. Lee
- Department of Urology Columbia University Medical Center, New York, New York
| | | | - Gregory W. Hruby
- Department of Urology Columbia University Medical Center, New York, New York
| | - Andrew T. Turk
- Department of Pathology, Columbia University Medical Center, New York, New York
| | - Ketan K. Badani
- Department of Urology Columbia University Medical Center, New York, New York
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Cooperberg MR, Kane CJ, Cowan JE, Carroll PR. Adequacy of lymphadenectomy among men undergoing robot-assisted laparoscopic radical prostatectomy. BJU Int 2010; 105:88-92. [DOI: 10.1111/j.1464-410x.2009.08699.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Reuter MA, Dietz K. [Radical transurethral resection of the prostate. An alternative therapy for the treatment of prostate cancer]. Urologe A 2009; 48:740-7. [PMID: 19484215 DOI: 10.1007/s00120-009-1982-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The value of radical transurethral resection of prostate cancer (TURPC) as an alternative therapy was investigated in this prospective study. From January 1995 to July 2008, 533 patients with a median age of 67 years (range 40-89 years) and with clinically localized prostate cancer were resected by the corresponding author with curative intention. The tumor stages were as follows: pT1 8%; pT2 61%; pT3 31%; G1 2%; G2 80%; G3 18%. TURPC requires continuous low-pressure irrigation with the irrigator liquid level at 10 cm water above the pubic region. It also requires a suprapubic trocar, a resectoscope with a 28F sheath, an autoregulated electrosurgical unit, and video monitoring. The prostate is resected completely with peripheral capsule and seminal vesicles. The specimen is retrieved in fractions for correct histopathological staging. If indicated, laparoscopic staging lymphadenectomy is performed. A secondary session for control of positive margins follows after 8 weeks. The transfusion rate was 1.5%, revision for hemorrhage 2.4%, lung embolism 0.2%, bladder neck incision 14%, grade 2 incontinence 0.6% out of 314, and impotence 30% out of 136. The prostate-specific antigen (PSA) nadir was < or =0.2 ng/ml in 95% of 444 cases. PSA recurrence at 5 years was 6% for pT1, 18% for pT2, and 31% for pT3. Postoperative survival at 10 years was 96% for pT1, 91% for pT2, and 85% for pT3 patients. Prostate cancer can be resected transurethrally with reasonable oncological results. The outcome with respect to survival and PSA recurrence is comparable with the results of other published procedures. Low-pressure irrigation with a suprapubic trocar is mandatory for safe performance.
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Affiliation(s)
- M A Reuter
- Urologische Klinik, Karl-Olga-Krankenhaus, Hackstrasse 61, 70190 Stuttgart.
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Silberstein JL, Derweesh IH, Kane CJ. Lymph node dissection during robot-assisted radical prostatectomy: where do we stand? Prostate Cancer Prostatic Dis 2009; 12:227-32. [PMID: 19546882 DOI: 10.1038/pcan.2009.17] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Since the initial report of robot-assisted laparoscopic prostatectomy (RALP) in 2001, the technique has gained rapid acceptance and utilization. When compared with more traditional forms of surgical intervention, there is still much debate with respect to cost, and impact on potency and continence. Less often is the focus on oncologic outcomes. Pelvic lymph node dissection (PLND) at the time of prostatectomy is an important part of the surgical intervention for prostate cancer and is currently underreported during robotic procedures. Herein, we review the current controversies on the value and extent of PLND and the status of emerging data regarding robot-assisted PLND.
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Affiliation(s)
- J L Silberstein
- Department of Surgery, Division of Urology, University of California, San Diego, Medical Center, San Diego, CA 92103-8897, USA.
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Murphy AM, Berkman DS, Desai M, Benson MC, McKiernan JM, Badani KK. The number of negative pelvic lymph nodes removed does not affect the risk of biochemical failure after radical prostatectomy. BJU Int 2009; 105:176-9. [PMID: 19549117 DOI: 10.1111/j.1464-410x.2009.08707.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To assess patients who had radical prostatectomy (RP) and pelvic lymph node dissection (PLND) for pT2-4 N0M0 prostate cancer, to determine if LN yield affects the risk of biochemical failure (BCF), as the extent of PLND at the time of RP has become increasingly uncertain with the decreasing trend in tumour stage. PATIENTS AND METHODS We reviewed the Columbia University Urologic Oncology Database for patients with pT2-4 N0M0 prostate cancer treated with RP from 1990 to 2005. Exclusion criteria included <12 months of follow-up, incomplete clinical and pathological data, and neoadjuvant androgen-deprivation therapy (ADT) or immediate adjuvant ADT or external beam radiotherapy. Unadjusted and adjusted models were used to determine the ability of clinical and pathological variables to predict BCF. RESULTS The final dataset included 964 patients, with a mean age of 60.5 years and median preoperative prostate-specific antigen (PSA) level of 6.2 ng/mL. The median (range) LN yield was 7 (1-42) and the median follow-up 59 (12-190) months. In the unadjusted and adjusted models, preoperative PSA, pathological Gleason score, pathological stage, surgical margin status and year of surgery were significant predictors of BCF. The LN group was not a significant predictor of BCF in both the unadjusted and adjusted model (P = 0.759 and 0.408, respectively). When patients were stratified into high- and low-risk groups, LN yield remained an insignificant predictor of BCF. CONCLUSION A higher LN yield at the time of RP does not increase the chance of cure for patients with pT2-4N0M0 prostate cancer. This lack of a survival advantage holds true for patients with high-risk disease.
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Affiliation(s)
- Alana M Murphy
- Department of Urology, Columbia University Medical Center, New York, NY 10032, USA.
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Briganti A, Blute ML, Eastham JH, Graefen M, Heidenreich A, Karnes JR, Montorsi F, Studer UE. Pelvic Lymph Node Dissection in Prostate Cancer. Eur Urol 2009; 55:1251-65. [DOI: 10.1016/j.eururo.2009.03.012] [Citation(s) in RCA: 391] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 03/03/2009] [Indexed: 11/28/2022]
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Two Positive Nodes Represent a Significant Cut-off Value for Cancer Specific Survival in Patients with Node Positive Prostate Cancer. A New Proposal Based on a Two-Institution Experience on 703 Consecutive N+ Patients Treated with Radical Prostatectomy, Extended Pelvic Lymph Node Dissection and Adjuvant Therapy. Eur Urol 2009; 55:261-70. [PMID: 18838212 DOI: 10.1016/j.eururo.2008.09.043] [Citation(s) in RCA: 243] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Accepted: 09/18/2008] [Indexed: 11/21/2022]
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Schlomm T, Börgermann C, Heinzer H, Rübben H, Huland H, Graefen M. Stellenwert der Lymphadenektomie beim Prostatakarzinom. Urologe A 2008; 48:37-45. [DOI: 10.1007/s00120-008-1758-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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40
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Stock RG. Counterpoint: High-risk prostate cancer: The case for combination brachytherapy and external beam irradiation. Brachytherapy 2008; 7:280-2; discussion 283. [DOI: 10.1016/j.brachy.2008.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Variations in surgeon volume and use of pelvic lymph node dissection with open and minimally invasive radical prostatectomy. Urology 2008; 72:647-52; discussion 652-3. [PMID: 18649928 DOI: 10.1016/j.urology.2008.03.067] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 03/16/2008] [Accepted: 03/29/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Although pelvic lymph node dissection (PLND) during radical prostatectomy (RP) improves staging, controversy remains concerning its indications and benefits on cancer control. We examined the factors associated with PLND use among men undergoing open RP (ORP) and minimally invasive RP (MIRP). METHODS Using a 5% national sample of Medicare beneficiaries from 2003 to 2005, we identified 2702 men who had undergone RP. Multivariate logistic regression analysis was used to assess whether the surgical approach, surgeon volume, patient demographics, comorbidity, and geographic region were associated with the likelihood of performing PLND. RESULTS Overall, 68% of men underwent PLND, although the rates varied by surgical approach (17% vs 83% for MIRP vs ORP, respectively, P <.001). In adjusted analyses, men undergoing MIRP vs ORP (odds ratio [OR] 0.02, 95% confidence interval [CI], 0.02-0.03), men > or = 75 vs 65-69 years old (OR 0.23, 95% CI 0.17-0.31), and men with multiple vs no comorbidities (OR 0.48, 95% CI 0.35-0.66 for Charlson score > or = 3 vs 0) were less likely to undergo PLND. High-volume minimally invasive surgeons were more likely to perform PLND (OR 1.19, 95% CI 1.14-1.25). Finally, men in the Western vs Southern United States (OR 1.61, 95% CI 1.19-2.17) were more likely to undergo PLND. CONCLUSIONS Men undergoing MIRP vs ORP were less likely to undergo PLND, although rates of the procedure increased with surgical volume. Additional studies are needed to determine the indications and benefits of this procedure for men with prostate cancer.
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Breyer BN, Greene KL, Dall'Era MA, Davies BJ, Kane CJ. Pelvic lymphadenectomy in prostate cancer. Prostate Cancer Prostatic Dis 2008; 11:320-4. [PMID: 18490935 DOI: 10.1038/pcan.2008.29] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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43
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Limited Pelvic Lymph Node Dissection Does Not Improve Biochemical Relapse-Free Survival at 10 Years After Radical Prostatectomy in Patients with Low-Risk Prostate Cancer. Urology 2008; 71:141-5. [DOI: 10.1016/j.urology.2007.08.027] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2007] [Revised: 06/26/2007] [Accepted: 08/10/2007] [Indexed: 11/23/2022]
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Klein EA, Kattan M, Stephenson A, Vickers A. How Many Lymphadenectomies Does It Take to Cure One Patient? Eur Urol 2008; 53:13-5; discussion 18-20. [PMID: 17900798 DOI: 10.1016/j.eururo.2007.09.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Accepted: 09/10/2007] [Indexed: 11/24/2022]
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45
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Joseph JV, Greene T. Re: Standard versus limited pelvic lymph node dissection for prostate cancer in patients with a predicted probability of nodal metastasis greater than 1% K. Touijer, F. Rabbani, J. R. Otero, F. P. Secin, J. A. Eastham, P. T. Scardino And B. Guillonneau J Urol 2007; 178: 120-124. J Urol 2007; 179:789-90. [PMID: 18082824 DOI: 10.1016/j.juro.2007.09.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2007] [Indexed: 12/01/2022]
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Jereczek-Fossa BA, Orecchia R. Evidence-based radiation oncology: Definitive, adjuvant and salvage radiotherapy for non-metastatic prostate cancer. Radiother Oncol 2007; 84:197-215. [PMID: 17532494 DOI: 10.1016/j.radonc.2007.04.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Revised: 04/08/2007] [Accepted: 04/18/2007] [Indexed: 02/07/2023]
Abstract
The standard treatment options based on the risk category (stage, Gleason score, PSA) for localized prostate cancer include surgery, radiotherapy and watchful waiting. The literature does not provide clear-cut evidence for the superiority of surgery over radiotherapy, whereas both approaches differ in their side effects. The definitive external beam irradiation is frequently employed in stage T1b-T1c, T2 and T3 tumors. There is a pretty strong evidence that intermediate- and high-risk patients benefit from dose escalation. The latter requires reduction of the irradiated normal tissue (using 3-dimensional conformal approach, intensity modulated radiotherapy, image-guided radiotherapy, etc.). Recent data suggest that prostate cancer may benefit from hypofractionation due to relatively low alpha/beta ratio; these findings warrant confirmation though. The role of whole pelvis irradiation is still controversial. Numerous randomized trials demonstrated a clinical benefit in terms of biochemical control, local and distant control, and overall survival from the addition of androgen suppression to external beam radiotherapy in intermediate- and high-risk patients. These studies typically included locally advanced (T3-T4) and poor-prognosis (Gleason score >7 and/or PSA >20 ng/mL) tumors and employed neoadjuvant/concomitant/adjuvant androgen suppression rather than only adjuvant setting. The ongoing trials will hopefully further define the role of endocrine treatment in more favorable risk patients and in the setting of the dose escalated radiotherapy. Brachytherapy (BRT) with permanent implants may be offered to low-risk patients (cT1-T2a, Gleason score <7, or 3+4, PSA <or=10 ng/mL), with prostate volume of <or=50 ml, no previous transurethral prostate resection and a good urinary function. Some recent data suggest a benefit from combining external beam irradiation and BRT for intermediate-risk patients. EBRT after radical prostatectomy improves disease-free survival and biochemical and local control rates in patients with positive surgical margins or pT3 tumors. Salvage radiotherapy may be considered at the time of biochemical failure in previously non-irradiated patients.
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Türkeri L. The Extent of Lymph Node Dissection in Patients with Localised Prostate Cancer: Debate Continues. Eur Urol 2007; 51:1472-4. [PMID: 17339074 DOI: 10.1016/j.eururo.2007.02.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2007] [Accepted: 02/14/2007] [Indexed: 11/30/2022]
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