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2023 Recommendations |
Extent of Dissection |
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Bladder Cancer |
· PLND is integral part of radical cystectomy |
Standard PLND defined as external iliac, internal iliac, obturator nodes* |
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Upper Tract Cancer
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· High risk non-metastatic: perform LND |
Use anatomic template if LND performed |
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Kidney Cancer
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· Low stage/Low grade: do not offer LND · High-risk or cN1: Case by case decision |
Use anatomic template if LND performed |
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Prostate Cancer |
· Use nomograms to select patients for ePLND · Do not omit based on PSMA-PET/CT findings |
Extended PLND defined as external iliac, internal iliac and obturator nodes* |
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Penile Cancer |
· cN0: Offer ILND if DSNB not available. · cN+: offer fascial-sparing or open radical ILND · cN2: offer open radical ILND |
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Use anatomic template if LND performed |
For bladder cancer, pivotal RCTs, namely SWOG S1011 and LEA, have shown no survival benefit with extended PLND. The 2023 standard is a meticulous PLND of the obturator fossa, internal and external iliac landing zones. PLND remains integral to RC, as imaging to detect occult LN metastases remains subpar.
For UTUC, a rare disease with limited evidence, LN mapping studies are considered key. Template-based dissection is recommended for staging and aligns with guidelines. However, NAC is increasingly used and its impact on LND is currently unknown.
For kidney cancer, LND is not recommended for low-grade/stage tumors. The value of LND in high-risk cases remains unclear and warrants case-by-case decision-making. An anatomical template for LND is proposed but not included in the guidelines. An anatomic LND may be prudent in cases with clinical lymphadenopathy.
For prostate cancer, there is a lack of consensus on PLND templates, and the terminology used is confusing. Extended Pelvic Lymph Node Dissection (EPLND) as per the EAU guidelines is defined the same as the Standard PLND for bladder cancer. In 2023, risk stratification with nomograms now incorporates PSMA testing. Ongoing de-escalation trials are awaited, including those comparing PLND with no PLND (NCT01407263, NCT04269512), and PSMA stratified trials (NCT05000827, NCT05109910)
For penile cancer, timely LND can be lifesaving. Inguinal Lymph Node Dissection (ILND) within 3 months of diagnosis improves survival. For high-risk cN0 patients, early surgical staging is crucial. High volume centers have shown success with sentinel node biopsies, potentially sparing men from more extensive surgeries. For those without access, ILND remains the global standard. For advanced penile cancer, the InPACT trial (NCT02305654) will evaluate post-chemotherapy ILND.
Written by: Amanda A. Myers,1 Alberto Briganti,2 Bradley Leibovich,3 Seth P. Lerner,4 Marco Moschini,2 Morgan Rouprêt,5 Shahrokh F. Shariat,6 Philippe E. Spiess,7 Arnulf Stenzl,8 Samir S. Taneja,9 Karim A. Touijer,10 Ashish M. Kamat1
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Division of Oncology, Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy.
- Department of Urology, Mayo Clinic, Rochester, MN, USA.
- Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA.
- Urology, GRC 5 Predictive Onco-Uro, AP-HP, Pitie-Salpetriere Hospital, Sorbonne University, Paris, France.
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
- Department of GU Oncology and Tumor Biology, Moffitt Cancer Center, Tampa, FL, USA.
- Department of Urology, Eberhard Karls University of Tübingen, Tübingen, Germany.
- Department of Urology, NYU Langone Health, New York, NY, USA.
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.