The role of extended pelvic lymphadenectomy with radical prostatectomy for high risk prostate cancer - Beyond the Abstract

I was pleased to learn that this publication was selected to become part of www.UroToday.com, since this topic is a particularly relevant one in the current urologic atmosphere. Two concurrent trends make the issues addressed in this article particularly relevant. First, with recent criticism of prostate specific antigen (PSA) testing (1) and the rise of active surveillance (2), urologists and other providers are beginning to question the necessity and extent of various treatments for prostate cancer (PCa). In particular, radical prostatectomy (RP) and pelvic lymph node dissection (PLND) are under increased scrutiny as potential sources of overtreatment (3). Secondly, the last several decades has seen an explosion in the implementation of robot-assisted technology for surgical management of PCa (4). As discussed in our article, this trend may have led to a decrease in both the utilization and the extent of PLND (5).

In the context of these two trends, a review of PLND in high risk PCa becomes quite relevant. The most important questions, which frequently plague many urologists on the front lines, are when to perform PLND and the appropriate extent of the dissection. The former question has been addressed multiple times in the literature; the overarching opinion is that nomograms – based on preoperative characteristics – are preferable to the various imaging techniques studied. However, the exact patient population to best benefit from PLND is a point of contention, as the various guideline panels have differing recommendations (6-8). Additionally, the current review addresses the differences between extended, limited and standard PLND (e, l, and s PLND, respectively) as well as the implications for the oncologic outcomes of each. This breeds disagreement by geographic lines, with the European contingent believing an e-PLND is effective in intermediate and high risk cases, while the Americans support l-PLND if one is performed at all.

Unfortunately this review cannot definitively answer any of the long debated questions about PLND and the role of surgery for PCa. However, in the current atmosphere it behooves the practicing urologist to familiarize oneself with the relevant literature, so as to better tackle this difficult question when it presents itself in clinical practice. Ultimately, a thorough knowledge of such difficult problems is the only way to ensure the highest quality of patient care.

References:
1. Moyer VA, Force USPST. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Annals of internal medicine. 2012;157(2):120-34.
2. Klotz L. Active surveillance for low-risk prostate cancer. Current urology reports. 2015;16(4):24.
3. van Vugt HA, Roobol MJ, van der Poel HG, van Muilekom EH, Busstra M, Kil P, et al. Selecting men diagnosed with prostate cancer for active surveillance using a risk calculator: a prospective impact study. BJU international. 2012;110(2):180-7.
4. Kang DC, Hardee MJ, Fesperman SF, Stoffs TL, Dahm P. Low quality of evidence for robot-assisted laparoscopic prostatectomy: results of a systematic review of the published literature. European urology. 2010;57(6):930-7.
5. Gandaglia G, Sammon JD, Chang SL, Choueiri TK, Hu JC, Karakiewicz PI, et al. Comparative effectiveness of robot-assisted and open radical prostatectomy in the postdissemination era. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2014;32(14):1419-26.
6. Heidenreich A, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, et al. [EAU guidelines on prostate cancer. Part I: screening, diagnosis, and treatment of clinically localised disease]. Actas urologicas espanolas. 2011;35(9):501-14.
7. Mohler JL. The 2010 NCCN clinical practice guidelines in oncology on prostate cancer. Journal of the National Comprehensive Cancer Network : JNCCN. 2010;8(2):145.
8. Thompson I, Thrasher JB, Aus G, Burnett AL, Canby-Hagino ED, Cookson MS, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. The Journal of urology. 2007;177(6):2106-31.

Written by:
Andrew Harbin, MD
Department of Urology, Temple University Hospital, Philadelphia, PA.  .

AbstractThe role of extended pelvic lymphadenectomy with radical prostatectomy for high risk prostate cancer.

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