BERKELEY, CA (UroToday.com) - Pelvic lymph node dissection (PLND) is an important part of the surgical therapy of prostate cancer (PCa), but it remains a procedure that can result in significant and well-recognized comorbidities. The most important of these complications is lymphocele formation, a condition that both lengthens patients' recovery time and and increases the incidence of deep venous thrombosis. Thus, a challenging topic is the effective need of performing pelvic lymph node dissection, its extension (monolateral versus bilateral), and if there are preoperative tools with a higher predictive value than currently used nomograms. In this article we focused on side-specific biopsy findings and their accuracy in predicting nodal metastatic involvement at the time of surgery. Through ROC analysis we demonstrated the existence of this association, but we also found that unilateral PLND is not recommended for several reasons.
First of all, about 36.8% of patients harbored contralateral lymph node metastases, while 23.6% of the whole population had nodal metastases only on the contralateral side. Moreover, those percentages were found to increase according to the risk class. According to these results, performing unilateral pelvic lymph node dissection results in an important missing of lymph node metastases, thus affecting the efficacy of this surgical procedure and resulting in the misdiagnosis of a significant percentage of (eventually) positive lymph nodes.
Tsivian, et al. suggested to improve biopsy accuracy by applying saturation schemes, but this solution has been found to lead to an improvement in biopsy-related complications (rectal bleeding, sepsis) while not significantly enhancing side-specific accuracy. Also, it does not take into consideration the biology of prostate cancer, which, in most cases, consists of a multifocal disease, not limited to a single prostatic lobe but involving both sides of the prostate. In fact, according to our study, about 40% of patients supposed to harbor unilateral PCa were found to have contralateral nodal metastases, a percentage which considerably increases if patients enrolled are found to be classified as intermediate and high risk.
Thus, unilateral PLND would lead to a significant understaging, potentially leaving many sides of nodal metastases not excised by the urologist and compromising the curative role that many authors have ascribed to this procedure.
Written by:
R. Schiavina,a M. Gacci,b A. Briganti,c C. Imbimbo,d A. Simonato,e M. Borghesi,a U. Capitanio,c E. Brunocilla,a G. Martorana,a M. Carini,b F. Montorsi,c V. Mirone,d D. Romagnoli,a M. Borghesi,a and G. Carmignanie as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
a Department of Urology, University of Bologna, S.Orsola-Malpighi Hospital, Palagi 9, 40134 Bologna, Italy
b Department of Urology, University of Florence, Florence, Italy
c Department of Urology, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
d Department of Urology, University Federico II of Naples, Naples, Italy
e Luciano Giuliani Department of Urology, University of Genoa, Genoa, Italy
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