Elsevier

Urology

Volume 69, Issue 2, February 2007, Pages 203-209
Urology

Review
Role of Pelvic Lymphadenectomy in Prostate Cancer Management

https://doi.org/10.1016/j.urology.2006.10.031Get rights and content

Section snippets

Does pelvic lymphadenectomy alter the prognosis

The therapeutic impact of pelvic lymphadenectomy for disease clearance in the era of prostate cancer stage migration and lymph node micrometastasis is still largely unknown. Bhatta-Dar et al.3 retrospectively examined the role of pelvic lymphadenectomy in 336 men who underwent radical prostatectomy. Patients had a prostate-specific antigen (PSA) level of less than 10 ng/mL, Gleason score of less than 7, and clinical Stage T1 or T2 disease. Only 140 men underwent pelvic lymphadenectomy,

Patient selection

The downward stage migration resulting from the earlier detection of prostate cancer during the past few decades has led to an apparent decrease in lymph node metastasis rates from 20% to 40% in the 1970s and 1980s to the present rate of about 6%.9, 10

The Partin tables, Memorial Sloan-Kettering Cancer Center Prostate Nomogram, and the Hamburg algorithm have been developed as methods of identifying patients who are at increased risk of lymph node metastasis preoperatively.11, 12, 13 These tools

Anatomic boundaries

Prostate lymphatics drain by way of three routes18: ascending ducts, which drain into the external iliac lymph nodes; lateral ducts, which drain into the hypogastric lymph nodes; and posterior ducts, which drain into the sacral lymph nodes.

Schuessler et al.19 published a description of the various types of lymphadenectomies performed on patients with prostate cancer in 1993. These lymph node groups are illustrated in Figure 1.

Do anatomic boundaries matter?

Bader et al.20 showed that the anatomic boundaries of lymphadenectomy influence the accuracy of lymph node detection. In their study, 88 of the 365 patients had positive lymph nodes. Of the 88 patients, 51 (58%) had positive internal iliac lymph nodes. Thus, internal iliac lymph node dissection is crucial. Heidenreich et al.21 also showed that significant lymph node metastasis (42%) occurred outside the external iliac and obturator lymph node distribution in the 103 patients who underwent

Histopathologic analysis

The role of frozen section diagnosis in the assessment of pelvic lymph nodes during radical prostatectomy has varied during the past 20 years. In 1986, Epstein et al.32 reviewed 310 patients, who had undergone frozen section analysis, and found that the frozen section analyses detected 67% of the positive lymph nodes that, grossly, were uninvolved and 100% of the grossly involved lymph nodes. These investigators concluded that this was a useful technique in grossly uninvolved nodes. Since then,

Surgical techniques

Pelvic lymphadenectomy can be performed using both the open and laparoscopic approaches. It has been shown that despite the limited access, the lymph node harvest during laparoscopic lymphadenectomy is comparable to that during the open procedure in centers in which the learning curve has been overcome.26, 41 Parkin et al.29 demonstrated that the laparoscopic procedure has low complication rates. The 132 cases (94 open cases and 38 laparoscopic cases) reported by Solberg et al.42 had a

SLN mapping in prostate cancer

Wawroschek et al.23 demonstrated the feasibility of SLN mapping in patients with prostate cancer. In 348 patients, a technetium-99m-labeled nanocolloid radioisotope was injected into each lobe of the prostate under transrectal ultrasound guidance. “Hot nodes” were then verified with preoperative lymphoscintigraphy and intraoperative gamma probe detection during lymphadenectomy. After removing the SLNs, the patients underwent either modified or extended lymphadenectomy, depending on their

Imaging pelvic lymph nodes in prostate cancer

Computed tomography (CT) and magnetic resonance imaging (MRI) of the pelvis lack the sufficient degree of sensitivity to replace the reference standard of surgical lymphadenectomy. Wolf et al.45 reviewed 25 published scientific reports on pelvic imaging that used histopathologic confirmation of lymph node metastasis. They revealed that CT and MRI had a combined low sensitivity of only 36% and specificity of 97% in detecting lymph node metastasis in prostate cancer.

In addition, a contemporary

Conclusions

The practice of pelvic lymphadenectomy in prostate cancer needs standardization of both the boundaries and terminology of the surgical procedure. Patient selection and the technique of histopathologic analysis also need to be standardized. Only through this can we get a better picture of the effect of pelvic lymphadenectomy as a staging and potential therapeutic tool.

Whether pelvic lymphadenectomy has a therapeutic role in prostate cancer management is still unknown. Some existing evidence has

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