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Review – Prostate Cancer

The Benefits and Harms of Different Extents of Lymph Node Dissection During Radical Prostatectomy for Prostate Cancer: A Systematic Review

By: Nicola Fossatia 1, Peter-Paul M. Willemseb 1, Roderick C.N. van den Berghc, Thomas Van den Broeckd, Cathy Yuhong Yuane, Erik Briersf, Joaquim Bellmuntg h, Michel Bollai, Philip Cornfordj, Maria De Santisk, Ekelechi MacPepplel, Ann M. Henrym, Malcolm D. Masonn, Vsevolod B. Matveevo, Henk G. van der Poelp, Theo H. van der Kwastq, Olivier Rouvièrer, Ivo G. Schootss t, Thomas Wiegelu, Thomas B. Lamv w, Nicolas Mottetx and Steven Joniaud

European Urology, February 2017

Published online: 09 February 2017

Keywords: Prostate cancer, Surgery, Lymph node dissection, Staging, Oncological outcome, Functional outcome, Complications, Systematic review

Abstract Full Text Full Text PDF (3,2 MB)

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.

Take Home Message

Although representing the most accurate staging procedure, pelvic lymph node dissection (PLND)—irrespective of the extent (limited/standard vs [super]extended PLND)—is 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.

Keywords: Prostate cancer, Surgery, Lymph node dissection, Staging, Oncological outcome, Functional outcome, Complications, Systematic review.

Footnotes

a Division of Oncology/Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy

b Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands

c Department of Urology, University Hospitals Leuven, and Laboratory of Molecular Endocrinology, KU Leuven, Leuven, Belgium

d Department of Urology, University Medical Centre, Utrecht, The Netherlands

e Division of Gastroenterology and Cochrane UGPD Group, Department of Medicine, Health Sciences Centre, McMaster University, Hamilton, Canada

f Patient Advocate, Hasselt, Belgium

g Bladder Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA

h Harvard Medical School, Boston, MA, USA

i Department of Radiation Therapy, CHU Grenoble, Grenoble, France

j Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK

k University of Warwick, Cancer Research Centre, Coventry, UK

l Surrey Health Economic Centre, School of Economics, University of Surrey, Guilford, UK

m Leeds Cancer Centre, St. James's University Hospital and University of Leeds, Leeds, UK

n Cardiff University, Velindre Hospital, Cardiff, UK

o N.N. Blokhin Cancer Research Center, Moscow, Russia

p Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands

q Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands

r Hospices Civils de Lyon, Radiology Department, Edouard Herriot Hospital, Lyon, France

s Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands

t Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands

u Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany

v Academic Urology Unit, University of Aberdeen, Aberdeen, UK

w Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK

x Department of Urology, University Hospital, St. Etienne, France

Corresponding author. Department of Urology, University Hospitals Leuven, Leuven, Belgium. Tel. +32 163 46945; Fax: +32 163 46931.

1 Both are co-first authors of this paper.

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