Pelvic lymph node dissection and robot-assisted laparoscopic radical prostatectomy

With the introduction of robot-assisted laparoscopic radical prostatectomy (RALP) there came suggestions from some surgeons that this technique made pelvic lymph node dissection (PLND) more difficult. However, a new review by a respected international group of authors clearly disagrees with this suggestion.

The new review by Ploussard et al. in European Urology does concur with the idea that there has been a decline in the frequency of PLND as a standard component of a radical prostatectomy in recent years, but emphasizes that this technique remains “the most effective method for detecting lymph node metastases.”

The authors findings, based on a thorough review of the published literature from January 1990 through December 2012, are as follows:

  • The nodal yield at PLND during RALP ranged from 3 to 24 nodes.
  • Lymph node positivity rate during RALP increases with the extent of dissection (in exactly the same way as it does for open and non-robot-assisted laparoscopic procedures).
  • PLND-only related complications are relatively rare.
    • The commonest complication after PLND is symptomatic pelvic lymphocele (in 0 to 8 percent of cases).
    • The rate of PLND-associated grade 3 and grade 4 complications ranges from 0 to 5 percent.
  • PLND is associated with increased operative time.
  • The available data suggest equivalence of PLND between RARP and other surgical approaches in terms of nodal yield, node positivity, and intraoperative and postoperative complications.

The authors further state that the decline in frequency of PLND since the advent of RALP probably has more to do with prostate cancer stage migration in the PSA screening era, i.e., the much more common finding and treatment of men with low-risk prostate cancers who do not actually need a PLND (if they needed any treatment at all in many cases).

Ploussard et al. conclude bluntly that “PLND during [RALP] can be performed effectively and safely. The overall number of nodes removed, the likelihood of node positivity, and the types and rates of complications of PLND are similar to pure laparoscopic and open retropubic procedures.”

As is true for many other aspects of the surgical treatment of prostate cancer … the conduct and quality of lymph node dissection (and the risk for complication asssociated with such a dissection) is almost certainly a function of the skill and experience of the surgeon as opposed to the equipment being used to carry out the operation.

5 Responses


    I’m thinking most of us who are closely following developments regarding lymph node mets would find the following statement by the authors no longer credible, the statement that pelvic lymph node dissection is “the most effective method for detecting lymph node metastases.”

    It appears that emerging scans, especially choline labeled with C11 and C11 acetate in PET/CT lymph node scans, with papers already published (more no doubt in progress from Mayo in Rochester and from Phoenix, Arizona), and with the feraheme USPIO 3Tesla MRI results about to be submitted for publication, offer far superior lymph node results, with much greater specificity, sensitivity, and comprehensiveness.

    I’m thinking the authors are exclusively from the surgery and pathology community, with no imaging experts. The group includes some very well known researcher-physicians.

    One advantage of the surgical approach to lymph node detection, especially in contrast with C11 and C11 acetate scans, is that the latter scans require highly specialized radiation equipment with special authorization.

  2. Dear Jim:

    Actually I think the authors’ statement is completely accurate. Certain types of scam can indicate the potential risk for the presence of a positive lymph node, but until you actually take that lymph node out, stain it, and look at it under a microscope, it is impossible to tell whether cancer is present or not with accuracy.

  3. As a real world example … I had an [11C]choline scan at Mayo which showed 3 positive nodes. I followed up the scan with salvage lymph node dissection. They removed 25 nodes; 15 were positive for cancer. In 2005 when I had my open RP they took out 13 nodes with 1 positive for cancer.

  4. Bill,

    Thanks for sharing your experience, though I’ll admit I thought that [11C]choline scan was more sensitive, that it would pick up a very high percentage of positive nodes. I’m wondering if yours was done when Mayo was just learning how to do and interpret the scan or when they were fully up to speed. Is the evidence suggesting your cancer is now completely gone?

    Information on the Feraheme USPIO scan being done in Florida has not yet been published, but I am aware that that team has gradually been upgrading its claim for smallest metastasis detected from around 2 mm to 1 mm, at least some of the time, if memory is serving me well. As Sitemaster has noted previously, the talent and experience of the radiologist makes a difference.

  5. Dear Jim:

    Bill had his PET scan at the Mayo some time after the approval of this technique by the FDA, so the facility was certainly “fully up to speed”. And no, Bill’s cancer is very definitely not “completely gone”.

    It is my personal opinion that patients often have a significant tendency to over-estimate the accuracy of things like PET scans and multiparametric MRIs, and that this tendency is (regrettably) fostered by some professionals in the imaging community. I further believe that the Mayo Clinic deserves credit for being very clear that they will not even attempt to use [11]choline PET scans on men with a PSA level of < 2 ng/ml.

    With respect to the ability to detect metastases as small as 1 or 2 mm with any type of scan … the issue is not whether this can be done, it it whether it can be done with a very high degree of predictability regardless of the location of a tumor of that size. I am not aware that anyone can make that claim yet, regardless of how skilled and experienced the radiologist or the quality of the equipment. The current situation is one in which such scans can be helpful in assessing the situation for some patients, but we can't make the assumption that what is seen on these scans converts with even 90% accuracy to the real clinical situation.

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