Prognostic Impact of Para-Aortic Lymph Node Dissection in Colorectal Cancer Patients Suspected of Para-Aortic Lymph Node Metastasis: A Retrospective Cohort Study.

BACKGROUND: Para-aortic lymph node metastasis (PALNM) is a rare occurrence in colorectal cancer (CRC), and the high risk of radical lymphadenectomy leads to persistent debate about the best treatment strategy. This study aims to evaluate the predictor for PALNM and the clinical value of para-aortic lymph node dissection (PALND) in CRC patients with radiologically suspected synchronous PALNM. METHODS: Patients who have synchronous radiologically suspected PALNM and underwent primary tumor resection were included. Logistic regression and receiver operating characteristic curve analysis were used to assess the predictive value of lymph node short axis in preoperative CT, identifying the optimal cut-off value. Propensity score matching and Cox regression explored factors affecting overall and disease-free survival, while Kaplan-Meier curves and decision tree models identified patient characteristics suitable for synchronous para-aortic lymph node dissection. RESULTS: A total of 578 patients were enrolled, and 125 patients received synchronous PALND. We found that simultaneous PALND significantly improved overall survival (HR, 0.56; 95% CI, 0.35-0.91; P = .019) in multivariate analysis, while disease-free survival showed no significant difference (P = .41). The short axis diameter of PALN on preoperative CT is a crucial predictor of PALNM (P < .001, AUC = 0.759) with a threshold of > 7 mm. N-stage and distant metastasis were included as independent predictors in the diagnostic model to enhance accuracy. A larger short axis diameter of PALN correlated with advanced tumor stage and poorer prognosis. Subgroup analysis revealed that PALND offers survival benefits for colorectal cancer patients at all stages with a short axis diameter >10 mm on preoperative CT (P = .037) and for stage III patients with a diameter between 7 to10 mm (P < .001, AUC = 0.810). CONCLUSION: Synchronous PALND can improve overall survival in CRC patients with suspected PALNM, with the maximum short axis diameter of PALN serving as a key criterion for selecting patients for surgery.

Clinical Outcomes of Pelvic Lymph Node Dissection Before Versus After Robot-Assisted Laparoscopic Radical Cystectomy.

Objective: The purpose of this study was to compare the clinical outcomes of bladder cancer patients treated with extended pelvic lymph node dissection (ePLND) before or after cystectomy under robotic-assisted radical cystectomy (RARC). Methods: A retrospective study to identify 348 patients with bladder cancer who underwent RARC was performed. Of the patients, 152 (42.8%) underwent ePLND before radical cystectomy (RC) (group A) and 196 (56.3%) underwent ePLND after RC (group B). The clinical, pathological, and overall survival were compared. Results: The total and RC operation time in Group A (total: 130.68 ± 29.25 minutes, RC: 59.45 ± 28.63 minutes) were both shorter than Group B (total: 154.17 ± 38.18 minutes, RC: 94.81 ± 41.21 minutes) (P < .05). However, no significant difference in time of ePLND. The estimate blood loss (EBL) of RC part and total operation (RC+ePLND) in group A was less than group B (both P < .05), while the ePLND part did not show significance. The result of vascular and nerve injury and surgical drain withdrawal time were similar in two groups. The total number of lymph nodes in group A was fewer than group B (16 versus 26; P < .05). Moreover, the number of bilateral internal iliac and presacral lymph nodes of group A was fewer than group B significantly, whereas the number of bilateral external iliac, common iliac, and obturator lymph nodes was similar in two groups. The lymph node density of group A was significantly lower than group B. The median follow-up of all patients was 33.0 months. Importantly, the survival of group B was better than group A (hazard ratio: 1.412; 95% confidence interval: 1.004-1.987; P = .048). Conclusions: Performing ePLND before RC reveals better result on operation time and EBL, while, when ePLND after RC, the total number of lymph nodes dissected is more and the survival is better. It recommended ePLND be performed before RC, and it is necessary to recheck the internal iliac and presacral area after cystectomy.

The management of clinically suspicious para-aortic lymph node metastasis in colorectal cancer: A systematic review.

Approximately 1%-2% of patients with colorectal cancer (CRC) develop para-aortic lymph node (PALN) metastases, which are typically considered markers of systemic disease, and are associated with a poor prognosis. The utility of PALN dissection (PALND) in patients with CRC is of ongoing debate and only small-scale retrospective studies have been published on this topic to date. This systematic review aimed to determine the utility of resecting PALN metastases with the primary outcome measure being the difference in survival outcomes following either surgical resection or non-resection of these metastases. A comprehensive systematic search was undertaken to identify all English-language papers on PALND in the PubMed, Medline, and Google Scholar databases. The search results identified a total of 12 eligible studies for analysis. All studies were either retrospective cohort studies or case series. In this systematic review, PALND was found to be associated with a survival benefit when compared to non-resection. Metachronous PALND was found to be associated with better overall survival as compared to synchronous PALND, and the number of PALN metastases (2 or fewer) and a pre-operative carcinoembryonic antigen level of <5 was found to be associated with a better prognosis. No PALND-specific complications were identified in this review. A large-scale prospective study needs to be conducted to definitively determine the utility of PALND. For the present, PALND should be considered within a multidisciplinary approach for patients with CRC, in conjunction with already established treatment regimens.

[Surgeon's role in CT-based preoperative determination of inferior mesenteric artery anatomy in colorectal cancer treatment]. / Rol' khirurga v opredelenii anatomii nizhnei bryzheechnoi arterii po dannym komp'yuternoi tomografii pri lechenii kolorektal'nogo raka.

BACKGROUND: The inferior mesenteric artery (IMA) is a blood vessel of great importance in left colon and rectal cancer surgery. We aimed to determine the role of surgeons in computed tomography (CT) based vascular anatomy interpretation. METHOD: Patients with left colon and rectal cancer treated surgically with D3 lymph node dissection and selective vascular ligation were included in this study. All patients (n=250) underwent preoperative CT with intravenous contrast. The IMA anatomy was schematically depicted by surgeon based on CT interpretation. Intraoperatively anatomy was defined by skeletonisation of the IMA. All patients had segmental resection with selective vascular ligation. The concurrence of prospectively obtained results were evaluated by intraclass correlation and Kendall's tau-b test. Misinterpretation of IMA anatomy was analysed by CT-specialist. RESULTS: The preoperative and intraoperative IMA anatomy features were correctly interpreted in 237 cases (in 94.8%) within skeletonisation extent, which is supported by high level of agreement and concordance of preoperative data regards to intraoperative findings (K=0.926; p<0.001; CC=0.912; p<0.001). As a result of the CT-based evaluation of the IMA, E, K, and H types of branching patterns were proposed. IMV position was mistakenly identified in 2.6% of cases. CONCLUSION: Surgeons are able to evaluate the IMA anatomy accurately with CT and use it in routine preoperative planning. The E, K, and H branching types may be used when defining approach to skeletonisation and level of vascular ligation.

Contemporary Trends and Efficacy of Pelvic Lymph Node Dissection at Radical Cystectomy for Urothelial and Variant Histology Carcinoma of the Urinary Bladder.

OBJECTIVE: To test 1) contemporary pelvic lymph node dissection (PLND) trends at radical cystectomy (RC) in variant histology bladder cancer (VHBC) patients and urothelial carcinoma of the urinary bladder (UCUB), as well as 2) to test the effect of PLND extent on cancer specific mortality (CSM) after RC. METHODS: Within the Surveillance, Epidemiology and End Results Registry (SEER, 2004-2016), we identified non-metastatic stage T1-2 or T3-4 VHBC and UCUB patients, who underwent RC. CSM and lymph node invasion (LNI) rates were stratified according to PLND extent, as well as coded continuously in multivariate Cox and logistic regression models. RESULTS: Of 19,020 patients, 1736 (9.1%) were coded as having VHBC (46.9% squamous cell carcinoma, 22.5% adenocarcinoma, 18.9% neuroendocrine carcinoma, 11.7% not otherwise specified) vs 17,284 (90.9%) UCUB. PLND was performed in 80.1 of VHBC vs. 83.5% UCUB patients. In both histological groups, PLND rates increased over time (70.9-89.6% and 76.2%-90.1%, both P < .01). PLND extent did not significantly affect CSM in stage T1-2 or T3-4 VHBC patients. Conversely, PLND extent was associated with lower CSM in T1-2, as well as in T3-4 UCUB patients, which was confirmed in multivariate Cox analyses (Hazard ratio [HR] 0.99, P < .001). Rates of LNI increased with extent of PLND in logistic regression analyses in stage T3-4 VHBC (Odds ratio [OR] 1.01, P = .001), stage T1-2 UCUB (OR 1.01, P < .001) and T3-4 UCUB (OR 1.01, P < .001), but not in stage T1-2 VHBC (OR 1.01, P = .3). CONCLUSION: PLND rates do not differ between VHBC and UCUB patients. A potential survival benefit related to more extensive PLND is operational in UCUB patients, but not in VHBC patients.

Low endogenous testosterone levels are associated with the extend of lymphnodal invasion at radical prostatectomy and extended pelvic lymph node dissection.

OBJECTIVE: To investigate clinical factors associated to lymphnodal metastasis load in patients who underwent to radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND). MATERIALS AND METHODS: Between November 2014 and December 2019, ET was measured in 617 consecutive patients not under androgen deprivation therapy who underwent RP and ePLND. Lymphnode invasion (LNI) was codified as not present (N = 0) or with one (N = 1) or more than one metastatic node (N > 1). The risk of multiple pelvic lymph node metastasis (N > 1, mPLNM) was assessed by comparing it to the other two groups (N > 1 vs. N = 0 and N > 1 vs. N = 1). Then, we assessed the association between ET and lymphnode invasion for standard predictors, such as PSA, percentage of biopsy positive cores (BPC), tumor stage greater than 1 (cT > 1) and tumor grade group greater than two (ISUP > 2). RESULTS: Overall, LNI was detected in 70 patients (11.3%) of whom 39 (6.3%) with N = 1 and 31 (5%) with N > 1. On multivariate analysis, ET was inversely associated with the risk of N > 1 when compared to both N = 0 (odds ratio, OR 0.997; CI 0.994-1; p = 0.027) as well as with N = 1 cases (OR 0.994; 95% CI 0.989-1.000; p = 0.015). CONCLUSIONS: In clinical PCa, the risk of mPLNM was increased by low ET levels. As ET decreased, patients had an increased likelihood of mPLNM. Because of the inverse association between ET and mPLNM, higher ET levels were protective against aggressive disease. The influence of locally advanced PCa with high metastatic load on ET levels needs to be explored by controlled trials.

Prediction of the Need for an Extended Lymphadenectomy at the Time of Radical Cystectomy in Patients with Bladder Cancer.

BACKGROUND: A prospective randomized trial (LEA AUO AB 25/02) found no survival benefit in extended compared with limited pelvic lymph node dissection (PLND) templates in bladder cancer (BCa) patients treated with radical cystectomy (RC). However, the rate of lymph node invasion (LNI) in the standard and extended templates was lower than estimated. OBJECTIVE: To assess the accuracy of preoperative clinical and pathological parameters to predict LNI and to develop a model to preoperatively select candidates for the extended PLND templates. DESIGN, SETTING, AND PARTICIPANTS: A total of 903 BCa patients treated at a single institution were retrospectively identified. The primary outcome was to identify preoperatively the risk of LNI to tailor the type of PLND. The extended PLND templates consisted in the removal of pelvic lymph nodes together with the common iliac, presacral, para-aortocaval, interaortocaval, and paracaval sites up to the inferior mesenteric artery. INTERVENTION: A total of 903 BCa patients were treated with RC and bilateral extended PLND templates. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Several models predicting LNI were evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots and decision curve analyses. A nomogram predicting LNI in the extended pattern was developed and validated internally. RESULTS AND LIMITATIONS: Overall, 55 patients (6.1%) had LNI in the extended PLND templates at RC. The median number of nodes removed was 19 (interquartile range: 13-26). A model including age, clinical T stage, clinical node stage, lymphovascular invasion, and presence of carcinoma in situ at the last transurethral resection before RC was developed. The AUC of this model is 73%. Using a cutoff of 3%, 108 extended PLNDs (12%) would be spared and only two LNIs (3%) would be missed. The main limitations of our model are the retrospective nature of the data, lack of external validation, and low rate of LNI. CONCLUSIONS: This is the first proposed model to predict LNI in the extended PLND templates. This model might help urologists identify which patients might benefit from an extended PLND at the time of RC, reserving a standard PLND for all the others. PATIENT SUMMARY: We developed the first nomogram to predict lymph node invasion (LNI) in the extended pelvic lymph node dissection templates in bladder cancer patients treated with radical cystectomy. The adoption of our model to identify candidates for the extended pelvic lymph node dissection templates could avoid up to 12% of these procedures at the cost of missing only 3% of patients with LNI.

Peritoneal Tuberculosis After Robot-Assisted Laparoscopic Prostatectomy with Extended Lymph Node Dissection.

Background: Peritoneal tuberculosis (TB) is a relatively uncommon presentation of extrapulmonary TB. Early diagnosis of peritoneal TB is difficult because of its nonspecific clinical manifestation such as abdominal pain, fever, or ascites. Especially early after surgery of abdomen or pelvis, these symptoms can be misdiagnosed as septic peritonitis. There are few reports of peritoneal TB as a postoperative complication of laparoscopic surgery. Here, we describe a first case of peritoneal TB after robot-assisted laparoscopic prostatectomy (RALP) with extended lymph node dissection. Case Presentation: A 78-year-old man presented 25 days after this surgery with fever and abdominal distension. Ultrasonography and computed tomography (CT) revealed massive abdominal ascites. Ascites sample was cloudy, with increased white blood cells and normal creatinine level. No anastomotic leak was found. Bacterial infection of a lymphocele was considered, and cefmetazole 2 g/day for 3 days was prescribed. Despite antibacterial therapy, fever persisted. Polymerase chain reaction testing of ascitic fluid was positive for Mycobacterium tuberculosis. The patient was effectively treated with anti-TB therapy. Conclusion: This is the first report of peritoneal TB as a postoperative complication of RALP with extended lymph node dissection. His preoperative chest CT showed granular shadows in left upper lung, indicating his old asymptomatic TB infection. Flare-up of TB can happen even after robot-assisted laparoscopic surgery, which is minimally invasive. Peritoneal TB must be considered especially when there is unexplained ascites unresponsive to antibiotics.

Prospective randomised non-inferiority trial of pelvic drain placement vs no pelvic drain placement after robot-assisted radical prostatectomy.

OBJECTIVE: To determine if eliminating the prophylactic placement of a pelvic drain (PD) after robot-assisted radical prostatectomy (RARP) affects the incidence of early (90-day) postoperative adverse events. PATIENTS AND METHODS: In this parallel-group, blinded, non-inferiority trial, we randomised patients planning to undergo RARP to one of two arms: no drain placement (ND) or PD placement. Patients with demonstrable intraoperative leakage upon bladder irrigation were excluded. Randomisation sequence was determined a priori using a computer algorithm, and included a stratified design with respect to low vs intermediate/high D'Amico risk classifications. Surgeons remained blinded to the randomisation arm until final eligibility was verified at the end of the RARP. The primary endpoint was overall incidence of 90-day complications which, based on our standard treatment using PD retrospectively, was estimated at 13%. The non-inferiority margin was set at 10%, and the planned sample size was 312. An interim analysis was planned and conducted when one-third of the planned accrual and follow-up was completed, to rule out futility if the delta margin was in excess of 0.1389. RESULTS: From 2012 to 2016, 189 patients were accrued to the study, with 92 patients allocated to the ND group and 97 to the PD group. Due to lower than expected accrual rates, accrual to the study was halted by regulatory entities, and we did not reach the intended accrual goal. The ND and PD groups were comparable for median PSA level (6.2 vs 5.8 ng/mL, P = 0.5), clinical stage (P = 0.8), D'Amico risk classification (P = 0.4), median lymph nodes dissected (17 vs 18, P = 0.2), and proportion of patients receiving an extended pelvic lymph node dissection (70.7% vs 79.4%, P = 0.3). Incidence of 90-day overall and major (Clavien-Dindo grade >III) complications in the ND group (17.4% and 5.4%, respectively) was not inferior to the PD group (26.8% and 5.2%, respectively; P < 0.001 and P = 0.007 for difference of proportions <10%, respectively). Symptomatic lymphocoele rates (2.2% in the ND group, 4.1% in the PD group) were comparable between the two arms (P = 0.7). CONCLUSIONS: Incidence of adverse events in the ND group was not inferior to the group who received a PD. In properly selected patients, PD placement after RARP can be safely withheld without significant additional morbidity.

Lymph node-positive prostate cancer after robotic prostatectomy and extended pelvic lymphadenectomy.

Optimal management of node-positive prostate cancer patients after prostatectomy remains a challenge. We evaluated clinically localized patients who demonstrated node positivity and identified predictors for secondary treatment. From 2010 to 2015, clinically localized prostate cancer patients who underwent robot prostatectomy with extended lymphadenectomy and node-positive disease on pathologic analysis were identified. Clinical N1, M1 or salvage cases were excluded. Patients were stratified based on secondary treatments. Kaplan-Meier method was used to determine the time to biochemical and metastatic recurrence. Multivariate logistic regression was used to identify predictors for additional treatment. 145 patients (45 no additional therapy, 47 adjuvant, 53 salvage) had a median follow-up of 31.2 months. Salvage patients had higher median pre-operative prostate-specific antigen (10.8 vs. 9.7 vs. 8.2, p = 0.1), higher percentage of pathologic Gleason ≥8 (50.9 vs. 38.3% and 22.2%, p < 0.01), and higher median-positive nodes (3 vs. 1 and 1, p < 0.0001) compared to adjuvant and no treatment groups, respectively. Pathologic Gleason ≥8 (OR = 3.5, p = 0.007) and positive nodes ≥2 (OR = 3.3, p = 0.006) were associated with additional therapy. In the no treatment group, two-year estimated BCRFS was 74.3%. Two-year metastatic recurrence-free rates for no treatment, adjuvant and salvage groups were 100, 87.5, and 80.9%, respectively (p = 0.01). Observation is a viable alternative for low metastatic burden patients. In the largest series of node-positive patients from robotic prostatectomy and extended lymphadenectomy, those with pathologic Gleason ≥8 and positive lymph nodes ≥2 were more likely to receive additional treatment.

Sentinel node biopsy for prostate cancer: report from a consensus panel meeting.

OBJECTIVE: To explore the evidence and knowledge gaps in sentinel node biopsy (SNB) in prostate cancer through a consensus panel of experts. METHODS: A two-round Delphi survey among experts was followed by a consensus panel meeting of 16 experts in February 2016. Agreement voting was performed using the research and development project/University of California, Los Angeles Appropriateness Methodology on 150 statements in nine domains. The disagreement index based on the interpercentile range, adjusted for symmetry score, was used to assess consensus and non-consensus among panel members. RESULTS: Consensus was obtained on 91 of 150 statements (61%). The main outcomes were: (1) the results from an extended lymph node dissection (eLND) are still considered the 'gold standard', and sentinel node (SN) detection should be combined with eLND, at least in patients with intermediate- and high-risk prostate cancer; (2) the role of SN detection in low-risk prostate cancer is unclear; and (3) future studies should contain oncological endpoints as number of positive nodes outside the eLND template, false-negative and false-positive SN procedures, and recurrence-free survival. A high rate of consensus was obtained regarding outcome measures of future clinical trials on SNB (89%). Consensus on tracer technology was only obtained in 47% of statements, reflecting a need for further research and standardization in this area. The low-level evidence in the available literature and the composition of mainly SNB users in the panel constitute the major limitations of the study. CONCLUSIONS: Consensus on a majority of elementary statements on SN detection in prostate cancer was obtained.; therefore, the results from this consensus report will provide a basis for the design of further studies in the field. A group of experts identified evidence and knowledge gaps on SN detection in prostate cancer and its application in daily practice. Information from the consensus statements can be used to direct further studies.

The impact of extended lymph node dissection versus neoadjuvant therapy with limited lymph node dissection on biochemical recurrence in high-risk prostate cancer patients treated with radical prostatectomy: a multi-institutional analysis.

The optimal treatment for high-risk prostate cancer (Pca) remains to be established. The current guidelines recommend extended pelvic lymph node dissection (e-PLND) for selected intermediate- and high-risk patients treated with RP. However, the indications, optimal extent, and therapeutic benefits of e-PLND remain unclear. The aim of this study was to assess whether e-PLND confers an oncological benefit for high-risk Pca compared to neoadjuvant luteinizing hormone-releasing hormone and estramustine (LHRH + EMP). The Michinoku Urological Cancer Study Group database contained the data of 2403 consecutive Pca patients treated with RP at four institutes between March 2000 and December 2014. In the e-PLND group, we identified 238 high-risk Pca patients who underwent RP and e-PLND, with lymphatic tissue removal around the obturator and the external iliac regions, and hypogastric lymph node dissection. The neoadjuvant therapy with limited PLND (l-PLND) group included 280 high-risk Pca patients who underwent RP and removal of the obturator node chain between September 2005 and June 2014 at Hirosaki University. The outcome measure was BRFS. The 5-year biochemical recurrence-free survival rates for the neoadjuvant therapy with l-PLND group and e-PLND group were 84.9 and 54.7%, respectively (P < 0.0001). The operative time was significantly longer in the e-PLND group compared to that of the neoadjuvant therapy with l-PLND group. Grade 3/4 surgery-related complications were not identified in both groups. Although the present study was not randomized, neoadjuvant LHRH + EMP therapy followed by RP might reduce the risk of biochemical recurrence.

Extended versus superextended lymph-node dissection in radical cystectomy: subgroup analysis of possible recurrence-free survival benefit.

Objective The aim of this study was to assess potential benefits of different extended lymph-node dissection templates at the time of radical cystectomy as treatment for invasive bladder cancer. Materials and methods Between 2004 and 2012, 578 patients underwent radical cystectomy with lymph-node dissection without prior radiotherapy or chemotherapy. Two different historical cohorts were constructed: 262 patients underwent intended superextended lymph-node dissection (seLND) from January 2004 to January 2009 and 316 patients underwent intended extended lymph-node dissection (eLND) from February 2009 to December 2012. Recurrence-free survival (RFS) was analysed as the primary outcome. Median follow-up was 93 (63-123) months and 38 (16-63) months in the two groups, respectively. Results There was no significant difference in RFS in the two cohorts (p = 0.87). When analysed according to lymph-node status (N0 or N+), there was no significant difference in RFS between the two cohorts in the two subgroups (p = 0.41 and p = 0.48, respectively). When analysed according to tumour stage, patients with non-organ-confined disease revealed a tendency towards better RFS in the seLND cohort (p = 0.14). This tendency was most clearly seen in the subgroup of T3-4 patients without lymph-node metastases (N0) (p = 0.14). Conclusions Extending LND up to the inferior mesenteric artery (seLND) does not seem to be beneficial to the overall population of patients with invasive bladder cancer compared to performing an eLND to the aortic bifurcation only. However, a subgroup of patients with non-organ-confined disease without macrometastases may benefit from seLND.

Laparoscopic Radical Prostatectomy Plus Extended Lymph Node Dissection in Combination With Immediate Androgen Deprivation Therapy for Cases of pT3-4N0-1M0 Prostate Cancer: A Multimodal Study of 8 Years' Follow-up.

PURPOSE: To investigate the functional and oncologic outcomes of patients with locally advanced or lymph node (LN) metastatic prostate cancer (PCa) treated by laparoscopic radical prostatectomy (LRP) with extended lymph node dissection (ePLND). METHODS: From June 2004 to March 2014, a total of 232 cases (pT3-4N0-1M0) including 160 locally advanced PCa and 72 LN metastatic PCa who received immediate androgen deprivation therapy after LRP plus ePLND were enrolled onto our study. The patients were followed up for 12 to 124 months. Surgical records, surgical margin status, complications, urinary continence, and oncologic outcomes were presented. RESULTS: The mean operation time and bleeding were 230 minutes and 105 mL, respectively. The rates of urinary continence were 91.4% and 94.8% at 6 and 12 months, respectively. We observed 122 biochemical recurrent cases. The 5- and 8-year biochemical relapse-free survival rates were 47.3% and 46.7%, respectively. The 5- and 8-year overall and cancer-specific survivals were 81.2%, 80.1%, 90.6%, and 90.6%, respectively. The survival analysis showed that biochemical recurrence-free survival rates were significantly lower for patients with higher Gleason score (77.3% vs. 39.6% vs. 30.8%, P = .003 log rank), higher T stage (55.7% vs. 41.4% vs. 21.4%, P = .039 log rank), positive surgical margin (51.1% vs. 29.3%, P = .000 log rank), and higher CAPRA-S score (68.6% vs. 35.0% vs. 29.2%, P = .000 log rank). There were no significant differences in biochemical relapse-free (40.9% vs. 49.3%, P = .286), overall (75.6% vs. 81.9%, P = .398), and cancer-specific (87.3% vs. 92.1%, P = .284) survival between LN-positive and -negative PCa. CONCLUSION: LRP plus ePLND in combination with immediate androgen deprivation therapy is a feasible approach to patients with pT3-4N0-1M0 PCa; favorable functional and oncologic outcomes were presented postoperatively.

Extended versus limited pelvic lymph node dissection during bilateral nerve-sparing radical prostatectomy and its effect on continence and erectile function recovery: long-term results and trifecta rates of a comparative analysis.

PURPOSE: To assess continence and erectile function (EF) recovery of extended pelvic lymph node dissection (ePLND) versus limited PLND (lPLND) after bilateral nerve-sparing radical prostatectomy (BNSRP). METHODS: Consecutive prostate cancer (PCa) patients undergoing BNSRP were stratified according to D'Amico into two groups: low-risk-PCa lPLND (obturator) and intermediate-/high-risk-PCa ePLND (obturator, external iliac artery, internal iliac artery, common iliac artery). Continence (no pad/one safety pad) and EF (IIEF-5 ≥ 17) recovery were assessed. Patients with phosphodiesterase type 5 inhibitors, neoadjuvant/adjuvant therapy, positive lymph nodes or positive surgical margins were excluded. RESULTS: From January 2007 to May 2012, a total 966 consecutive patients were included. Four hundred and sixty patients met the inclusion/exclusion criteria: 262 patients had ePLND and 198 patients had lPLND. Mean number of lymph nodes was 20.4 (range 10-65) and 4.7 (range 0-10), respectively (p < 0.001). Continence and spontaneous EF recovery after 12 months were 89.7 versus 93.4 % and 40.4 versus 47.5 %, respectively (all p > 0.05). Patient age at surgery (p = 0.001), preoperative EF (p < 0.001) and pathological tumor stage (p = 0.008), but not ePLND (p = 0.561), were independent predictors of EF recovery. No association was detected for continence recovery. Seven-year BCR-free survival for pT2 PCa was 100 and 94.8 % in lPLND and ePLND, respectively (p = 0.011). For pT3 PCa, this was 94.7 and 81.2 %, respectively (p = 0.287). At 2 years, the trifecta of continence, potency and recurrence freedom was achieved in 47.5 and 44.1 % in lPLND and ePLND, respectively (p = 0.451). CONCLUSIONS: ePLND is not associated with increased risk of postoperative incontinence or erectile dysfunction. Only patient age at surgery, preoperative EF and pathological tumor stage represent predictors of EF recovery.

Comparison of semi-extended and standard lymph node dissection in radical prostatectomy: A single-institute experience.

Standard lymphadenectomy for prostate cancer is limited to the obturator lymph nodes (LNs), although the internal and external iliac LNs represent the primary landing zone for prostatic lymphatic drainage. We performed anatomically semi-extended pelvic lymph node dissection (PLND) to assess the incidence of LN metastasis in cases of clinically localized prostate cancer. A total of 730 consecutive patients underwent radical prostatectomy with either semi-extended PLND, comprising 6 selective fields, namely the external iliac, internal iliac and obturator LNs bilaterally, or standard LND (obturator LNs alone). A total of 131 patients undergoing semi-extended PLND were compared with 599 patients undergoing standard LND. The patients were stratified into high-risk [prostate-specific antigen (PSA)>20 ng/ml, Gleason score (GS)≥8], intermediate-risk (PSA 10-20 ng/ml, GS=4+3) and low-risk (PSA<10 ng/ml, GS≤3+4) subgroups. Following semi-extended LND, positive LNs were detected in 12/61 (20%) of the high-risk, 1/30 (3%) of the intermediate-risk and 0/40 (0%) of the low-risk cases. Following standard LND, positive LNs were detected in 13/182 (7%) of the high-risk, 1/164 (0.6%) of the intermediate-risk and 0/253 (0%) of the low-risk cases. In high-risk patients, the detection rate of LN metastasis was significantly higher following extended LND compared with standard LND (P<0.01). In 9 of 13 patients (69%), metastases were identified in the internal and external iliac regions, despite negative obturator LNs. There were no significant differences regarding intraoperative and postoperative complications or blood loss in the two groups. There was no lymphocele formation in patients undergoing either standard or semi-extended LND. Extended pelvic LND (PLND) is associated with a high rate of LN metastasis detection outside the fields of standard LND in cases with clinically localized prostate cancer. Therefore, LND including the internal and external iliac LNs should be performed in all patients with high-risk prostate cancer; however, in the low-risk group, PLND may be omitted.

Prospective mapping of lymph node metastasis in Japanese patients undergoing radical cystectomy for bladder cancer: characteristics of micrometastasis.

OBJECTIVE: To investigate node-disease prevalence including micrometastases and its survival impact on bladder cancer patients. METHODS: A total of 60 patients participated in this study, in which extended lymph node dissection was carried out according to the prospective rule (below aortic bifurcation). Radical cystectomy and extended lymph node dissection were performed by open surgery (n = 23) or laparoscopically (n = 37). Perioperative, pathological and follow-up data were collected. Micrometastasis in lymph nodes was investigated by pan-cytokeratin immunohistochemistry. Recurrence-free survival was estimated with the Kaplan-Meier method. RESULTS: The median number of lymph nodes removed was 29 (range: 10-103) and there was no significant difference between the two groups (open group: median 30, laparoscopic group: median 29). Routine pathological examination revealed that 10 patients had lymph node metastases. Immunohistochemistry revealed micrometastases in four additional patients (pNmicro+), who had been diagnosed with pN0 on routine pathological examination. After excluding the three patients with pure nonurothelial carcinoma on the final pathology (small cell carcinoma: n = 2, adenocarcinoma: n = 1), 10 out of the 57 urothelial carcinoma patients (17.5%) had node metastasis, and an additional 4 out of the 47 pN0 patients (4/47, 8.5%) had micrometastasis. The 2-year recurrence-free survival rates divided by pN stage were 82.4% for pN0, 66.7% for pNmicro+ and 12.5% for pN+ (three-sample log-rank test, P < 0.0001). Three out of the four patients with pNmicro+ were disease free at the last follow-up. CONCLUSIONS: We confirmed under extended lymph node dissection that a substantial proportion of the patients had node metastasis (pN+: n = 10 and pNmicro+: n = 4), and the pN stage influenced patient survival. Our observations of micrometastasis yielded additional evidence for the potential survival benefit of extended lymphadenectomy by eliminating microdisease.

Pathologic nodal staging scores in patients treated with radical prostatectomy: a postoperative decision tool.

BACKGROUND: Nodal metastasis is the strongest risk factor of disease recurrence in patients with localized prostate cancer (PCa) treated with radical prostatectomy (RP). OBJECTIVE: To develop a model that allows quantification of the likelihood that a pathologically node-negative patient is indeed free of nodal metastasis. DESIGN, SETTING, AND PARTICIPANTS: Data from patients treated with RP and pelvic lymph node dissection (PLND; n=7135) for PCa between 2000 and 2011 were analyzed. For external validation, we used data from patients (n=4209) who underwent an anatomically defined extended PLND. INTERVENTION: RP and PLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We developed a novel pathologic (postoperative) nodal staging score (pNSS) that represents the probability that a patient is correctly staged as node negative based on the number of examined nodes and the patient's characteristics. RESULTS AND LIMITATIONS: In the development and validation cohorts, the probability of missing a positive node decreases with an increasing number of nodes examined. Whereas in pT2 patients, a 90% pNSS was achieved with one single examined node in both the development and validation cohort, a similar level of nodal staging accuracy was achieved in pT3a patients by examining five and nine nodes, respectively. The pT3b/T4 patients achieved a pNSS of 80% and 70% when 17 and 20 nodes in the development and validation cohort were examined, respectively. This study is limited by its retrospective design and multicenter nature. The number of nodes removed was not directly correlated with the extent/template of PLND. CONCLUSIONS: Every patient needs PLND for accurate nodal staging. However, a one-size-fits-all approach is too inaccurate. We developed a tool that indicates a node-negative patient is indeed free of lymph node metastasis by evaluating the number of examined nodes, pT stage, RP Gleason score, surgical margins, and prostate-specific antigen. This tool may help in postoperative decision making.

Extended pelvic lymph node dissection: before or after radical cystectomy? A multicenter study of the Turkish society of urooncology.

PURPOSE: We aimed to ascertain the effects of performing extended pelvic lymph node dissection (PLND) on the duration of surgery, morbidity, and the number of lymph nodes removed when the dissection was performed before or after radical cystectomy (RC). MATERIALS AND METHODS: We used the database of our previous prospective multicenter study. A total of 118 patients underwent RC and extended PLND. Of the 118 patients, 48 (40.7%) underwent extended PLND before RC (group 1) and 70 (59.3%) underwent extended PLND after RC (group 2). The two groups were compared for extended PLND time, RC time, and total operation times, per operative morbidity, and the total numbers of lymph nodes removed. RESULTS: Clinical and pathologic characteristics were comparable in the two groups (p>0.05). The mean RC time and mean total operation times were significantly shorter in group 1 than in group 2 (p<0.001). The mean number of lymph nodes removed was 27.31±10.36 in group 1 and 30.87±8.3 in group 2 (p=0.041). Only at the presacral region was the mean number of lymph nodes removed significantly fewer in group 1 than in group 2 (p=0.001). Intraoperative and postoperative complications and drain withdrawal time were similar in both groups (p=0.058, p=0.391, p=0.613, respectively). CONCLUSIONS: When extended PLND was performed before RC, the duration of RC and consequently the total duration of the operation were significantly shorter than when extended PLND was performed after RC. Practitioners may consider performing extended PLND before RC and rechecking the presacral area for additional lymph nodes after RC, particularly in elderly patients with high co-morbidity for whom the duration of surgery matters.