In the era of modern prostate imaging, indications for bilateral extended pelvic lymph node dissection may be revised
In the context of prostate cancer management, the standard practice of performing bilateral extended pelvic lymph node dissection (PLND) during radical prostatectomy is being questioned with advancements in
imaging technology. Magnetic resonance imaging (MRI)-targeted biopsies now provide more accurate staging, potentially allowing for a more selective approach to PLND.
A recent study assessed the feasibility of unilateral extended PLND in patients diagnosed with prostate cancer using MRI-targeted biopsy and classified as cN0 (clinically node- negative). The study analyzed data from 2,253 patients who underwent prostatectomy and bilateral extended PLND across multiple institutions. Among these patients, 13% were found to have lymph node metastases with 4% specifically showing metastases on the opposite side (contralateral) of the dominant prostatic lobe.
The researchers developed a model to guide the decision to perform contralateral PLND that considered factors such as PSA levels, and the size of the largest tumor in the prostate gland, MRI evidence of seminal vesicle invasion, Gleason grade in the non- dominant side of the prostate, and percentage of positive biopsy cores in the non-dominant side. After validation, the model demonstrated predictive accuracy.
Based on their findings, the researchers proposed a strategy in which contralateral PLND could be omitted in selected patients, particularly those with low predicted risk of contralateral lymph node invasion.
The authors conclude that unilateral (one side only) extended PLND could be a viable alternative in appropriately selected patients, capitalizing on the precision of MRI-targeted biopsies for staging. This approach aims to reduce unnecessary surgeries and maintain high diagnostic accuracy. Implementing predictive models, like this one, could potentially improve patient care by personalizing the extent of surgical intervention based on individual risk profiles.
J Urol. 2023 Jul;210(1):117-127. doi: 10.1097/JU.0000000000003442. Epub 2023 Apr 13.
