Multicenter evaluation of guideline adherence for pelvic lymph node dissection in patients undergoing open retropubic vs. laparoscopic or robot assisted radical prostatectomy according to the recent German S3 guideline on prostate cancer
Pelvic lymph node dissection (PLND) is recommended for patients with prostate cancer (PCa) and significant risk for nodal metastases. This study aimed to assess guideline adherence regarding PLND according to the German S3 guideline as example for a national but highly used guideline on prostate cancer and to compare the rate of complications different approaches for radical prostatectomy (RP).
Patients undergoing open (RRP), laparoscopic (LARP) or robot-assisted (RARP) RP in six centers in Germany and Austria were included. The primary endpoint was the total number of removed lymph nodes (LN) between the different surgical approaches according to recent guideline recommendations. Secondary endpoints were the number of patients undergoing a sufficient PLND, defined as a removal of at least 10 LN and associated complication rates.
2634 patients undergoing RP were included (RRP: 66%, RARP/LARP: 34%). PLND was performed in 88% (RRP: 88.5%, RARP/LARP: 86.8%, p = 0.208). In intermediateor high risk PCa, PLND was performed in 97.2% (RRP: 97.7%, RARP/LARP: 96.2, p = 0.048). Of those, the mean number of LN was 19 (RRP: 19 vs. RARP/LARP: 17, p < 0.005) and sufficient PLND was observed in 84.6% of RRP compared to 77.2% of RARP/LARP (p < 0.005). Symptomatic lymphoceles requiring surgical treatment occurred more often in RRP than in RARP/LARP (4.0% vs. 1.6%, p = 0.001).
The general guideline adherence regarding performing PNLD and the LN yield is high, regardless of the surgical approach. As expected, lymph node yield was higher when very experienced surgeons conducted the procedure. This should be considered in patients’ counseling.
KeywordsPelvic lymph node dissection Guidelines Adherence Prostate cancer Prostatectomy
Pelvic lymph node dissection
Laparoscopic radical prostatectomy
Robot-assisted radical prostatectomy
Retropubic radical prostatectomy
AB Project development, Data collection and management, Data analysis, Manuscript writing; JB Project development, Data collection; MD Project development, Data collection; JH Project development, Data collection; HI Project development, Data collection, supervision; BB Project development, Data collection, Manuscript writing.
Compliance with ethical standards
Conflict of interests
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable standards. For this type of study formal consent is not required. This article does not contain any studies with or animals performed by any of the authors.
Informed consent was obtained from all individual participants included in the study.
- 1.Briganti A, Larcher A, Abdollah F, Capitanio U, Gallina A, Suardi N, Bianchi M, Sun M, Freschi M, Salonia A, Karakiewicz PI, Rigatti P, Montorsi F (2012) Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores. Eur Urol 61(3):480–487. https://doi.org/10.1016/j.eururo.2011.10.044 CrossRefPubMedGoogle Scholar
- 2.Mohler JL, Armstrong AJ, Bahnson RR, D’Amico AV, Davis BJ, Eastham JA, Enke CA, Farrington TA, Higano CS, Horwitz EM, Hurwitz M, Kane CJ, Kawachi MH, Kuettel M, Lee RJ, Meeks JJ, Penson DF, Plimack ER, Pow-Sang JM, Raben D, Richey S, Roach M 3rd, Rosenfeld S, Schaeffer E, Skolarus TA, Small EJ, Sonpavde G, Srinivas S, Strope SA, Tward J, Shead DA, Freedman-Cass DA (2016) Prostate cancer, version 1.2016. J Natl Compr Cancer Netw 14(1):19–30CrossRefGoogle Scholar
- 3.Mottet N, Bellmunt J, Bolla M, Briers E, Cumberbatch MG, De Santis M, Fossati N, Gross T, Henry AM, Joniau S, Lam TB, Mason MD, Matveev VB, Moldovan PC, van den Bergh RCN, Van den Broeck T, van der Poel HG, van der Kwast TH, Rouviere O, Schoots IG, Wiegel T, Cornford P (2017) EAU-ESTRO-SIOG guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent. Eur Urol 71(4):618–629. https://doi.org/10.1016/j.eururo.2016.08.003 CrossRefPubMedGoogle Scholar
- 9.Silberstein JL, Vickers AJ, Power NE, Parra RO, Coleman JA, Pinochet R, Touijer KA, Scardino PT, Eastham JA, Laudone VP (2012) Pelvic lymph node dissection for patients with elevated risk of lymph node invasion during radical prostatectomy: comparison of open, laparoscopic and robot-assisted procedures. J Endourol 26(6):748–753. https://doi.org/10.1089/end.2011.0266 CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Ploussard G, Briganti A, de la Taille A, Haese A, Heidenreich A, Menon M, Sulser T, Tewari AK, Eastham JA (2014) Pelvic lymph node dissection during robot-assisted radical prostatectomy: efficacy, limitations, and complications-a systematic review of the literature. Eur Urol 65(1):7–16. https://doi.org/10.1016/j.eururo.2013.03.057 CrossRefPubMedGoogle Scholar
- 12.Albisinni S, Aoun F, Le Dinh D, Zanaty M, Hawaux E, Peltier A, Vanv A (2017) Comparing conventional laparoscopic to robotic-assisted extended pelvic lymph node dissection in men with intermediate and high-risk prostate cancer: a matched-pair analysis. Minerva Urol Nefrol 69(1):101–107. https://doi.org/10.23736/S0393-2249.16.02799-5 PubMedGoogle Scholar
- 14.Briganti A, Chun FK, Salonia A, Suardi N, Gallina A, Da Pozzo LF, Roscigno M, Zanni G, Valiquette L, Rigatti P, Montorsi F, Karakiewicz PI (2006) Complications and other surgical outcomes associated with extended pelvic lymphadenectomy in men with localized prostate cancer. Eur Urol 50(5):1006–1013. https://doi.org/10.1016/j.eururo.2006.08.015 CrossRefPubMedGoogle Scholar
- 17.Budiharto T, Joniau S, Lerut E, Van den Bergh L, Mottaghy F, Deroose CM, Oyen R, Ameye F, Bogaerts K, Haustermans K, Van Poppel H (2011) Prospective evaluation of 11C-choline positron emission tomography/computed tomography and diffusion-weighted magnetic resonance imaging for the nodal staging of prostate cancer with a high risk of lymph node metastases. Eur Urol 60(1):125–130. https://doi.org/10.1016/j.eururo.2011.01.015 CrossRefPubMedGoogle Scholar
- 18.Cornford P, Bellmunt J, Bolla M, Briers E, De Santis M, Gross T, Henry AM, Joniau S, Lam TB, Mason MD, van der Poel HG, van der Kwast TH, Rouviere O, Wiegel T, Mottet N (2017) EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part II: treatment of Relapsing, Metastatic, and Castration-Resistant Prostate Cancer. Eur Urol 71(4):630–642. https://doi.org/10.1016/j.eururo.2016.08.002 CrossRefPubMedGoogle Scholar
- 19.Thompson I, Thrasher JB, Aus G, Burnett AL, Canby-Hagino ED, Cookson MS, D’Amico AV, Dmochowski RR, Eton DT, Forman JD, Goldenberg SL, Hernandez J, Higano CS, Kraus SR, Moul JW, Tangen CM, Panel AUAPCCGU (2007) Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol 177(6):2106–2131. https://doi.org/10.1016/j.juro.2007.03.003 CrossRefPubMedGoogle Scholar
- 20.Suardi N, Larcher A, Haese A, Ficarra V, Govorov A, Buffi NM, Walz J, Rocco B, Borghesi M, Steuber T, Pini G, Briganti A, Mottrie AM, Guazzoni G, Montorsi F, Pushkar D, Van Der Poel H, Section EAUYAU-R (2014) Indication for and extension of pelvic lymph node dissection during robot-assisted radical prostatectomy: an analysis of five European institutions. Eur Urol 66(4):635–643. https://doi.org/10.1016/j.eururo.2013.12.059 CrossRefPubMedGoogle Scholar
- 21.Schiffmann J, Larcher A, Sun M, Tian Z, Berdugo J, Leva I, Widmer H, Lattouf JB, Zorn KC, Shariat SF, Montorsi F, Graefen M, Saad F, Karakiewicz PI (2016) Suboptimal use of pelvic lymph node dissection: differences in guideline adherence between robot-assisted and open radical prostatectomy. Can Urol Assoc J 10(7–8):269–276. https://doi.org/10.5489/cuaj.3563 CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Abdollah F, Sun M, Thuret R, Jeldres C, Tian Z, Briganti A, Shariat SF, Perrotte P, Montorsi F, Karakiewicz PI (2012) Lymph node count threshold for optimal pelvic lymph node staging in prostate cancer. Int J Urol 19(7):645–651. https://doi.org/10.1111/j.1442-2042.2012.02993.x CrossRefPubMedGoogle Scholar
- 23.Abdollah F, Sun M, Briganti A, Thuret R, Schmitges J, Gallina A, Suardi N, Capitanio U, Salonia A, Shariat SF, Perrotte P, Rigatti P, Montorsi F, Karakiewicz PI (2011) Critical assessment of the European Association of Urology guideline indications for pelvic lymph node dissection at radical prostatectomy. BJU Int 108(11):1769–1775. https://doi.org/10.1111/j.1464-410X.2011.10204.x CrossRefPubMedGoogle Scholar
- 24.Choo MS, Kim M, Ku JH, Kwak C, Kim HH, Jeong CW (2017) Extended versus standard pelvic lymph node dissection in radical prostatectomy on oncological and functional outcomes: a systematic review and meta-analysis. Ann Surg Oncol 24(7):2047–2054. https://doi.org/10.1245/s10434-017-5822-6 CrossRefPubMedGoogle Scholar
- 25.Schiavina R, Manferrari F, Garofalo M, Bertaccini A, Vagnoni V, Guidi M, Borghesi M, Baccos A, Morselli-Labate AM, Concetti S, Martorana G (2011) The extent of pelvic lymph node dissection correlates with the biochemical recurrence rate in patients with intermediate- and high-risk prostate cancer. BJU Int 108(8):1262–1268. https://doi.org/10.1111/j.1464-410X.2010.10016.x CrossRefPubMedGoogle Scholar
- 27.DiMarco DS, Zincke H, Sebo TJ, Slezak J, Bergstralh EJ, Blute ML (2005) The extent of lymphadenectomy for pTXNO prostate cancer does not affect prostate cancer outcome in the prostate specific antigen era. J Urol 173(4):1121–1125. https://doi.org/10.1097/01.ju.0000155533.93528.4c CrossRefPubMedGoogle Scholar
- 28.Mitropoulos D, Artibani W, Graefen M, Remzi M, Roupret M, Truss M, European Association of Urology Guidelines P (2012) Reporting and grading of complications after urologic surgical procedures: an ad hoc EAU guidelines panel assessment and recommendations. Eur Urol 61(2):341–349. https://doi.org/10.1016/j.eururo.2011.10.033 CrossRefPubMedGoogle Scholar