Review – Prostate CancerThe Benefits and Harms of Different Extents of Lymph Node Dissection During Radical Prostatectomy for Prostate Cancer: A Systematic Review
Introduction
The current European Association of Urology (EAU) prostate cancer (PCa) guidelines recommend performing extended pelvic lymph node dissection (PLND) in high-risk and intermediate-risk patients when the estimated risk for positive lymph nodes exceeds 5% [1]. However, the therapeutic role of PLND during radical prostatectomy for the management of PCa remains controversial. There are reports suggesting that PLND results in improved pathological staging, and that extending the PLND template may increase its staging accuracy. Nevertheless, the oncological benefit of the procedure is still unclear [2].
Historically, the decision to perform PLND, and on how extensive it ought to be, has been left to the clinical judgment of the surgeon. The lack of clarity regarding the oncological benefit of performing PLND, and the lack of standardized definitions and terminologies regarding the PLND template, have led to a wide variety of “experience-based approaches” [3], [4] which render any comparisons between them difficult and fraught with uncertainties. It is also unclear whether the PLND outcomes vary between different patient subgroups (ie, low- vs intermediate- vs high-risk localized disease). Furthermore, PLND may be associated with an increased risk of adverse events, morbidity, length of stay, and healthcare costs. However, the assertion that more extensive PLND leads to higher complication rates has not always been confirmed [5], [6], [7].
The objective of this systematic review was to evaluate the benefits and harms of PLND, incorporating the comparison between PLND of differing extent (ie, no PLND, limited PLND, standard PLND, extended PLND, and super-extended PLND) during radical prostatectomy for PCa, and to identify which patients benefit most from PLND.
Section snippets
Search strategy, selection of studies, and data extraction
The protocol for this review has been published (www.crd.york.ac.uk/PROSPERO; registration number CRD42015024848), and the search strategy is outlined in the Supplementary material. In brief, databases including MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were systematically searched. Only English language articles and studies published from January 1980 to December 2015 were included. The search was complemented by additional sources including the reference lists of
Quantity of evidence identified
The study selection process is outlined in a Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram (Fig. 2). In total, 4377 records were identified through database searching, and 3840 were screened after removal of duplicates. Of these, 178 articles were eligible for full-text screening, and 139 conference abstracts were assessed for eligibility. Finally, 66 studies recruiting a total of 275 269 patients met the inclusion criteria (44 full-text papers and 22
Conclusions
The majority of studies showed that PLND and its extent 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 a need for robust and adequately powered clinical trials. In the meantime, because of its recognized staging benefits, ePLND should be undertaken whenever PLND is indicated in appropriate patients who are judiciously selected using a
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