Pelvic lymphadenectomy for prostate and bladder cancer

Pelvic lymph node dissection (PLND) is an integral part of radical urologic surgery for pelvic malignancies. For many years PLND was part and parcel of radical retropubic prostatectomy for prostate cancer, though recent guidelines recommend performing PLND in conjunction with radical prostatectomy only when the nomogram-predicted risk of lymph nodes being involved with metastatic prostate cancer is greater than 2-2.5 %. This is not only because there is significant potential morbidity to PLND, but also because the therapeutic benefit of dissections in such cases is quite limited. A standard PLND is nevertheless recommended for all intermediate-risk men, and an extended PLND is recommended for high-risk men. The greatest predictor of lymph node involvement may well be the percentage of cores that are found positive on initial prostate biopsy (number of positive cores/total number of cores taken). It is recommended that one of several nomograms be used to define this risk in individual cases before deciding on whether or not to perform PLND and to what extent. While the therapeutic benefit of PLND is controversial, it is clear that men with small volume nodal disease (typically, one or two positive nodes) can be cured by removing these nodes alone and without adjuvant therapy. Strong consideration should be given to androgen deprivation therapy for most men found to have positive nodes however, particularly with several positive nodes, or lymph node density of 15 % or greater. PLND as part of a radical cystectomy for bladder cancer remains a nonnegotiable part of this operation. It appears that there is no patient who should not receive PLND during radical cystectomy, as positive lymph node rates are high in essentially all published series. An extended template PLND, superiorly to the uretero-iliac junction, is recommended for all radical cystectomy patients. High lymph node yields and a low positive lymph node density (<15-20 %) have both been associated with survival advantages, but of course extended templates do engender more morbidity than standard prostate cancer PLND templates. Morbidities associated with PLND include venous thromboembolic events, lymphocele, lower extremity edema, obturator nerve injury, and major vascular injury.