The Role of Anatomic Extented Pelvic Lymphadenectomy in Men Undergoing Radical Prostatectomy for Prostate Cancer

The rationale for locoregional staging lymphadenectomy in prostate cancer lies in the accurate diagnosis of occult micrometastases in order to stratify patients who might benefit from adjuvant therapeutic measures. In prostate cancer, extended pelvic lymphadenectomy (EPLA) including the lymphatic tissue along the common iliac region with the ureteral crossing as cranial margin, external and internal iliac region and the obturator fossa has been shown to significantly increase the yield of both total lymph nodes and lymph node metastases. The total number of lymph nodes removed is about 2 to 3-fold higher and the frequency of micrometastatic lymph nodes is approximately 2-fold higher compared to standard lymphadenectomy. Furthermore, the frequency of observed positive lymph nodes in clinically localized and locally advanced prostate cancer is significantly higher than predicted by nomograms such as Partin tables and CART analysis. Although there are no prospective randomized trials demonstrating a survival benefit associated with EPLA, there might be an advantage for those with minimal lymph node involvement. Progression-free survival is significantly improved in patients undergoing EPLA with a 35% benefit compared to standard lymphadenectomy. Various studies have documented an equal risk of cancer associated mortality in patients with no or only 1-2 positive lymph nodes. Since the surgery associated morbidity of EPLA is not increased as compared to standard lymphadenectomy, EPLA should be favoured at least for all intermediate and high risk patients undergoing radical prostatectomy; in low risk patients the option of EPLA has to be discussed thoroughly. For the future, ongoing prospective trials have to demonstrate a clear benefit in terms of biochemical free and cancer specific survival.