Number of Lymph nodes removed during radical prostatectomy for early prostate cancer as it relates to outcome

Ebrahim Abdal, Dr, Amina Bouhelal, Dr, Bijendra Patel, Mr, Hitendra Patel, Professor. Barts Cancer Institute Queen Mary University of London.

Background: Pelvic lymphadenectomy has always been considered as a gold standard method in staging of prostate cancer. It is also worthy to note that to this date there is no consensus within the medical literature concerning localized prostate cancer LPC on the ideal number of lymph nodes LN that should be removed in order to cause a beneficial outcome to patients.

Aims: To find an optimum number LN which are removed during pelvic lymph node excision in radical prostatectomy for LPC which has an influence on post-operative outcome in terms of the following parameters; post-operative complications, biochemical recurrence (BCR), pathological TNM and pathological Gleason score.

Methodology: applying PRISMA we searched PubMed and Sciencedirect databases covering all articles published in the English language since 1996 that included the following; studies where radical prostatectomy was performed, pelvic lymphadenectomy was performed, studies which included non-metastatic prostate cancer (T1-T2,N0, M0), articles which include number of lymph nodes removed, studies mentioning Pre and post-operative complications and oncological outcomes.

Results: 26 studies were analysed. The mean number of LN removed during pelvic lymphadenectomy in radical prostatectomy ranged from 4-28. Post-operative lymphocoeles (Clavien score IIIa) were the highest reported complication of 161 cases associated with the excision of a mean number of 17.7 LN
Neuropraxia was second recorded complication associated with a removal of 17.8 LN. The third post-operative complication was SSIs associated with a removal of a mean number of 18 LN. DVT and PE both were associated with the removal of a mean number of 28 LN. On the oncological outcomes , high number NL removed (23.1) uncovered larger number of patients with positive biochemical recurrence (BCR) (91%). Longer follow-up period (152-2831 days) does play a role in uncovering more patients with positive biochemical recurrence. When BCR was analyzed it shoed a strong association with T2 pathological stage. Survival rates where not always reported .Two studies reported that 81% and 83% of their patients had a 5-year survival (Masterson et al. and Toujier et al. respectively). Both these studies remove a mean number of 9 lymph nodes and 12 lymph nodes respectively.

Conclusion: No clear cut off point can be drawn from the available literature in regard to the optimum number LN that can be removed during pelvic lymphadenectomy that may influence post-operative complications in patients with localized prostate cancer. The highest reported complication was lymphocoeles. Data also illustrated that the higher the number of LN removed (23.1) during pelvic lymph node dissection in radical prostatectomy for localized prostate cancer the greater the number of patients with BCR is uncovered (Jindong et al. 91% of patients )

In the absence of large sample single-center studies ,a unified reporting system is highly warranted in future studies for better analysis comparative evaluation toward a more definitive cut off point of optimum number LN which are removed during pelvic lymph node excision in radical prostatectomy for LPC

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