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An extended pelvic lymph-node dissection should be performed in most patients if radical prostatectomy is truly indicated

Nature Clinical Practice Urology volume 3, pages 454–455 (2006)Cite this article

There is no doubt that extended pelvic lymph-node dissection (PLND) at the time of radical prostatectomy improves the accuracy of prostate cancer staging, and there is strong evidence to indicate a survival benefit in some patients. Why, then, does the controversy regarding extended PLND persist? Unlike in other tumors, the role and appropriate extent of PLND in prostate cancer have not been clearly defined. Some urologists believe that PLND should be reserved for high-risk patients, whereas others offer PLND to all patients undergoing local treatment for prostate cancer. In addition, some feel that removal of the lymphatic tissue along the external iliac vein and in the obturator fossa (a limited PLND) is adequate; others advocate an extended PLND, which includes the tissue along the internal iliac vessels.

Opponents of extended PLND quote the low incidence of lymph-node metastasis;1 however, this observation could be misleading or even incorrect, as most reports are of patients who underwent limited, or standard, PLND. Heidenreich and others have shown that limited PLND results in the removal of fewer nodes, and a lower incidence of lymph-node metastasis, compared with extended PLND.2 This was confirmed by Bader et al., who, in a large retrospective series, convincingly showed that the number of positive nodes detected is strongly correlated to the number of nodes removed.3 Another consideration is that a limited PLND does not remove the nodes most frequently found to harbor disease. Approximately 70% of positive lymph nodes are located along the internal iliac vessels, and, in roughly 20% of node-positive patients, this is the sole location of lymph-node involvement.4 Thus, node sampling can only be considered representative if an adequate number of nodes (>10), and the relevant nodes (along the internal iliac vessels), are removed.

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Authors and Affiliations

  1. staff physician,

    Fiona C Burkhard, Martin C Schumacher & Urs E Studer

  2. staff member,

    Fiona C Burkhard, Martin C Schumacher & Urs E Studer

  3. Director in the Department of Urology at the University Hospital in Bern, Switzerland

    Fiona C Burkhard, Martin C Schumacher & Urs E Studer

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  1. Fiona C Burkhard
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  2. Martin C Schumacher
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  3. Urs E Studer
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Correspondence to Urs E Studer.

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Burkhard, F., Schumacher, M. & Studer, U. An extended pelvic lymph-node dissection should be performed in most patients if radical prostatectomy is truly indicated. Nat Rev Urol 3, 454–455 (2006). https://doi.org/10.1038/ncpuro0558

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