Therapeutic Value of Standard Versus Extended Pelvic Lymph Node Dissection During Radical Prostatectomy for High-Risk Prostate Cancer

  • Michele Colicchia
  • Vidit Sharma
  • Firas Abdollah
  • Alberto Briganti
  • R. Jeffrey KarnesEmail author
Prostate Cancer (S Prasad, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Prostate Cancer


Extent of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) remains a subject of debate. Here, we review the literature covering the value of extended PLND (ePLND) during RP for high-risk prostate cancer (PCa) over a standard PLND, with a focus on potential therapeutic advantage. PLND may provide valuable prognostic information to high-risk PCa patients, and incorporating the common iliac and presacral nodes to ePLND templates further improves pathologic nodal staging accuracy. Although increased PLND extent is associated with increased lymphocele/lymphedema rates, it is not associated with increased venous thromboembolism rates. The therapeutic role of ePLND remains uncertain. While recent retrospective studies suggest an increased number of nodes removed within the ePLND template are associated with improved survival outcomes, such retrospective studies cannot completely adjust for the Will Rodgers phenomenon or surgeon-specific factors. Thus, the results of randomized trials are eagerly awaited in this arena.


Prostate cancer Pelvic lymphadenectomy Extended lymphadenectomy Radical prostatectomy 



The authors thank Francesca Dallago for drawing the figure depicting anatomical regions of lymph node dissections.

Compliance with Ethical Standards

Conflict of Interest

Michele Colicchia, Vidit Sharma, Firas Abdollah, Alberto Briganti, and R. Jeffrey Karnes each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Mottet N, Bellmunt J, Briers E, Bolla M, Bourke L, Cornford P, et al. EAU ESTRO SIOG Guidelines on Prostate Cancer. Update March. 2017 Available from:;
  2. 2.
    Schröder FH, Hugosson J, Roobol MJ, Tammela TLJ, Ciatto S, Nelen V, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360(13):1320–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Cooperberg MR, Cowan J, Broering JM, Carroll PR. High-risk prostate cancer in the United States, 1990–2007. World J Urol. 2008;26(3):211–8.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    NCCN Clinical practice guidelines in oncology: prostate cancer. [Internet]. National Comprehensive Cancer Network web site. 2017. Available from:
  5. 5.
    Bill-Axelson A, Holmberg L, Ruutu M, Garmo H, Stark JR, Busch C, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2011;364(18):1708–17.CrossRefPubMedGoogle Scholar
  6. 6.
    Wilt TJ, Brawer MK, Jones KM, Barry MJ, Aronson WJ, Fox S, et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med. 2012;367(3):203–13.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Freedland SJ, Humphreys EB, Mangold LA, Eisenberger M, Dorey FJ, Walsh PC, et al. Risk of prostate cancer–specific mortality following biochemical recurrence after radical prostatectomy. JAMA. 2005;294(4):433.CrossRefPubMedGoogle Scholar
  8. 8.
    Cooperberg MR, Broering JM, Carroll PR. Time trends and local variation in primary treatment of localized prostate cancer. J Clin Oncol. 2010;28(7):1117–23.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Van Den Bergh L, Lerut E, Haustermans K, Deroose CM, Oyen R, Isebaert S, et al. Final analysis of a prospective trial on functional imaging for nodal staging in patients with prostate cancer at high risk for lymph node involvement. Urol Oncol Semin Orig Investig. 2015;33(3):109.e23–31.CrossRefGoogle Scholar
  10. 10.
    Budiharto T, Joniau S, Lerut E, Van Den Bergh L, Mottaghy F, Deroose CM, et al. Prospective evaluation of 11C-choline positron emission tomography/computed tomography and diffusion-weighted magnetic resonance imaging for the nodal staging of prostate cancer with a high risk of lymph node metastases. Eur Urol. 2011;60(1):125–30.CrossRefPubMedGoogle Scholar
  11. 11.
    Eifler JB, Feng Z, Lin BM, Partin MT, Humphreys EB, Han M, et al. An updated prostate cancer staging nomogram (Partin tables) based on cases from 2006 to 2011. BJU Int. 2013;111(1):22–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Fossati N, Willemse P-PM, van den Bergh RCN, Van den Broeck T, Yuan CY, Briers E, et al. The benefits and harms of different extents of lymph node dissection during radical prostatectomy for prostate cancer: a systematic review. Eur Urol. 2017;Google Scholar
  13. 13.
    Cunéo B, Marcille M. Topographie des ganglions ilio-pelviens. Bull etMemoires la Soc d’Anthropologie Paris. 1901;3:653–63.Google Scholar
  14. 14.
    Golimbu M, Morales P, Al-Askari S, Brown J. Extended pelvic lymphadenectomy for prostatic cancer. J Urol. 1979;121(5):617–20.PubMedGoogle Scholar
  15. 15.
    • Joniau S, Van Den Bergh L, Lerut E, Deroose CM, Haustermans K, Oyen R, et al. Mapping of pelvic lymph node metastases in prostate cancer. Eur Urol. 2013;63(3):450–8. Precise overview of the lymphatic drainage pattern and definition of dissemination patterns of nodal metastasis in a cohort of patients affected by intermediate high-risk PCa CrossRefPubMedGoogle Scholar
  16. 16.
    Briganti A, Suardi N, Capogrosso P, Passoni N, Freschi M, Di Trapani E, et al. Lymphatic spread of nodal metastases in high-risk prostate cancer: the ascending pathway from the pelvis to the retroperitoneum. Prostate. 2012 Feb 1;72(2):186–92.CrossRefPubMedGoogle Scholar
  17. 17.
    Hansen J, Budäus L, Spethmann J, Schlomm T, Salomon G, Rink M, et al. Assessment of rates of lymph nodes and lymph node metastases in periprostatic fat pads in a consecutive cohort treated with retropubic radical prostatectomy. Urology. 2012;80(4):877–82.CrossRefPubMedGoogle Scholar
  18. 18.
    Yuh B, Wu H, Ruel N, Wilson T. Analysis of regional lymph nodes in periprostatic fat following robot-assisted radical prostatectomy. BJU Int. 2012 Feb;109(4):603–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Weingärtner K, Ramaswamy A, Bi ‘itinger A, Gerharz EW, Voge D, Riedmiller H. Anatomical basis for pelvic lymphadenectomy in prostate cancer: results of an autopsy study and implications for the clinic. J Urol 1999;156(1):1969–1971.Google Scholar
  20. 20.
    Allaf ME, Palapattu GS, Trock BJ, Carter HB, Walsh PC. Anatomical extent of lymph node dissection: impact on men with clinically localized prostate cancer. J Urol. 2004 Nov;172(5 Pt 1):1840–4.CrossRefPubMedGoogle Scholar
  21. 21.
    Heidenreich A, Varga Z, Von Knobloch R. Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis. J Urol. 2002 Apr;167(4):1681–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Stone NN, Stock RG, Unger P. Laparoscopic pelvic lymph node dissection for prostate cancer: comparison of the extended and modified techniques. J Urol. 1997 Nov;158(5):1891–4.CrossRefPubMedGoogle Scholar
  23. 23.
    Hatzichristodoulou G, Wagenpfeil S, Wagenpfeil G, Maurer T, Horn T, Herkommer K, et al. Extended versus limited pelvic lymph node dissection during bilateral nerve-sparing radical prostatectomy and its effect on continence and erectile function recovery: long-term results and trifecta rates of a comparative analysis. World J Urol. 2016;34:811–20.CrossRefPubMedGoogle Scholar
  24. 24.
    Yuh BE, Ruel NH, Mejia R, Novara G, Wilson TG. Standardized comparison of robot-assisted limited and extended pelvic lymphadenectomy for prostate cancer. BJU Int. 2013 Jul;112(1):81–8.CrossRefPubMedGoogle Scholar
  25. 25.
    • Kim KH, Lim SK, Kim HY, Shin TY, Lee JY, Choi YD, et al. Extended vs standard lymph node dissection in robot-assisted radical prostatectomy for intermediate- or high-risk prostate cancer: a propensity-score-matching analysis. BJU Int. 2013;112(2):216–23. Retrospective comparative study of ePLND versus sPLND depicting oncological (including a propensity-score-matching analysis) and non-oncological outcomes in intermediate and high-risk PCa patients CrossRefPubMedGoogle Scholar
  26. 26.
    Jung JH, Seo JW, Lim MS, Lee JW, Chung BH, Hong SJ, et al. Extended pelvic lymph node dissection including internal iliac packet should be performed during robot-assisted laparoscopic radical prostatectomy for high-risk prostate cancer. J Laparoendosc Adv Surg Tech A. 2012;22(8):785–790.Google Scholar
  27. 27.
    Gandaglia G, Trinh QD, Hu JC, Schiffmann J, Becker A, Roghmann F, et al. The impact of robot-assisted radical prostatectomy on the use and extent of pelvic lymph node dissection in the “post-dissemination” period. Eur J Surg Oncol. 2014;40(9):1080–6.CrossRefPubMedGoogle Scholar
  28. 28.
    Wang EH, Yu JB, Gross CP, Abouassaly R, Cherullo EE, Smaldone MC, et al. Association between surgeon and hospital characteristics and lymph node counts from radical prostatectomy and pelvic lymph node dissection. Urology. 2015;85(4):890–5.CrossRefPubMedGoogle Scholar
  29. 29.
    Suardi N, Larcher A, Haese A, Ficarra V, Govorov A, Buffi NM, et al. Indication for and extension of pelvic lymph node dissection during robot-assisted radical prostatectomy: an analysis of five European institutions. Eur Urol. 2014;66(4):635–43.CrossRefPubMedGoogle Scholar
  30. 30.
    Schwerfeld-Bohr J, Kaemper M, Krege S, Heidenreich A. Prospective randomized multicenter study comparing limited vs extended pelvic lymphadenectomy in intermediate and high risk prostate cancer—first descriptive results (SEAL, AUO AP 55/09). Eur Urol Suppl. 2014;13:e747.CrossRefGoogle Scholar
  31. 31.
    Hoshi S, Hayashi N, Kurota Y, Hoshi K, Muto A, Sugano O, et al. Comparison of semi-extended and standard lymph node dissection in radical prostatectomy: a single-institute experience. Mol Clin Oncol. 2015;3(5):1085–7.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Yang Y, Luo Y, Hou G-L, Huang Q-X, Pang J, Gao X. Laparoscopic radical prostatectomy plus extended lymph node dissection in combination with immediate androgen deprivation therapy for cases of pT3-4N0-1M0 prostate cancer: a multimodal study of 8 years’ follow-up. Clin Genitourin Cancer. 2016;14(4):e321–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Gandaglia G, De Lorenzis E, Novara G, Fossati N, De Groote R, Dovey Z, et al. Robot-assisted radical prostatectomy and extended pelvic lymph node dissection in patients with locally-advanced prostate cancer. Eur Urol. 2016.Google Scholar
  34. 34.
    • Abdollah F, Gandaglia G, Suardi N, Capitanio U, Salonia A, Nini A, et al. More extensive pelvic lymph node dissection improves survival in patients with node-positive prostate cancer. Eur Urol. 2015;67(2):212–9. Single-center retrospective study on 315 PCa patients with pathological nodal involvement, showing a potential therapeutic effect of a higher number of removed LNs during RP CrossRefPubMedGoogle Scholar
  35. 35.
    Moschini M, Fossati N, Abdollah F, Gandaglia G, Cucchiara V, Dell’oglio P, et al. Determinants of long-term survival of patients with locally advanced prostate cancer: the role of extensive pelvic lymph node dissection. Prostate Cancer Prostatic Dis. 2016;19(10):63–7.Google Scholar
  36. 36.
    Seiler R, Studer UE, Tschan K, Bader P, Burkhard FC. Removal of limited nodal disease in patients undergoing radical prostatectomy: Long-term results confirm a chance for cure. J Urol. 2014;191(5):1280–5.Google Scholar
  37. 37.
    Schiavina R, Bertaccini A, Franceschelli A, Manferrari F, Vagnoni V, Borghesi M, et al. The impact of the extent of lymph-node dissection on biochemical relapse after radical prostatectomy in node-negative patients. Anticancer Res. 2010 Jun;30(6):2297–302.PubMedGoogle Scholar
  38. 38.
    Joslyn SA, Konety BR. Impact of extent of lymphadenectomy on survival after radical prostatectomy for prostate cancer. Urology. 2006 Jul;68(1):121–5.CrossRefPubMedGoogle Scholar
  39. 39.
    Porter CR, Suardi N, Capitanio U, Hutterer GC, Kodama K, Gibbons RP, et al. A nomogram predicting prostate cancer-specific mortality after radical prostatectomy. Urol Int. 2010;84(2):132–40.CrossRefPubMedGoogle Scholar
  40. 40.
    Abdollah F, Sun M, Thuret R, Jeldres C, Tian Z, Briganti A, et al. Lymph node count threshold for optimal pelvic lymph node staging in prostate cancer. Int J Urol. 2012 Jul;19(7):645–51.CrossRefPubMedGoogle Scholar
  41. 41.
    Froehner M, Wirth MP. Re: Firas Abdollah, Giorgio Gandaglia, Nazareno Suardi, et al. More extensive pelvic lymph node dissection improves survival in patients with node-positive prostate cancer. Eur Urol 2015;67:212–9: extended lymph node dissection and the will Rogers phenome Eur Urol. 2015;67(6):e112.Google Scholar
  42. 42.
    Ji J, Yuan H, Wang L, Hou J. WITHDRAWN: is the impact of the extent of lymphadenectomy in radical prostatectomy related to the disease risk? A single center prospective study. J Surg Res. 2012;178:779–84.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Michele Colicchia
    • 1
  • Vidit Sharma
    • 1
  • Firas Abdollah
    • 2
  • Alberto Briganti
    • 3
  • R. Jeffrey Karnes
    • 1
    Email author
  1. 1.Department of UrologyMayo Clinic RochesterRochesterUSA
  2. 2.Center for Outcomes Research Analytics and Evaluation, Vattikuti Urology InstituteHenry Ford Health SystemDetroitUSA
  3. 3.Division of Oncology/Unit of Urology, Urological Research InstituteSan Raffaele Scientific InstituteMilanItaly

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