Extensive PLND: Better staging, more complications

Atlanta-The prostate cancer staging benefits of an extensive pelvic lymph node dissection (PLND) come at a price of a significantly increased risk of complications and a significantly longer hospitalization.

"We know that more extensive PLND improves the accuracy of staging, so these detriments should at least be balanced so that the staging benefit can be preserved and the complication rate decreased after extensive PLND," said Alberto Briganti, MD, of the department of urology, Vita-Salute University in Milan.

However, the risks associated with extensive PLND have not been clearly defined. To evaluate the risks, Dr. Briganti's team reviewed medical records of 963 patients who underwent radical prostatectomy and PLND, of which 80% of the cases were extensive nodal dissections. Among the most frequent complications were lymphocele, deep venous thrombosis, fever, acute urinary retention, urinary anastomotic leakage, blood loss, pelvic hematoma, need for surgical re-intervention, percutaneous draining of a lymphocele, and pulmonary embolism, as well as the overall complication rate.

The median age of the study population was 66 years. Patients who underwent extensive PLND had a significantly higher mean PSA value (11.3 ng/mL vs. 8.8 ng/mL, p=.04) and were significantly more likely to have biopsy Gleason sum ≥7, seminal vesicle invasion, and lymph node invasion. Significantly more patients undergoing limited PLND had organ-confined disease.

Weighing PLND options

Extensive PLND was associated with an overall complication rate of 19.8% compared with 8.2% for limited PLND (p<.001). Lymphocele occurred in 10.3% of extensive PLNDs versus 4.6% of limited nodal dissections (p=.012).

Fewer than 1% of patients who had extensive PLNDs developed acute urinary retention, but no patient in the limited PLND group did (p=.05). Rates of other complications did not differ between the two groups.

Limited PLND was associated with significantly greater blood loss, which averaged 1,364 cc compared with 1,179 cc in patients who had extensive PLND (p=.001). Operating room time averaged 133 to 134 minutes in both groups. Patients who underwent extensive PLND had significantly longer postoperative hospital stays, averaging 9.9 days compared with 8.2 days in the limited PLND group (p<.001).

In analyzing the differences between treatment groups, Dr. Briganti's team adjusted for age, PSA, Gleason sum, extracapsular extension, seminal vesicle invasion, and lymph node invasion. The multivariate analysis revealed that extensive PLND increased the risk of any complication threefold compared with limited PLND (OR: 3.1, p<.001). In addition, extensive PLND significantly increased the odds of developing lymphocele (OR: 2.4, p=.02) and of longer hospital stay (OR: 1.6, p<.001). Limited PLND retained its significant association with blood loss (p=.01).