Pelvic lymph node dissection in prostate cancer - is it really necessary? A multicentric longitudinal study assessing oncological outcomes in prostate cancer patients undergoing pelvic lymph node dissection vs radical prostatectomy only.

Purpose
With the availability of PSMA-PET scans, it is controversial whether pelvic lymph-node dissection (PLND) at time of radical prostatectomy (RP) is still the most reliable and accurate staging modality for lymph-node assessment. Furthermore, the oncological benefit of PLND remains unclear. Aim of this study was to assess whether omitting PLND in patients undergoing RP for prostate cancer is associated with the risk of tumor recurrence and progression to metastasis.
Material And Methods
In this longitudinal multicentre cohort-study, we reviewed data of 2346 consecutive patients with prostate cancer who underwent RP with (n=1650) and without (n=696) extended-PLND between 01/1996 and 12/2021. Recurrence-free survival (RFS) and metastases-free survival (MFS) were analysed as a time-to-event outcome using Kaplan-Meier analyses with log-rank tests. To assess effect of PLND, we created multivariable Cox proportional hazards models adjusting for relevant clinical and demographic characteristics.
Results And Limitations
Median follow-up was 44 months. There was no difference in RFS between men who had a PLND and those who did not [HR 1.07, 95%CI 0.87-1.32, p=0.52]. Patients with D'Amico high-risk-disease (PSA>20ug/l and/or ISUP-GG≥4) demonstrated a significantly prolonged MFS if they underwent PLND [HR 0.57, 0.36-0.91, p=0.02]. PLND also improved MFS in patients with intermediate-risk disease [HR 0.48, 95%CI 0.25-0.90, p=0.023]. Further significant prognostic variables for MFS on multivariable Cox proportional hazard regression were PSA, ISUP-GG, and pathological T-stage.
Conclusions
PLND improves MFS in D'Amico intermediate and high-risk prostate cancer patients and may therefore be considered in men undergoing RP.