Reliability of preoperative values to determine the need for lymphadenectomy in patients with prostate cancer and meticulous lymph node dissection

Introduction: The only definite way to determine lymph node metastasis, an unfavorable prognostic factor in prostate cancer is lymphadenectomy. Due to increased morbidity and the increasing trend towards minimally invasive surgery, ways to avoid or at least limit lymphadenectomy are being sought. We routinely performed a meticulous lymphadenectomy in all patients and the goal of this study was to evaluate which of the previously proposed criteria determining who needs a lymphadenectomy can be applied in our patients. Patients and Methods: Patients with clinically localized prostate cancer confirmed by fine needle aspiration cytology, without neoadjuvant hormone therapy, negative pelvic and abdominal CT scans and negative bone scan underwent a radical prostatectomy with simultaneous bilateral extended lymphadenectomy. Results: Between 1989 and 1999, 463 patients were included in this study. The median age was 64 (range 44-76) years and the median PSA was 11.0 (range 0.42-172) ng/ml. A median of 21 nodes were removed per patient. One hundred and nine (24%) had lymph node metastasis: 17% of patients with a PSA value less than or equal to20 ng/ml and 12% with a PSA value less than or equal to10 ng/ml. None of the patients with a preoperative grading of 1 and a PSA value less than or equal to10 ng/ml and 10% of the "low-risk patients" with a PSA value less than or equal to10 ng/ml and a preoperative grading <3 had lymph node metastases. Seven percent with a PSA value less than or equal to10 ng/ml and a prostatectomy Gleason score under 7 were found to be node positive. Conclusions: A significant number of patients would have been understaged and left with diseased nodes when applying preoperative PSA value less than or equal to10 ng/ml and grading <3/Gleason <7 as criteria for omitting lymphadenectomy. Therefore we consider meticulous lymphadenectomy a must for correct staging in all patients undergoing radical prostatectomy for prostate cancer, with the exception of patients with a grading of 1 and a PSA less than or equal to10 ng/ml. (C) 2002 Elsevier Science B.V All rights reserved.