We did not attempt to segregate lymph nodes removedfrom different anatomical regions such as obturator or pre-sacral. These are arbitrary anatomical groupings, and thereare direct and identifiable communications between the var-ious lymph node groups removed as part of a pelvic nodedissection. Therefore, we performed en bloc removal of thepelvic nodes within the targeted anatomical boundaries de-scribed. Our method for pathological analysis of the lymphnodes also mimicked the usual clinical situation. We did notperform step sectioning of the entire lymphatic package.Multiple sections were obtained from identifiable lymphnodes and examined histologically. While minute segmentsof lymph node metastasis may be overlooked by this process,it is in keeping with customary practice and provides morerelevant clinical data for patient management. Furthermore,the information is more readily compared to other reports.

For most patients undergoing radical prostatectomy, pelviclymphadenectomy has become a relatively unimportant stag-ing procedure. The contrast with surgical series from a de-cade or more ago is created by inclusion of stage T1c as themost common category in contemporary series. The inci-dences of positive nodes in these patients is less than 5% andunder staging because of a modified node dissection occursinfrequently. Pelvic node dissection may not be essential inall patients before radical prostatectomy and limitation inthe anatomical boundaries of dissection for patients withgood prognostic features of the primary tumor seems appro-priate.

CONCLUSIONS

Extended pelvic lymphadenectomy in patients undergoingradical prostatectomy does not yield a substantially higherrate of positive nodes than a more limited lymph node re-moval. In patients with good prognostic features the rate ofpositive nodes is low. Complications attributable to the nodedissection such as lymphocele or lower extremity edema oc-cur more commonly with extended dissection.

REFERENCES

1. Gervasi, L. A., Mata, J., Easley, J. D., Wilbanks, J. H.,Seale-Hawkins, C., Carlton, C. E., Jr. et al: Prognostic signif-icance of lymph nodal metastases in prostate cancer. J Urol,142: 332, 1989

2. Donohue, R. E., Mani, J. H., Whitesel, J. A., Mohr, S., Scanavino,D., Angspurger, R. R. et al: Pelvic node dissection. Guide topatient management in clinically locally confined adenocarci-noma of prostate. Urology, 20: 559, 1982

3. Danella, J. F., deKernion, J. B., Smith, R. B. and Steckel, J.: Thecontemporary incidence of lymph node metastases in prostatecancer: implications for laparoscopic lymph node dissection.J Urol, 149: 1488, 1993

4. Bishoff, J. T., Reyes, A., Thompson, I. M., Harris, M. J., St. Clair,S. R., Gomella, L. et al: Pelvic lymphadenectomy can be omit-ted in selected patients with carcinoma of the prostate: devel-opment of a system of patient selection. Urology, 45: 270, 1995

5. Petros, J. A. and Catalona, W. J.: Lower incidence of unsus-pected lymph node metastases in 521 consecutive patientswith clinically localized prostate cancer. J Urol, 147: 1574,1992

6. McLaughlin, A. P., Saltzstein, S. L., McCullough, D. L. andGittes, R. F.: Prostatic carcinoma: incidence and location ofunsuspected lymphatic metastases. J Urol, 115: 89, 1976

7. Golimbu, M., Morales, P., Al-Askari, S. and Brown, J.: Extendedpelvic lymphadenectomy for prostatic cancer. J Urol, 121: 617,1979

8. Stone, N. N., Stock, R. G. and Unger, P.: Laparoscopic pelviclymph node dissection for prostate cancer: comparison of theextended and modified techniques. J Urol, 158: 1891, 1997

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EDITORIAL COMMENTS

I thoroughly enjoyed reading this study and might subtitle themanuscript “Back To The Future.” The authors conducted an elegantstudy comparing what was, in the early 1980s, an extended pelviclymphadenectomy to what has become the standard limited nodedissection today. They found little increase in detection rates and yeta dramatic increase in complications, most of which could be attrib-uted to the extended dissection.

We have been interested in our ability to detect extraprostaticdisease for years and have sought innovative methods to identifythese high risk patients. Methods that have been suggested includemonoclonal antibody scans and the use of molecular staging (exam-ining peripheral blood for mRNA for PSA). Both of these studies havefallen on hard times due to their poor performance characteristicsand penchant for false-positivity (for example a positive scan whenno disease is present and for polymerase chain reaction PSA positiveresults in patients with T1–2 disease). The authors could have taken1 step further and looked for molecular signatures of prostate cancerin the pelvic lymph nodes using the same polymerase chain reactiontechnology. While this would have reduced the likelihood of a false-negative interpretation due to missing a small focus of disease, italso would have the same risk of detecting circulating PSA producingcells that were of unknown significance.

We desperately need better staging tools for clinically localizedprostate cancer. Certainly, the current limited pelvic lymphadenec-tomy seems to have a low risk of complications and should be con-sidered for omission in low risk patients. However, the answer willalmost certainly be in either systemic testing or imaging studies,both of which are based on molecular signatures of prostate cancercells. I congratulate the authors for helping us move in that direc-tion.

Ian M. ThompsonDivision of UrologyUniversity of Texas Health Science CenterSan Antonio, Texas

While pelvic lymph node dissection has historically been consid-ered an essential method for further staging for presumed clinicallylocalized prostate cancer, the reported incidence of positive lymphnodes histologically at the time of radical retropubic prostatectomyhas declined greatly during the last 2 decades. In the late 1980s asmany as 1 of 4 men presenting for surgical treatment of prostatecancer were found at the time of surgery or at the time of finalpathological analysis to harbor microscopic evidence of prostate can-cer in the pelvic lymph nodes. Numbers as low as 2% to 3% are nowreported in large contemporary series of men undergoing radicalretropubic prostatectomy. The authors question whether these lownumbers of lymph node metastasis represent better patient selectionor worse lymph node dissection anatomically.

Their prospectively randomized study addressed whether an ex-tended pelvic lymph node dissection similar to that performed forstaging invasive bladder cancer as opposed to the more standardlimited pelvic lymph node dissection performed for prostate cancermight detect more evidence of microscopic foci of cancer. The authorsrandomized 123 men undergoing radical retropubic prostatectomywith a contemporary distribution of stages, PSA levels and grades toundergo an extended pelvic lymph node dissection on 1 side versus a“limited pelvic lymph node dissection” on the opposite side. To limitthe bias as to the volume of cancer on the side of the prostate inwhich the nodes were found to be positive, the authors randomizedthe patients to which side would receive the extended node dissec-tion. Interestingly enough, they determined that extended lymphnode dissection not only did not find more evidence of metastaticspread of prostate cancer in the pelvic, but led to unacceptably higherlevels of complications attributable to the lymphadenectomy.

These results support the contention that early detection pro-grams and rational selection of patients for radical retropubic pros-tatectomy have in fact potentially lowered the likelihood of pelviclymph node metastasis at the time of surgical treatment for clinicallylocalized prostate cancer. More importantly, as newer treatments forclinically localized prostate cancer become more popular (for exam-ple brachytherapy, cryosurgery and thermotherapy, as well as res-urrection of the perineal approach to surgical treatment for clinicallylocalized prostate cancer), the need for pelvic lymph node dissectionhas been questioned. The authors have concluded that extendedpelvic lymphadenectomy in these patients does not substantiallyincrease the likelihood of detecting higher rates of positive lymphnodes and provides unacceptable increased risks of complication due

LYMPH NODE DISSECTION IN PATIENTS WITH CLINICALLY LOCALIZED PROSTATE CANCER 147