You are in: eMedicine Specialties > Urology > Surgery Lymph Node Dissection, PelvicArticle Last Updated: Jun 13, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Frank Papanikolaou, MD, Clinical Fellow, The Hospital for Sick Children, Department of Surgery, Division of Urology, University of Toronto, Canada Editors: Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dan Theodorescu, MD, PhD, Paul Mellon Professor of Urologic Oncology, Department of Urology, University of Virginia Health Sciences Center; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Bradley Fields Schwartz, DO, FACS, Associate Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine Author and Editor Disclosure Synonyms and related keywords: pelvic lymphadenectomy, lymph node dissection, pelvic lymph node dissection, PLND, bladder cancer, prostate cancer, urethral cancer, penile cancer, genitourinary cancer INTRODUCTIONSection 2 of 12
  Pelvic lymph node dissection (PLND) has a role in the treatment of several genitourinary cancers but is most commonly used in bladder cancer and prostate cancer. Others include urethral cancer and penile cancer. PLND has an additional role in the management of gynecologic cancers and other pelvic malignancies. While the anatomic approach is similar, the focus of this article is urological indications. For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education article Bladder Cancer. History of the ProcedureAfter it had been demonstrated that patients with breast and colon cancer with lymph node metastases could be cured surgically, attempts were made to apply lymphadenectomy to cancers of the pelvic organs. In 1932, Godard and Kaliopoulos reported pelvic lymphadenectomy with total cystectomy for bladder cancer. In 1950, Leadbetter and Cooper also were proponents of pelvic lymphadenectomy with cystectomy for bladder cancer. INDICATIONSSection 3 of 12
Pelvic lymph node dissection (PLND) for bladder cancer is performed at the time of a radical cystectomy or a partial cystectomy. It provides staging information and can be therapeutic. Several studies, including by Skinner (1982)1 and by Viewed et al (1994),2 have confirmed that patients with pelvic lymph node metastases can be cured with PLND during radical cystectomy. However, the curability seemed to hold for organ-confined cancer (pathologic T stage 2) but not for non–organ-confined cancer (pathologic T stage 3). The decision to perform PLND for prostate cancer prior to performing radical retropubic prostatectomy is based on the probability of pelvic lymph node metastases. This can be determined using the Partin nomograms. The Partin nomograms are included below: Table 1. Multivariate Logistic Regression Analysis for Prediction of Pathologic Stage Using Prostate-Specific Antigen, Gleason Score, and Clinical Stage (TNM): Prediction of Organ-Confined Disease (Percent)
Table 2. Multivariate Logistic Regression Analysis for Prediction of Pathologic Stage Using Prostate-Specific Antigen, Gleason Score, and Clinical Stage (TNM): Prediction of Lymph Nodal Status (Percent)
These and other nomograms are available at www.nomograms.org. The following is an example of a clinical scenario in which the Partin nomograms are used to determine the percent probability of lymph node involvement: With a stage of T2a, a prostate-specific antigen level of 14 ng/mL, and Gleason sum of 6, the nomogram calculates a 38% probability of organ-confined disease, a 52% probability of capsular penetration, a 5% probability of seminal vesicle involvement, and a 4% probability of lymph node involvement. Metastatic prostate cancer that involves the pelvic lymph nodes is generally considered to be incurable with surgery. Because these patients cannot be cured with lymph node dissections or other radical surgeries, the purpose of the PLND procedure is to accurately determine which patients would not benefit from more aggressive, definitive therapy. Essentially, the PLND is a staging procedure that can prevent the morbidity of a radical prostatectomy in patients unlikely to benefit from the procedure. The threshold for performing PLND for prostate cancer is determined by the Partin nomograms, but it varies with the treatment modality used. For an open retropubic prostatectomy, PLND adds minimal morbidity. Therefore, a 3% probability of lymph node involvement is used as a threshold above which one would perform a PLND. For a perineal prostatectomy, PLND requires an extra operation, and a 10% cutoff is used. In patients who undergo external beam radiation therapy and who may benefit from radiation as treatment for microscopic pelvic lymph node–positive disease, a 35% cutoff is used. Other urologic scenarios in which PLND is performed include selected cases of urethral and penile cancer. Pelvic lymphadenectomy in the setting of penile cancer is controversial. General agreement indicates that the probability of finding positive pelvic lymph nodes is increased in the presence of positive inguinal lymph nodes. Also known is the fact that survival of patients with positive iliac nodes is limited. Therefore, some would argue against PLND for penile cancer. However, an argument can be made that it is a reasonable therapy for a young patient, given that some evidence shows that indicates pelvic lymphadenectomy may lengthen survival. Adjuvant chemotherapy should also be considered if pelvic lymph nodes are positive. In regard to primary urethral cancer, lesions of the entire urethra or posterior urethra in females and in the bulbomembranous urethra in males are usually associated with invasion and a high incidence of pelvic nodal metastases. Pelvic lymphadenectomy is performed along with exenterative surgery because, occasionally, patients with nodal metastases can be cured. Urethral carcinoma in male patients is classified into 3 groups based on the location of the lesion: (1) penile, (2) bulbomembranous, or (3) prostatic. Most cases (59%) occur posteriorly and involve the bulbomembranous urethra. Less frequent sites include the penile (33%) and the prostatic (7%) portions. In women, approximately 50% of carcinomas occur in the distal urethra. Lymphatic metastases in the inguinal lymph nodes typically result from tumor in the anterior urethra, while pelvic lymphatic metastases are associated with posterior urethral tumors. Like its male counterpart, the female urethra has an anterior portion that comprises the distal one third of the urethra and a posterior portion that comprises the remaining proximal two thirds. The distal third drains into the inguinal nodes, and the proximal two thirds empty into the pelvic lymph nodes. RELEVANT ANATOMYSection 4 of 12
There are 8-10 external iliac lymph nodes. These receive efferent lymphatics from the inguinal nodes, the lymphatics of the iliac fossa, and the lower anterior abdominal wall and afferent lymphatics from the pelvic viscera The internal iliac lymph nodes receive afferents from the pelvic viscera. Their efferents pass to the common iliac nodes. There are 4-6 common iliac nodes whose efferent lymphatics pass to the lumbar nodes. The lymphatics of the pelvis follow the arteries, and the group of nodes accompanying each is named accordingly: internal iliac, external iliac, and common iliac. The details of lymphatic drainage from each organ of the pelvis are outlined in the table below. Table 3. Pelvic Lymph Node Drainage
CONTRAINDICATIONSSection 5 of 12
Metastatic prostate cancer that involves the pelvic lymph nodes is generally considered to be incurable with surgery. Because these patients cannot be cured with lymph node dissections or other radical surgeries, the purpose of the pelvic lymph node dissection (PLND) procedure is to accurately determine which patients would not benefit from more aggressive, definitive therapy. Pelvic lymphadenectomy in the setting of penile cancer is controversial. General agreement indicates that the probability of finding positive pelvic lymph nodes is increased in the presence of positive inguinal lymph nodes. Also known is the fact that survival of patients with positive iliac nodes is limited. Therefore, some would argue against PLND for penile cancer. However, an argument can be made that it is a reasonable therapy for a young patient, given that some evidence shows that indicates pelvic lymphadenectomy may lengthen survival. WORKUPSection 6 of 12
Imaging Studies
TREATMENTSection 7 of 12
Preoperative detailsStaging with pelvic CT scanning for bladder cancer can provide information about the bladder tumor and the presence of pelvic or paraaortic lymphadenopathy. However, the presence of lymphadenopathy does not necessarily indicate metastatic disease. Moreover, CT scanning can fail to reveal nodal metastases in up to 40% of cases. The staging information that is useful for pelvic lymph node dissection (PLND) in prostate cancer includes T stage, prostate-specific antigen level, and Gleason score. Currently, imaging studies have no role in the evaluation of the pelvic lymph nodes. Intraoperative detailsBladder cancer The limits of PLND in bladder cancer are as follows: The cephalad limit is 2 cm above the bifurcation of the common iliac artery, the caudad limit is the endopelvic fascia, the medial limit is the bladder, and the lateral limit is the genitofemoral nerve. A PLND for bladder cancer is usually performed in conjunction with a radical cystectomy. A modified dissection, leaving the nodes along the external iliac artery intact, may be appropriate in low-risk patients because skeletonization of the external iliac artery is associated with an increased risk of lymphedema. The procedure is as follows:
Prostate cancer PLND in prostate cancer can be performed as either an open or a laparoscopic procedure. In addition, the open procedure can be performed as part of a radical prostatectomy or as a minilaparotomy. The minilaparotomy and laparoscopic approaches can be used when a perineal approach is being considered. The discussion that follows applies to both the open and laparoscopic approach, with procedural information specific to each and then information common to both. However, the technical aspects of laparoscopy are not addressed in this article. The limits of node dissection for PLND in prostate cancer are as follows: The cephalad limit is the bifurcation of the common iliac artery, the caudad limit is the node of Cloquet, the medial limit is the obturator vessels, and the lateral limit is the pelvic sidewall. The procedure specifically for open PLND is as follows:
The procedure specifically for laparoscopic PLND is to create a pneumoperitoneum and obtain laparoscopic access using 3 operating ports. Incise the peritoneum midway between the internal ring and the obliterated umbilical artery to expose the external iliac vein. The procedure common to both the open and laparoscopic techniques is as follows:
COMPLICATIONSSection 8 of 12
Complications of pelvic lymph node dissection (PLND) that are common to both bladder and prostate cancer include the following:
OUTCOME AND PROGNOSISSection 9 of 12
Patients with bladder cancer only occasionally benefit from pelvic lymph node dissection (PLND). Approximately 20% of patients present with lymph node metastases at the time of cystectomy. This percentage is higher in selected populations considered to be high grade and stage. Approximately 50% of these patients have limited regional metastases (1 or 2 nodes below the iliac bifurcations) and are theoretically amenable to cure. Of the latter patients, 10-35% are cured with cystectomy and PLND alone. The management of prostate cancer accompanied with lymph node metastases after permanent histologic evaluation is controversial. The debate is centered on whether to institute hormonal therapy immediately or upon prostate-specific antigen progression.4 Four prospective randomized trials have supported a survival benefit of early androgen ablation in locally advanced disease.5 The Messing et al (1999) study demonstrated a 25% overall survival benefit at 8 years in men with node-positive prostate cancer treated with radical prostatectomy and orchidectomy/goserelin compared to radical prostatectomy alone. However, given that the prostate-specific antigen level is a good index of disease progression, an argument also can be made to delay treatment until the prostate-specific antigen level rises. FUTURE AND CONTROVERSIESSection 10 of 12
Ablative therapies for prostate cancer (eg, cryotherapy) and investigative treatments (eg, high-intensity focused ultrasound [HIFU]) are increasing in popularity. As such, many patients who undergo these treatment modalities do not undergo lymph node dissection for staging. Laparoscopic lymph node dissections and nodal sampling through minilaparotomy are options for these patients, especially those at high risk of node-positive disease, such as patients with a prostate-specific antigen level of more than 20 ng/mL, a Gleason grade of 8-10, or high-risk biopsy data. ACKNOWLEDGMENTSSection 11 of 12
The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Laurence Klotz, MD, to the development and writing of this article. REFERENCESSection 12 of 12
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