COMPLICATIOMS OF ROBOTIC PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER: AN ANALYSIS OF THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM TARGETED RADICAL PROSTATECTOMY DATABASE

Abstract

Introduction

Prostate cancer is the second most common cancer in men worldwide and accounts for

3.8% of all cancer deaths in men. Treatment of localized prostate cancer includes radical prostatectomy (RP) with or without pelvic lymph node dissection (PLND). Multiple guidelines recommend PLND for staging purposes and there may also be a therapeutic benefit. However, PLND is not without complications and nomograms predicting risk of LN metastasis may be employed to optimize selection. There remains, however, a paucity of real-world data assessing the morbidity of contemporary robot assisted PLND. We therefore sought to use the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted prostatectomy database to quantify the rates of real-world 30-day post-operative outcomes of patients undergoing PLND at the time of RP for prostate cancer, quantify the incremental morbidity by comparing to those who underwent RP without PLND.

Methods

We conducted a retrospective cohort study using the ACS-NSQIP database of adult patients undergoing radical prostatectomy from 2019-2022. The primary outcome was a composite of any of the following 30-day major postoperative outcomes: mortality, reoperation, cardiac event, and neurologic event. Secondary outcomes were composed of individual complications of the composite primary outcome as well as infectious and venous thromboembolic complications, unplanned intubation and ventilation, transfusion, readmission, and prolonged length of stay (LOS). We also assessed the rates of procedure specific outcomes such as rectal injury, ureteral obstruction, and lymphocele. PLND and non-PLND groups were balanced using propensity score matching (PSM) with a 1:1 ratio with a caliper of 0.01 using demographic characteristics (age, race, BMI, modified frailty index etc.), prior medical history (prior pelvic radiotherapy or operations), and cancer staging (pathologic T stage). Likelihood of complications was assessed by conditional logistic regression.

Results

There were 13,413 patients identified between 2019 and 2022 who underwent prostatectomy: 11,341 (85%) had PLND while 2,072 (15%) did not. After PSM, our cohort included 2,071 matched pairs of patients with and without PLND. In PLND cohort, the detectable prevalence of PLND related complications included lymphocele or lymphatic leak (1.8%), urinary leak or fistula (1.4%), ureter obstruction (0.29%) and rectal injury (.38%). In the non-PLND cohort, the prevalence of complications was: lymphocele or lymphatic leak (0.43%), urinary leak or fistula (1.3%), ureter obstruction (0.20%), and rectal injury (0.30%). There were no significant differences between the two groups in primary outcome (OR 0.84; 95% CI 0.48, 1.48). Receipt of PLND was associated with higher rates of deep vein thrombosis (DVT, OR 2.51; 95% CI 1.10, 5.74) as well as lymphocele or other lymphatic leak (OR 4.17; 95% CI 2.00, 8.68). There was no significant association between the receipt of PLND and the risk of rectal injury, urinary leak or fistula, or ureteral obstruction.

Conclusions

Contemporary PLND is associated with an increased risk of 30-day postoperative complications including an 2.5 times increased risk of deep vein thrombosis (0.39% vs 0.97% in patients who had PLND) and a 4 times increased risk of lymphocele or other lymphatic leak (.43% vs 1.79% in patients who had PLND). These data provide important insights for patient counseling and optimizing patient selection for PLND.