Reevaluating the Therapeutic Role of Pelvic Lymph Node Dissection in Robot-Assisted Radical Prostatectomy

Abstract

Introduction

Extended pelvic lymph node dissection (PLND) is recommended for intermediate- and high-risk prostate cancer according to D'Amico risk classification, and there is evidence supporting its diagnostic value in staging. However, its therapeutic benefit remains unproven. We, therefore, aimed to evaluate the therapeutic significance of PLND in patients undergoing robot-assisted radical prostatectomy (RARP).

Methods

We retrospectively analyzed 329 patients with intermediate- or high-risk prostate cancer (per D'Amico risk classification) who underwent RARP at two centers. Patients were divided into two groups: those who did not undergo lymph node dissection (no-PLND group) and those who underwent an extended PLND (extended-PLND group). After excluding patients who received neoadjuvant hormone therapy, 313 cases remained for analysis. Propensity score matching was performed to balance baseline characteristics, yielding 85 matched pairs. We compared prostate-specific antigen progression-free survival (PSA-PFS) and overall survival (OS) between the matched groups. Perioperative outcomes (complications, console time, and blood loss) were also compared.

Results

Kaplan–Meier analysis showed no significant differences in PSA-PFS (p = 0.163) or OS (p = 0.323) between the extended-PLND and no-PLND groups after matching. Similarly, when stratified by risk category, PSA-PFS did not differ significantly between the two groups for either intermediate-risk or high-risk patients. Perioperative blood loss was similar between groups, but the no-PLND group had a significantly lower overall complication rate (5.1% vs. 30.4%, p < 0.001) and shorter median console time (160.2 vs. 230.5 min, p < 0.001) than the extended-PLND group. Notably, no Grade 3–4 complications (Clavien–Dindo) occurred in the no-PLND group, compared to 11 cases in the extended-PLND group.

Conclusion

In intermediate- and high-risk prostate cancer, performing an extended PLND during RARP did not improve biochemical recurrence-free or OS, suggesting minimal therapeutic benefit.