1) The document discusses pelvic lymph node dissection for prostate cancer surgery. It addresses the incidence of lymph node positive prostate cancer, guidelines for when pelvic lymph node dissection is indicated, and which lymph node templates should be removed. 2) One of the key points discussed is that the incidence of lymph node positive prostate cancer may be underestimated due to decreasing rates and extent of pelvic lymph node dissection. Pelvic lymph node dissection provides important staging information to guide treatment strategies. 3) Removal of the primary tumor through radical prostatectomy provides a survival advantage for lymph node positive patients over abandoning the surgery. However, the number and characteristics of positive lymph nodes also impact survival outcomes.

1. Pelvic Nodes : Surgery Hein Van Poppel Steven JoniauUZ Gasthuisberg Leuven, BelgiumECCLU 2011 is held under the auspices ofthe European School of UrologyLugano 2011

2. Radical Prostatectomy% patientswithoutprogression100p<0.000190p=0.00180706050403020100Lymph nodemetastasesLocalisedEstablishedcapsularpenetrationSeminalvesicleinvasionFocalcapsularpenetrationEpstein et al 1996

3. PelvicLymphnodeDissection

4. Issues thatwillbecoveredWhat is the incidence of LN positivePCa in contemporarypatients?When is pLNDindicated?Whichtemplateshouldberemoved?Whatdetermines prognosis: primary tumor orpositive LN?Take home messages

5. What is the incidence of LN pos PCa in contemporarypatients?

6. SEER database analysis (1988-2006), >130.000 patients% of ptswithpN+Stage migration + lessersurgery

7. SEER database analysis (1988-2006), >130.000 patientsNumber of removednodes

8. When is pLND indicated?

9. EAU guidelinesfor RP in High-riskDisease“RP is a reasonabletreatmentoption in selectedpatientswith cT3a PCa, Gleason score 8-10 or PSA >20”“If RP is performed, an extendedpelviclymphadenectomy must beperformed, as lymph nodeinvolvement is frequent”Heidenreich A, Bolla M, Joniau S. et al. EAU prostate cancerguidelines.

10. Lymphnodedissection : Yesorno?Low-risk (cT1c-2a, Gl.≤6 and PSA <10) - lymph node dissectioncanbesafelyomittedIntermediate-risk (cT2b-c orGl. score 7 or PSA 10-20)High-risk (≥cT3 orGleason score ≥8 or PSA >20) - eLNDshouldbeperformedif the nomogrampredicted risk of +velymphnodesexceeds 7%. Heidenreich A, Bolla M, Joniau S. et al. EAU prostate cancerguidelines.

11. Probability of Lymphnode InvasionBriganti A et al Eur Urol 51: 1573–1581, 2007

12. Rationaleforpelvic LND (PLND)PLND is the onlystagingmethodwhichallowsfor correct staging

13. LimitedvseLND: 2-fold increase in pos LN detection

14. Improvement in patient-tailored management

15. May improve survival …Heidenreich A, Bolla M, Joniau S. et al. EAU prostate cancerguidelines.

16. Which template should be removed?

17. Anatomicalboundariesof PLND Ext.Obt.Int.

18. Mapping of lymphnodesClassical extended PLNDNew extended PLND63%75%38%New LND template, includingthe commoniliac LN up to the uretericcrossingMattei A et al. EurUrol 2008;53:118-25

19. Cansentinel node dissectionapproacheLNDwhilelimitingcomplications?

20. Rationale of sentinel node dissectionThe primaryrationale:AVOID morbidity (lymfocele, DVT, lymfedema, pulmonaryembolism…)

21. RETAIN DIAGNOSTIC ACCURACY compared to extended LNDSecondaryrationale:Shorteroperative time (eLNDprolongssurgeryfor 30-45’)

22. Allow the use of minimallyinvasivetechniquesfor LN staging

23. Leuven University experience 47 patientswith full data available

24. 946 LN removed (median 20, range 7 – 42)

25. 21 patientswith N+ (45% of patients!)

26. 46 positive LN in totalJoniau S, Van den Bergh L et al., submitted

27. Leuven University experienceWhere are the sentinelnodeslocated?Ext. iliac 17%Common iliac 20%Obturator 15%Paraaortic 8%Bifurcation 6%Int. Iliac 26%Presacral 4%Perirectal 4%Joniau S, Van den Bergh L et al., submitted

28. Leuven University experienceWhere are the positivenodeslocated?Joniau S, Van den Bergh L et al., submitted

29. Accuracy of stagingusing different LNDtemplatesJoniau S, Van den Bergh L et al., submitted

30. Complicationsvsyieldlimited (stand.) extendedN+ 6% 20%Lymphocele 9% 18%Pulmemb. 1.6% 4.6%DVT 1% 1.5%Hematoma/inf. 0% 8%Lindberg et al., Scand J UrolNephrol 25:1, 2009

31. Whatdetermines prognosis: the primary tumor or the nodes?Influence of the primary tumor on survivalInfluence of the (number of) positivenodeson survival OM70%CRM35%50%nCRM25%

32. 85%95%80%75%OSCSS

33. 95%85%RP +RP +85%65%70%60%RP -40%30%RP -CSSOSMUNICH CANCER REGISTRY: 1413 LN-positive patients: 456 LN-positive patients, RP was abandoned

34. 957 underwent RP despite LN-positiveJoniau

35. Influence of the (number of) positivenodeson survival

36. Survival & Positive lymphnodes– Micrometastases –Disease-specific survivalOverall survivalFleischmann A et al., Prostate 69: 352–362, 2009.

37. Survival/Positive LNLargest metastasis >10mm Fleischmann A et al., Prostate69: 352–362, 2009.

38. Survival & Positive LNExtranodal extension (ENE) LCLNMLC