Prostatic biopsy undergrading: the feasibility of secondary laparoscopic pelvic lymphadenectomy

Prostate biopsy grade is a key factor when deciding whether to perform pelvic lymph node dissection (PLND) at laparoscopic radical prostatectomy. In common with many laparoscopic radical prostatectomy centers, we perform PLND in patients found to have intermediate and high-risk prostate cancer based upon preoperative PSA, prostate biopsy and imaging. We assessed the feasibility of performing a secondary laparoscopic PLND 6 weeks postoperatively in the presence of postoperative upgrading in patients who did not have PLND.

A prospective study recording the pathological results and operative outcomes prospectively over a 10-month period during which 24 patients underwent a secondary PLND. All patients had a preoperative PSA level <10 ng/ml and biopsy Gleason score of ≤6 (3 + 3) and the prostatectomy specimen was subsequently found to have a Gleason score of ≥7 (4 + 3) or increased stage.

During the 10-month period, 377 prostatectomies were carried out in our department in which 54 (18.3%) had an upgrading in the prostatectomy specimen. 24 patients (mean age 60 and mean PSA 6.7 ng/ml) agreed to a secondary PLND. No lymph nodes metastases were observed. One patient who was sexually potent following a nerve-sparing prostatectomy was impotent after the secondary PLND.

Upgrading of prostate Gleason score is seen in up to a third of cases in many large published series that is reflected in our experience. A laparoscopic secondary lymphadenectomy is feasible with low morbidity and yields valuable pathological clinical staging for subsequent surveillance and therapy for these high-risk patients.