Robotic-assisted super-extended pelvic lymph node dissection for prostate cancer: safety and pathologic findings

We examined the pathology and safety outcomes associated with the extent of pelvic lymph node dissection in patients with high-risk prostate cancer undergoing radical prostatectomy.

We retrospectively identified men with prostate cancer who underwent robot-assisted radical prostatectomy with pelvic lymph node dissection between May 2016 and September 2021. Cases were categorized using Current Procedural Terminology (CPT) codes (38571) for extended lymph node dissection and super-extended lymph node dissection (38572). Using logistic regression, we compared the groups on a number of factors, including recurrence.

Super-extended lymph node dissection had significantly higher median prostate-specific antigen and National Comprehensive Cancer Network risk classification prior to surgery. Significant differences were observed in the pathologic T stage and pathology grade group. Time on robot was significantly longer for the super-extended group, while estimated blood loss was lower. No differences were observed in length of stay or any complication-related variable. Super-extended had significantly higher node positivity (36.1% vs. 7.6%, p < 0.001) and recurrence. 10.0% of super-extended cases had node positivity in the aortic bifurcation, the common iliac, or the pre-sacral chains that would have been missed with an extended dissection. 2.2% of patients had node positivity in these chains only.

Super-extended lymph node dissection is safe and feasible for patients with high-risk prostate cancer. Further research is needed to better understand its clinical benefit and to further inform optimal patient selection.