Decision Analysis of Pelvic Lymph Node Dissection During Radical Prostatectomy.

Area of Science:

• Urology
• Oncology
• Decision Analysis

Background:

• Controversy exists regarding pelvic lymph node dissection (PLND) during radical prostatectomy for prostate cancer.
• Concerns include potential complications like lymphocele versus benefits of reduced metastasis.
• Guidelines vary on recommending PLND due to conflicting evidence and risk-benefit assessments.

Purpose of the Study:

• To conduct a decision analysis evaluating the benefits and harms of PLND versus no PLND during radical prostatectomy.
• To quantify the impact of varying estimates for benefit, harm, and uncertainty on the decision to perform PLND.
• To determine the conditions under which PLND offers more benefit than harm for prostate cancer patients.

Main Methods:

• A decision tree model was developed comparing PLND to no PLND in radical prostatectomy.
• Initial analyses used inputs unfavorable to PLND, such as high lymphocele rates and no long-term metastasis reduction.
• Sensitivity analyses were performed by varying these parameters to assess robustness of findings.

Main Results:

• The decision analysis favored PLND across a wide range of scenarios, even with unfavorable assumptions.
• PLND demonstrated higher expected utility compared to no PLND, despite low probabilities of benefit and high complication risks.
• PLND was also favored for patients with PSMA PET-negative disease, attributed to the imaging modality's imperfect sensitivity.

Conclusions:

• Pelvic lymph node dissection (PLND) should be considered the standard of care for patients with grade group 2 or higher prostate cancer undergoing radical prostatectomy.
• The benefits of PLND in reducing locoregional metastases outweigh potential harms for most relevant patient populations.
• Findings support PLND even in cases where PSMA PET imaging is negative, highlighting its role in comprehensive staging and treatment planning.