Pelvic lymph node dissection at robot-assisted radical prostatectomy: Assessing utilization and nodal metastases within a statewide quality improvement consortium.
Lescay H, Abdollah F, Cher ML, Qi J, Linsell S, Miller DC, Montie JE, Peabody J, Kaffenberger S, Morgan T, Loeb A, and Lane BR. Pelvic lymph node dissection at robot-assisted radical prostatectomy: Assessing utilization and nodal metastases within a statewide quality improvement consortium. Urol Oncol 2019.
PURPOSE: Several guidelines recommend pelvic lymph node dissection (PLND) at robot-assisted radical prostatectomy (RARP) only when lymph node involvement (LN+) is >2%. Individual surgeon use of PLND is not well-known. We sought to examine variability in PLND performance and detection of LN+ across the Michigan Urological Surgery Improvement Collaborative.
METHODS: Data regarding all RARP (3/2012-9/2018) were prospectively collected, including patient and surgeon characteristics. Univariable and multivariable analyses of PLND rate and LN+ rate were performed.
RESULTS: Among 9,751 men undergoing RARP, 79.8% had PLND performed (n = 7,781), of which 5.2% were LN+ (n = 404). In univariate and multivariable analyses, predictors of PLND included higher Prostate-Specific Antigen (PSA), biopsy Gleason grade (bGG), number of positive cores, and maximum core involvement at P < 0.05 for each. Higher PSA, cT stage, bGG, number of positive cores, and maximum core involvement predicted LN+ when PLND was performed (P < 0.05 for each). There was significant surgeon variation in the proportion of PLND performed at RARP, yet neither surgeon-annualized RARP volume nor % of PLND performed was associated with LN+ disease (P > 0.05). Grade was associated with PLND (60.0%, 77.6%, 91.0%, 97.3%, and 98.5%; P < 0.001) and LN+ (0.7%, 2.5%, 5.8%, 8.6%, and 19.9%; P < 0.001) for bGG 1,2,3,4,5, respectively. Maximum core involvement also strongly predicted LN+ with rates of 1.5%, 3.8%, and 9.4% for65%, respectively (P < 0.001).
CONCLUSIONS: Nearly 80% of RARP in Michigan Urological Surgery Improvement Collaborative were performed with PLND, including 60% of bGG1 patients (with LN+ in only 0.7%), but significant variability exists between surgeons. Our data indicate limited benefit for favorable-risk CaP patients and support efforts to decrease PLND use going forward.
ePub ahead of print