Radical Prostatectomy Without Pelvic Lymph Node Dissection Is Widely Practiced in High-Risk Patients Despite Poorer Survival

The study investigated practice patterns and outcomes of pelvic lymph node dissection (PLND) in patients receiving radical prostatectomy using the National Cancer Data Base. Fifty-one percent of those with favorable risk disease did not receive PLND; 39.2% of those with unfavorable risk disease did not receive a PLND, and those who did not receive nodal dissection had significantly worse survival. Patients with unfavorable risk prostate cancer undergoing surgery should strongly be considered for PLND. Purpose: Radical prostatectomy with pelvic lymph node dissection (PLND) is the standard of care for unfavorable risk prostate cancer. We investigated dissection practice patterns and their impact on overall survival using a large national database. Patients and Methods: Men with prostate adenocarcinoma diagnosed between 2004 and 2013 were identified from the National Cancer Data Base. Disease was classified as either favorable or unfavorable on the basis of National Comprehensive Cancer Network guidelines. Minimum follow-up was 4 years. All patients received riskappropriate surgery: prostatectomy with or without PLND. Prostatectomy alone and prostatectomy with PLND was propensity score matched within each risk cohort. Survival analysis included Kaplan-Meier statistics, Cox proportional hazards model, and multivariate logistic regression. Results: A total of 66,469 subjects met the inclusion criteria. Median (range) age was 63 (27-90) years. Median (range) follow-up was 59.53 (48-143.54) months. Within the cohort of patients with favorable risk disease, 51% did not undergo nodal dissection. Matched analysis demonstrated no difference in survival (P = .926). Within the cohort of patients with unfavorable risk disease, 39.2% did not receive nodal dissection. Matched analysis demonstrated that nodal dissection had superior survival (log-rank P = .002; hazard ratio - 0.624; 95% confidence interval, 0.466-0.835; P= .002). Greater odds of receiving nodal dissection included an open or robot-assisted approach compared to a laparoscopic approach, academic/research programs, and higher risk groups. Conclusion: Although PLND is associated with a significant survival benefit in men with unfavorable risk prostate cancer, nearly 40% of patients with unfavorable risk disease did not receive PLND. Published by Elsevier Inc.