LAPAROSCOPIC PELVIC LYMPHADENECTOMY FOR PROSTATE CANCER SCREENING: PROS AND CONS

March 2009
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Despite its “kinder, gentler” technique, some doctors question the value of laparoscopic pelvic lymphadenectomy. For one thing, minimally invasive or not, it’s still invasive, and it’s not without side effects. These don’t occur often, but they can be significant and may include injury to the bladder or bowel, internal bleeding, damage to blood vessels, gas embolism (when air, pumped into the abdomen, escapes into the bloodstream), or even, rarely, heart failure and death.

Is the procedure ultimately necessary? It has no therapeutic benefit—a doctor can’t cure a man’s prostate cancer by removing cancerous lymph nodes; once the cancer spreads to the lymph nodes, it always spreads to other sites, like bone, as well. Perhaps the most useful benefit of this procedure is that it can rule out surgery for a man who doesn’t need it—but so can careful staging.

Also, finding that the lymph nodes are cancer-free still does not mean a man’s cancer is curable. Say, for example, a man has a large, palpable cancer that invades the muscles in the pelvic side wall (stage T3 or C), a Gleason score of 8, and a PSA level of 30. Sadly, there is no reason for this man to go ahead with a lymph node dissection; his disease is already extensive, and treatment for him should be aimed at relieving symptoms and pain. To put this man through the rigors of a procedure that ultimately won’t help him is neither helpful nor kind.

And finally, when surgical candidates are carefully evaluated, only about 5 percent wind up having positive lymph nodes—so a separate procedure just to determine the state of the lymph nodes is probably unnecessary in most men. Even this number may decrease as doctors begin computing the results of the digital rectal exam, PSA and the Gleason score. Methods for determining the scope of prostate cancer are constantly being refined.

However, the laparoscopic pelvic lymph node dissection can be useful in some instances—in a man who’s scheduled to undergo a radical perineal prostatectomy, for example, instead of a retropubic operation. (With the perineal approach, the lymph nodes aren’t dissected.) Also, sometimes this procedure provides more information than the frozen sections obtained during prostatectomy, and this may be helpful in determining the state of cancer in a man with a high Gleason score (8, 9 or 10).

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