eMedicine Specialties > Urology > Surgery

Lymph Node Dissection, Pelvic

Author: Frank Papanikolaou, MD, Clinical Fellow, The Hospital for Sick Children, Department of Surgery, Division of Urology, University of Toronto, Canada
Contributor Information and Disclosures

Updated: Jun 13, 2008

Introduction

Pelvic lymph node dissection (PLND) has a role in the treatment of several genitourinary cancers but is most commonly used in bladder cancer and prostate cancer. Others include urethral cancer and penile cancer. PLND has an additional role in the management of gynecologic cancers and other pelvic malignancies. While the anatomic approach is similar, the focus of this article is urological indications.

For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education article Bladder Cancer.

History of the Procedure

After it had been demonstrated that patients with breast and colon cancer with lymph node metastases could be cured surgically, attempts were made to apply lymphadenectomy to cancers of the pelvic organs.

In 1932, Godard and Kaliopoulos reported pelvic lymphadenectomy with total cystectomy for bladder cancer. In 1950, Leadbetter and Cooper also were proponents of pelvic lymphadenectomy with cystectomy for bladder cancer.

Indications

Pelvic lymph node dissection (PLND) for bladder cancer is performed at the time of a radical cystectomy or a partial cystectomy. It provides staging information and can be therapeutic. Several studies, including by Skinner (1982)1 and by Viewed et al (1994),2 have confirmed that patients with pelvic lymph node metastases can be cured with PLND during radical cystectomy. However, the curability seemed to hold for organ-confined cancer (pathologic T stage 2) but not for non–organ-confined cancer (pathologic T stage 3).

The decision to perform PLND for prostate cancer prior to performing radical retropubic prostatectomy is based on the probability of pelvic lymph node metastases. This can be determined using the Partin nomograms. The Partin nomograms are included below:

Table 1. Multivariate Logistic Regression Analysis for Prediction of Pathologic Stage Using Prostate-Specific Antigen, Gleason Score, and Clinical Stage (TNM): Prediction of Organ-Confined Disease (Percent)

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Table
Prostate-Specific Antigen Level (ng/mL)
Score0-4
Clinical Stage		4.1-10
Clinical Stage
T1aT1bT1cT2aT2bT2cT3aT1aT1bT1cT2aT2bT2cT3a
2-41008592887682—1007882836771—
51007881816773—100707173566443
6100686972546042100535962444833
7—5455614146—100394351323726
8-10———4831———323139222512
Prostate-Specific Antigen Level (ng/mL)
Score10.1-20
Clinical Stage		>20
Clinical Stage
T1aT1bT1cT2aT2bT2cT3aT1aT1bT1cT2aT2bT2cT3a
2-4100——6152————33207——
5100495558433726——2432—3—
6—364144283719——2214145
7—242436192414——718453
8-10—11—2914159——33—22
Prostate-Specific Antigen Level (ng/mL)
Score0-4
Clinical Stage		4.1-10
Clinical Stage
T1aT1bT1cT2aT2bT2cT3aT1aT1bT1cT2aT2bT2cT3a
2-41008592887682—1007882836771—
51007881816773—100707173566443
6100686972546042100535962444833
7—5455614146—100394351323726
8-10———4831———323139222512
Prostate-Specific Antigen Level (ng/mL)
Score10.1-20
Clinical Stage		>20
Clinical Stage
T1aT1bT1cT2aT2bT2cT3aT1aT1bT1cT2aT2bT2cT3a
2-4100——6152————33207——
5100495558433726——2432—3—
6—364144283719——2214145
7—242436192414——718453
8-10—11—2914159——33—22

Table 2. Multivariate Logistic Regression Analysis for Prediction of Pathologic Stage Using Prostate-Specific Antigen, Gleason Score, and Clinical Stage (TNM): Prediction of Lymph Nodal Status (Percent)

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Table
Prostate-Specific Antigen Level (ng/mL)
Score0-4
Clinical Stage		4.1-10
Clinical Stage
T1aT1bT1cT2aT2bT2cT3aT1aT1bT1cT2aT2bT2cT3a
2-402<1124—021125—
5041248—04125108
60823917150924111916
7—15271831—01838203428
8-10———1332———30515355350
Prostate-Specific Antigen Level (ng/mL)
Score10.1-20
Clinical Stage		>20
Clinical Stage
T1aT1bT1cT2aT2bT2cT3aT1aT1bT1cT2aT2bT2cT3a
2-40——13————627——
5053261311——93—29—
6—1145132220——89185331
7—2179243935——2411446255
8-10—41—17405954——4135767365
Prostate-Specific Antigen Level (ng/mL)
Score0-4
Clinical Stage		4.1-10
Clinical Stage
T1aT1bT1cT2aT2bT2cT3aT1aT1bT1cT2aT2bT2cT3a
2-402<1124—021125—
5041248—04125108
60823917150924111916
7—15271831—01838203428
8-10———1332———30515355350
Prostate-Specific Antigen Level (ng/mL)
Score10.1-20
Clinical Stage		>20
Clinical Stage
T1aT1bT1cT2aT2bT2cT3aT1aT1bT1cT2aT2bT2cT3a
2-40——13————627——
5053261311——93—29—
6—1145132220——89185331
7—2179243935——2411446255
8-10—41—17405954——4135767365

These and other nomograms are available at www.nomograms.org.

The following is an example of a clinical scenario in which the Partin nomograms are used to determine the percent probability of lymph node involvement: With a stage of T2a, a prostate-specific antigen level of 14 ng/mL, and Gleason sum of 6, the nomogram calculates a 38% probability of organ-confined disease, a 52% probability of capsular penetration, a 5% probability of seminal vesicle involvement, and a 4% probability of lymph node involvement.

Metastatic prostate cancer that involves the pelvic lymph nodes is generally considered to be incurable with surgery. Because these patients cannot be cured with lymph node dissections or other radical surgeries, the purpose of the PLND procedure is to accurately determine which patients would not benefit from more aggressive, definitive therapy. Essentially, the PLND is a staging procedure that can prevent the morbidity of a radical prostatectomy in patients unlikely to benefit from the procedure.

The threshold for performing PLND for prostate cancer is determined by the Partin nomograms, but it varies with the treatment modality used. For an open retropubic prostatectomy, PLND adds minimal morbidity. Therefore, a 3% probability of lymph node involvement is used as a threshold above which one would perform a PLND. For a perineal prostatectomy, PLND requires an extra operation, and a 10% cutoff is used. In patients who undergo external beam radiation therapy and who may benefit from radiation as treatment for microscopic pelvic lymph node–positive disease, a 35% cutoff is used.

Other urologic scenarios in which PLND is performed include selected cases of urethral and penile cancer.

Pelvic lymphadenectomy in the setting of penile cancer is controversial. General agreement indicates that the probability of finding positive pelvic lymph nodes is increased in the presence of positive inguinal lymph nodes. Also known is the fact that survival of patients with positive iliac nodes is limited. Therefore, some would argue against PLND for penile cancer. However, an argument can be made that it is a reasonable therapy for a young patient, given that some evidence shows that indicates pelvic lymphadenectomy may lengthen survival. Adjuvant chemotherapy should also be considered if pelvic lymph nodes are positive.

In regard to primary urethral cancer, lesions of the entire urethra or posterior urethra in females and in the bulbomembranous urethra in males are usually associated with invasion and a high incidence of pelvic nodal metastases. Pelvic lymphadenectomy is performed along with exenterative surgery because, occasionally, patients with nodal metastases can be cured.

Urethral carcinoma in male patients is classified into 3 groups based on the location of the lesion: (1) penile, (2) bulbomembranous, or (3) prostatic. Most cases (59%) occur posteriorly and involve the bulbomembranous urethra. Less frequent sites include the penile (33%) and the prostatic (7%) portions. In women, approximately 50% of carcinomas occur in the distal urethra.

Lymphatic metastases in the inguinal lymph nodes typically result from tumor in the anterior urethra, while pelvic lymphatic metastases are associated with posterior urethral tumors. Like its male counterpart, the female urethra has an anterior portion that comprises the distal one third of the urethra and a posterior portion that comprises the remaining proximal two thirds. The distal third drains into the inguinal nodes, and the proximal two thirds empty into the pelvic lymph nodes.

Relevant Anatomy

There are 8-10 external iliac lymph nodes. These receive efferent lymphatics from the inguinal nodes, the lymphatics of the iliac fossa, and the lower anterior abdominal wall and afferent lymphatics from the pelvic viscera

The internal iliac lymph nodes receive afferents from the pelvic viscera. Their efferents pass to the common iliac nodes.

There are 4-6 common iliac nodes whose efferent lymphatics pass to the lumbar nodes.

The lymphatics of the pelvis follow the arteries, and the group of nodes accompanying each is named accordingly: internal iliac, external iliac, and common iliac.

The details of lymphatic drainage from each organ of the pelvis are outlined in the table below.

Table 3. Pelvic Lymph Node Drainage 

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Table
 Internal Iliac NodesExternal Iliac NodesCommon Iliac Nodes
Prostate

X

X

X

Seminal vesicles

X

  
Membranous urethra

X

X

 
Penile urethra

X

  
Glans penis or clitoris 

X

X

Bladder

X

X

 
Bladder neck 

X

X

Uterus

X

X

X

Vagina 

X

X

Rectum

X

  
Perineum

X

  
Lower abdominal wall 

X

X

Superficial and deep inguinal nodes 

X

X

 Internal Iliac NodesExternal Iliac NodesCommon Iliac Nodes
Prostate

X

X

X

Seminal vesicles

X

  
Membranous urethra

X

X

 
Penile urethra

X

  
Glans penis or clitoris 

X

X

Bladder

X

X

 
Bladder neck 

X

X

Uterus

X

X

X

Vagina 

X

X

Rectum

X

  
Perineum

X

  
Lower abdominal wall 

X

X

Superficial and deep inguinal nodes 

X

X



Contraindications

Metastatic prostate cancer that involves the pelvic lymph nodes is generally considered to be incurable with surgery. Because these patients cannot be cured with lymph node dissections or other radical surgeries, the purpose of the pelvic lymph node dissection (PLND) procedure is to accurately determine which patients would not benefit from more aggressive, definitive therapy.

Pelvic lymphadenectomy in the setting of penile cancer is controversial. General agreement indicates that the probability of finding positive pelvic lymph nodes is increased in the presence of positive inguinal lymph nodes. Also known is the fact that survival of patients with positive iliac nodes is limited. Therefore, some would argue against PLND for penile cancer. However, an argument can be made that it is a reasonable therapy for a young patient, given that some evidence shows that indicates pelvic lymphadenectomy may lengthen survival.

More on Lymph Node Dissection, Pelvic

Overview: Lymph Node Dissection, Pelvic
Workup: Lymph Node Dissection, Pelvic
Treatment: Lymph Node Dissection, Pelvic
Follow-up: Lymph Node Dissection, Pelvic
References
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References

  1. Skinner DG. Management of invasive bladder cancer: a meticulous pelvic node dissection can make a difference. J Urol. Jul 1982;128(1):34-6. [Medline].

  2. Vieweg J, Whitmore WF Jr, Herr HW, Sogani PC, Russo P, Sheinfeld J, et al. The role of pelvic lymphadenectomy and radical cystectomy for lymph node positive bladder cancer. The Memorial Sloan-Kettering Cancer Center experience. Cancer. Jun 15 1994;73(12):3020-8. [Medline].

  3. Paik ML, Scolieri MJ, Brown SL, et al. Limitations of computerized tomography in staging invasive bladder cancer before radical cystectomy. J Urol. Jun 2000;163(6):1693-6. [Medline].

  4. Messing EM, Manola J, Sarosdy M, Wilding G, Crawford ED, Trump D. Immediate hormonal therapy compared with observation after radical prostatectomy and pelvic lymphadenectomy in men with node-positive prostate cancer. N Engl J Med. Dec 9 1999;341(24):1781-8. [Medline].

  5. Pilepich MV, Krall JM, al-Sarraf M, John MJ, Doggett RL, Sause WT, et al. Androgen deprivation with radiation therapy compared with radiation therapy alone for locally advanced prostatic carcinoma: a randomized comparative trial of the Radiation Therapy Oncology Group. Urology. Apr 1995;45(4):616-23. [Medline].

  6. Abeloff MD, Armitage JO, Lichter AS, Niederhuber JE, eds. Urethral Carcinoma. In: Clinical Oncology. 2nd ed. St Louis, Mo: Churchill Livingstone; 2000.

  7. Bolla M, Gonzalez D, Warde P, Dubois JB, Mirimanoff RO, Storme G, et al. Improved survival in patients with locally advanced prostate cancer treated with radiotherapy and goserelin. N Engl J Med. Jul 31 1997;337(5):295-300. [Medline].

  8. Carter H, Partin AW. Diagnosis and Staging of Prostate Cancer. In: Walsh PC, Retik AB, Vaughn ED, Wein AJ, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998:2519-37.

  9. Granfors T, Modig H, Damber JE, Tomic R. Combined orchiectomy and external radiotherapy versus radiotherapy alone for nonmetastatic prostate cancer with or without pelvic lymph node involvement: a prospective randomized study. J Urol. Jun 1998;159(6):2030-4. [Medline].

  10. Hinman F. Pelvic Lymphadenectomy. In: Hinman F, ed. Atlas of Urologic Surgery. 2nd ed. Philadelphia, Pa: WB Saunders; 1998:517-24.

  11. Hinman F. Modified Pelvic Lymph Node Dissection, Laparoscopic and Minilaparotomy Pelvic Lymph Node Dissection. In: Hinman F, ed. Atlas of Urologic Surgery. 2nd ed. Philadelphia, Pa: WB Saunders; 1998:465-75.

  12. Janetschek G. Pelvic lymph node dissection in prostate cancer: editorial review. Curr Opin Urol. Mar 2005;15(2):65-7. [Medline].

  13. Koppie TM, Vickers AJ, Vora K, Dalbagni G, Bochner BH. Standardization of pelvic lymphadenectomy performed at radical cystectomy: can we establish a minimum number of lymph nodes that should be removed?. Cancer. Nov 15 2006;107(10):2368-74. [Medline].

  14. Messing EM, Catalona W. Urothelial Tumors of the Urinary Tract. In: Walsh PC, Retik AB, Vaughn ED, Wein AJ, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998:2327-2410.

  15. Mills RD, Fleischmann A, Studer UE. Radical cystectomy with an extended pelvic lymphadenectomy: rationale and results. Surg Oncol Clin N Am. Jan 2007;16(1):233-45. [Medline].

  16. Partin AW, Kattan MW, Subong EN, Walsh PC, Wojno KJ, Oesterling JE, et al. Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update. JAMA. May 14 1997;277(18):1445-51. [Medline].

  17. Stein JP. The role of lymphadenectomy in patients undergoing radical cystectomy for bladder cancer. Curr Oncol Rep. May 2007;9(3):213-21. [Medline].

  18. Stein JP, Penson DF, Cai J, Miranda G, Skinner EC, Dunn MA, et al. Radical cystectomy with extended lymphadenectomy: evaluating separate package versus en bloc submission for node positive bladder cancer. J Urol. Mar 2007;177(3):876-81; discussion 881-2. [Medline].

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Further Reading

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Keywords

pelvic lymphadenectomy, lymph node dissection, pelvic lymph node dissection, PLND, bladder cancer, prostate cancer, urethral cancer, penile cancer, genitourinary cancer

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Contributor Information and Disclosures

Author

Frank Papanikolaou, MD, Clinical Fellow, The Hospital for Sick Children, Department of Surgery, Division of Urology, University of Toronto, Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Dan Theodorescu, MD, PhD, Paul Mellon Professor of Urologic Oncology, Department of Urology, University of Virginia Health Sciences Center
Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center
J Stuart Wolf, Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Bradley Fields Schwartz, DO, FACS, Associate Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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