eMedicine Specialties > Urology > Surgery

Lymph Node Dissection, Pelvic

Frank Papanikolaou, MD, Clinical Fellow, The Hospital for Sick Children, Department of Surgery, Division of Urology, University of Toronto, Canada

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)

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)

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 

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.

Workup

Imaging Studies

• Prediction of lymph node status can help in preoperative staging. CT scanning is used most commonly for this purpose.  
  • This imaging modality has been evaluated in numerous studies looking at pelvic lymph node metastases in bladder cancer.³
  • Studies by several groups have found sensitivities of detecting pelvic lymph node metastases ranging from 10-94%, for a cumulative sensitivity of only 48%. However, when detected, nodal enlargement is specific, with a range of 83-100%, for a cumulative specificity of 94%.
  • Approximately 40% of cases are understaged, and approximately 5% are overstaged.

Treatment

Preoperative Details

Staging with pelvic CT scanning for bladder cancer can provide information about the bladder tumor and the presence of pelvic or paraaortic lymphadenopathy. However, the presence of lymphadenopathy does not necessarily indicate metastatic disease. Moreover, CT scanning can fail to reveal nodal metastases in up to 40% of cases.

The staging information that is useful for pelvic lymph node dissection (PLND) in prostate cancer includes T stage, prostate-specific antigen level, and Gleason score. Currently, imaging studies have no role in the evaluation of the pelvic lymph nodes.

Intraoperative Details

Bladder cancer

The limits of PLND in bladder cancer are as follows: The cephalad limit is 2 cm above the bifurcation of the common iliac artery, the caudad limit is the endopelvic fascia, the medial limit is the bladder, and the lateral limit is the genitofemoral nerve.

A PLND for bladder cancer is usually performed in conjunction with a radical cystectomy. A modified dissection, leaving the nodes along the external iliac artery intact, may be appropriate in low-risk patients because skeletonization of the external iliac artery is associated with an increased risk of lymphedema.

The procedure is as follows:

1. Position the patient supine in the dorsal lithotomy position.
2. Make a midline lower-abdominal incision. For a PLND in conjunction with a radical cystectomy, the incision should extend from the pubic symphysis to above the umbilicus. Incise the fascia and peritoneum at the level of the umbilicus.
3. Explore the abdominal and pelvic viscera and paraaortic nodes for evidence of metastatic spread.
4. Dissect the peritoneum off the posterior rectus sheath.
5. Develop a flap of peritoneum in the shape of a V, with its apex at the umbilicus and its ends directed toward the internal inguinal rings. Grasp the apex and pull it caudad.
6. Incise the peritoneum and investing tissue covering the external iliac vessels to the bifurcation of the common iliac artery. Isolate the ureters as they pass in front of the common iliac arteries.
7. Dissect free the psoas and iliopsoas muscles.
8. Skeletonize the external iliac artery from the inguinal ligament to 2 cm above the bifurcation of the common iliac artery. Identify and preserve the circumflex iliac, inferior epigastric vessels, and the genitofemoral nerve.
9. Divide the nodal package anteromedially over the external iliac artery. Roll the tissue posteriorly off the artery, and then dissect it off the external iliac vein.
10. Dissect the fat overlying the fascia of the psoas and iliopsoas muscles. Identify the obturator fossa by retracting the bladder medially, and ligate and divide the obturator vessels. Carry the dissection of fat and nodes medially and superiorly along the obturator vessels. At the junction of the obturator vessels with the internal iliac vessels, ligate and divide the obturator vessels, if necessary.
11. Remove the pelvic lymph node packet, and send it for histologic evaluation.
12. Repeat the procedure on the opposite side.

Prostate cancer

PLND in prostate cancer can be performed as either an open or a laparoscopic procedure. In addition, the open procedure can be performed as part of a radical prostatectomy or as a minilaparotomy. The minilaparotomy and laparoscopic approaches can be used when a perineal approach is being considered.

The discussion that follows applies to both the open and laparoscopic approach, with procedural information specific to each and then information common to both. However, the technical aspects of laparoscopy are not addressed in this article.

The limits of node dissection for PLND in prostate cancer are as follows: The cephalad limit is the bifurcation of the common iliac artery, the caudad limit is the node of Cloquet, the medial limit is the obturator vessels, and the lateral limit is the pelvic sidewall.

The procedure specifically for open PLND is as follows:

1. Proceed to make a midline lower-abdominal incision. For a PLND in a patient with prostate cancer, the incision should extend from the pubic symphysis to just below the umbilicus. Incise the anterior rectus fascia at the decussation of the fibers along the length of the skin incision.
2. Incise the transversalis fascia beneath the rectus muscle. This allows mobilization of the peritoneum medially and cephalad.
3. Isolate, divide, and ligate the vas deferens.
4. Gain exposure with a Bookwalter retractor. To retract the bladder, place a malleable retractor blade on one side of the nodes and a straight blade on the opposite side. Place a Jackson retractor on top of the external iliac vein.

The procedure specifically for laparoscopic PLND is to create a pneumoperitoneum and obtain laparoscopic access using 3 operating ports. Incise the peritoneum midway between the internal ring and the obliterated umbilical artery to expose the external iliac vein.

The procedure common to both the open and laparoscopic techniques is as follows:

1. Skeletonize the external iliac vein. Clean down to the pelvic sidewall alongside the external iliac vein, and insert a vein retractor.
2. Push the fatty tissue along the Cooper ligament, laterally towards the distal margin of the nodal packet. Tease the node of Cloquet from the femoral canal. Clip and divide.
3. Identify and preserve the obturator nerve and vessels.
4. Remove the pelvic lymph node packet, and send it for histologic evaluation.
5. Repeat the procedure on the opposite side.

Complications

Complications of pelvic lymph node dissection (PLND) that are common to both bladder and prostate cancer include the following:

• During dissection of the lymph nodes, acute bleeding may result from injury to the iliac vessels. Treatment entails repair of the vascular injury using an open surgical technique.
• Postoperative development of a deep vein thrombosis, with the possibility of a resultant pulmonary embolism, remains a significant problem with PLND. Postoperative prophylaxis with subcutaneous heparin can decrease this risk.
• Obturator nerve injury with resultant loss of adduction of the thigh is rare.
• Development of a symptomatic lymphocele is also rare. Treatment includes conservative management, percutaneous drainage, or marsupialization.
• Lymphedema of the extremities can result in significant morbidity. Sparing of the lymphatics lateral to the iliac vessels can decrease the rate of this complication.

Outcome and Prognosis

Patients with bladder cancer only occasionally benefit from pelvic lymph node dissection (PLND). Approximately 20% of patients present with lymph node metastases at the time of cystectomy. This percentage is higher in selected populations considered to be high grade and stage. Approximately 50% of these patients have limited regional metastases (1 or 2 nodes below the iliac bifurcations) and are theoretically amenable to cure. Of the latter patients, 10-35% are cured with cystectomy and PLND alone.

The management of prostate cancer accompanied with lymph node metastases after permanent histologic evaluation is controversial. The debate is centered on whether to institute hormonal therapy immediately or upon prostate-specific antigen progression.⁴ Four prospective randomized trials have supported a survival benefit of early androgen ablation in locally advanced disease.⁵ The Messing et al (1999) study demonstrated a 25% overall survival benefit at 8 years in men with node-positive prostate cancer treated with radical prostatectomy and orchidectomy/goserelin compared to radical prostatectomy alone. However, given that the prostate-specific antigen level is a good index of disease progression, an argument also can be made to delay treatment until the prostate-specific antigen level rises.

Future and Controversies

Ablative therapies for prostate cancer (eg, cryotherapy) and investigative treatments (eg, high-intensity focused ultrasound [HIFU]) are increasing in popularity. As such, many patients who undergo these treatment modalities do not undergo lymph node dissection for staging. Laparoscopic lymph node dissections and nodal sampling through minilaparotomy are options for these patients, especially those at high risk of node-positive disease, such as patients with a prostate-specific antigen level of more than 20 ng/mL, a Gleason grade of 8-10, or high-risk biopsy data.   

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. 2^nd 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. 7^th 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. 2^nd 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. 2^nd 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. 7^th 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].

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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

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.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Laurence Klotz, MD, to the development and writing of this article.

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