Extended Lymph Node Dissection May Not Provide a Therapeutic Benefit in Patients with Intermediate-to High-Risk Prostate Cancer Treated with Robotic-Assisted Radical Prostatectomy

The therapeutic efficacy of extended lymph node dissection (ePLND) for intermediate- and high-risk (IR/HR) prostate cancer remains controversial. This study evaluated whether PLND improved biochemical recurrence (BCR) rates in patients with prostate cancer undergoing robotic-assisted radical prostatectomy (RARP) using a propensity matching method with cases from two facilities. The study included 1002 patients with IR/HR disease who underwent RARP at two facilities with equivalent surgical techniques and hospital size but different ePLND policies for IR/HR between July 2012 and November 2022. We compared perioperative outcomes, complications, and biochemical recurrence-free survival (bRFS) between the centers. After propensity matching, 221 and 124 cases, each at intermediate and high risk, respectively, were compared. Except for age, preoperative clinicopathological variables did not differ significantly between the matched ePLND and non-PLND groups. A median of 18 lymph nodes were assessed in the dissection group. The 3-year bRFS rates did not differ significantly between ePLND and non-PLND among intermediate-risk and high-risk patients. The dissection group had significantly longer operative times and more complications associated with ePLND, including lower extremity edema, pelvic hematoma, and neuropathy. A multivariable Cox regression analysis performed after propensity adjustment identified initial prostate-specific antigens, pathological tumor stage (high-risk only), and positive surgical margins as independent prognostic factors for bRFS while ePLND was not significant. These results suggest that ePLND may not be necessary in intermediate- to high-risk PCa patients undergoing RARP, although further study with a longer follow-up is required.