Changing use and extent of pelvic lymph node dissection (PLND) during radical prostatectomy after American Urological Association (AUA) guideline revision

Abstract

Pelvic lymph node dissection (PLND) during radical prostatectomy (RP) for prostate cancer provides valuable staging information, but its therapeutic benefit remains uncertain. Our study aimed to characterize PLND use after the revised 2007 American Urological Association (AUA) guidelines for node dissection. Using data from the National Cancer Database (NCDB), we identified men with prostate cancer who underwent RP and stratified based on time of diagnosis in relation to the revised guidelines – 2004–2006 versus 2008–2020. Those diagnosed in 2007 were excluded as a washout period. Patients were stratified by Gleason score into low-risk (⩽ 6), intermediate-risk (7), and high-risk (⩾ 8) groups. Multivariable logistic and Poisson regression models assessed trends in PLND use and number of regional nodes examined before and after guideline revision. A total of 560,769 patients were identified who underwent surgery for prostate cancer. In the entire cohort, node dissection (79% to 88%, p < 0.001) and median number of examined nodes (3 to 5, p < 0.001) increased after 2007. Post-guideline revision, PLND use increased year-over-year in the low-risk (odds ratio [OR] per year = 1.12, p < 0.001), intermediate-risk (OR = 1.16, p < 0.001), and high-risk (OR = 1.09, p < 0.001) groups. Similarly, a number of nodes examined increased year-over-year in the low-risk (incidence rate ratio [IRR] = 1.06), intermediate-risk (IRR = 1.04), and high-risk (IRR = 1.03) groups. Following the 2007 AUA guidelines, there was a significant increase in PLND use and nodal yield across all risk groups, reflecting evolving practice patterns following the guideline revision. However, the median lymph node yields remain below recommended thresholds for optimal staging. These findings highlight the importance of adequate nodal yield in PLND and emphasize the ongoing need for randomized evidence to determine the role of PLND in providing meaningful oncological benefit over surgery without nodal dissection.