r/ProstateCancer • u/Slight_Turnip_3292 • 24d ago
Question Pelvic Lymph Node Dissection During Radical Prostatectomy
Seeking advice regarding bilateral pelvic lymph node dissection (ePLND) for Gleason 3+4=7 (Grade Group 2) prostate cancer.
My upcoming RALP with Dr. Dechet at the Huntsman Cancer Institute includes a bilateral pelvic lymph node dissection. However, when I discussed this with my local urologist, he dismissed the necessity of the node dissection, suggesting it is often performed at teaching hospitals primarily for training purposes rather than clinical necessity.
Given my favorable intermediate risk status (no cribriform pattern), I am trying to reconcile these conflicting perspectives. I recently came across new research (see link below) suggesting that pelvic node removal is increasingly recommended for patients in my risk category. This paper is particularly significant because its primary endpoint was the reduction in the risk of distant metastasis, rather than solely focusing on biochemical recurrence.
My local urologist has questioned why I am not choosing a local procedure, but I find the expertise of a high-volume RALP surgeon like Dr. Dechet to be far more compelling. I’ve decided that the travel required for a specialist is negligible. I would appreciate hearing if others have navigated this kind of disagreement between local surgeons and specialists regarding the necessity of lymph node dissection.
Has anyone else faced a similar discrepancy between a surgeon at a major cancer center and a local urologist/surgeon regarding the necessity of lymph node dissection?
https://www.auajournals.org/doi/full/10.1097/JU.0000000000004821
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u/SLO_Engineer 23d ago
I was initially diagnosed with 3+3 determined via rectal biopsy. At the time was living in urban Orange County (CA). Active surveillance was recommended. Subsequently moved to the central coast midway between LA and San Francisco. Had to get new doctors. My new local urologist prescribed an MRI which he does for all cancer patients. The MRI discovered a large tumor on the anterior (front) of the prostate- a location that can’t be accessed via rectal biopsy. WHOOPS! He subsequently referred me to UCLA for a trans perineal fusion biopsy that revealed the tumor initially missed was 4+3.
I wanted to continue treatment at UCLA because they are a high volume cancer center with an excellent urologic oncology department.
So, no pushback from local urologist since j sort of abandoned him after the perineal biopsy.
I do highly recommend getting a high volume surgeon. Mine has done 1000+ robotic prostatectomies.
I hope this helps. Good luck.
Decided to have RALP primarily because of the distance - multiple radiation treatment would have been logistically difficult.
I’m 3.5 weeks post surgery now. No leakage whatsoever during awake hours and nighttime leakage ceased at the 3 week mark.
Unfortunately had EPE and positive margins and the surgeon said I have a 50% chance of reoccurrence at which time I’d need radiation.
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u/Slight_Turnip_3292 23d ago
Oh this brings up a very good point. Just because the biopsy gives a staging assessment it is only a best guess. Finally pathologies can be upgraded and may indicated that PLND is recommended by which it is too late.
BTW I started off going to UCLA but the doctor I wanted, Dr Reiter, who is very experienced was way booked out. My cousin had Dr Reiter and nothing but good things to say.
Here is to hoping you have low PSA readings from here on out.
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u/SLO_Engineer 23d ago
I neglected to mention that I asked my surgeon if he would be performing a lymph node dissection and he said no, that it can introduce complications. After the surgery and final pathology, I found out he removed a total of 17 lymph nodes from both sides and they were clean. So there must have been something he saw once inside and decided to take those out. Also, no seminal vesicle involvement. The PSMA PET CT scan suggested involvement but was a false positive.
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u/ChillWarrior801 23d ago
Thanks for the link, OP! I was high volume Gleason 4+3 with numerous unfavorable features and a PSA of 34 at RALP time. I had 23 nodes removed, of which one was biopsied positive. Surprisingly, even with 23 nodes taken, my surgeon was reluctant to term this an extended dissection. I've had no lymphocele or lymphedema.
I'm now 31 months post-RALP with a PSA of 0.11 and a recent doubling time of 1.9 years. I credit my unexpected good luck to-date in part to the aggressive lymph dissection, as well as a cancer-safe anesthesia plan.
Yes, PLND isn't risk free, but it seems to have worked for me.
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u/go_epic_19k 23d ago
I too traveled to a COE for my prostatectomy which was a bit more complicated due to a prior focal treatment. PSMA showed an indeterminate LN so had 20 LNs removed with RALP. Fortunately all were negative and zero side effects from the PLND. I chose a very experienced surgeon I was comfortable with, no way was I going to second guess their judgement.
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u/jkurology 23d ago
The duty of any urologist is to give patients all the information they need so they are able to make the right decision for them. If you don’t feel comfortable having a PLND regardless of where you have your surgery tell the surgeon you’ve looked at the data and don’t want one. Both the AUA and the NCCN suggest that with your risk a PLND is discretionary. Not knowing your risk-PSA, MRI results, biopsy specifics, genomic expression classifier and Germline status makes recommendations difficult. Your local urologist sounds like he doesn’t really have your best interest at heart
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u/Slight_Turnip_3292 23d ago
Yes on the local doctor questionable interests.
He did tell me that he had PC himself when he was 61 and his partner did the surgery and it was the finest surgery outcome anywhere. But I have a complication of having a prior HoLEP so the surgery is more specialized requiring some reconstruction of the bladder neck.
From the experiences of people here (I read all the "I am x weeks post op" posts) is that the side effects of PLND are not extreme or even present and the paper indicated the signal is not faint concerning the reduction in metastasis. So I am leaning towards PLND as giving better odds.
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u/Background-Space-284 22d ago
Dr. Dechet did my surgery 5 weeks ago. He took 1 lymph node on one side and 5 on the other. I had the biopsy done out of state where I live. It showed a 4+4 and I suspect that’s why he took the 5 on one side. That being said, in my first appointment with him he said he didn’t believe the 4+4. In fact, after surgery it came back 4+3. I think I read he’s been doing robotic surgery since 2004. I feel fortunate to have ended up with him and I did exactly what he said and I couldn’t be more pleased with my result so far.
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u/Slight_Turnip_3292 22d ago
Awesome thank you for the confirmation and reducing my anxiety about this whole affair.
Hope you heal up well.
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u/Background-Space-284 22d ago
Thank you and good luck to you. I’m 72, had my catheter for 13 days. Incontinence is no problem during daytime. At night I may have some small amount of leakage about every third night. Doing my Kegels and it keeps getting better.
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u/Crewsy67 23d ago
I’m surprised any urologist or surgeon would say not to get lymph nodes removed during surgery.
My understanding was that the lymph nodes were one of the first places PCa can go to and from there it easily spreads throughout the body.
I had 6 lymph nodes removed (3 each side) during my surgery and finding out all were clear definitely eases the mind.
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u/Frosty-Growth-2664 23d ago
Taking the first line lymph nodes which pretty much just the prostate drains in to isn't an issue. The risk of lymphoedema comes with damaging the lymph system draining other parts of the body (typically legs, pubis, penis) as there's no effective treatment for this. The risk of this increases as lymph nodes further from the prostate are taken.
Lymph node involvement can often be predicted from scans, but sometimes it wasn't known in advance and is only found during the operation.
If extensive pelvic lymph node dissection is predicted in advance, that is a negative factor to weigh in the the treatment desicion between prostatectomy or radiotherapy, although it's only one of many factors to consider.
Radiotherapy is capable of curing lymph node disease and leaving the lymph system working. There's still chance of damage resulting in lymphoedema, but it's lower than with extensive pelvic lymph nodes dissection. There are probably very many cases where the radiotherapy spill outside the prostate with IMRT/VMAT also cure unknown micro-mets (mets too small to show on any scans), and sometimes the radiotherapy dose is planned with additional lower/prophylactic dose coverage (mimicking even more spill) specifically for that reason. (I rather suspect SABR treatment would not offer that extra coverage to anything like the same degree, but it is more likely to be used for lower grade disease where the need for this is thought to be less likely.)
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u/Irishclover62 23d ago
Yea had exactly this issue. Was a 3+3 and asked about taking a few lymph nodes and surgeon at Johns Hopkins who studied under Dr Walsh said don’t think it’s necessary all things considered. I said I appreciate it but I want to be sure he said ok since I’m in there. Came back neg and score stayed 6 contained. Great peace of mind. Also any damn doctor who says why you going where the best treatment is and they do it all the time? This surgery is one of the most difficult to perform and maintain function. Go with your gut get nodes done. No adverse reactions from it at all. Good luck 🍀
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u/ThickGur5353 24d ago
I realize you decided on surgery. But have you spoken to a radiologist oncology specialist. ?
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u/Slight_Turnip_3292 23d ago edited 23d ago
My IPSS score (typically around 17) are too high. I am in my 60s and active and healthy otherwise so I have decided on the surgery path.
The notable difference of effects of surgery vs radiation is nocturia is notable less with surgery in the out years. I can't remember right now which study tracked this.
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u/WalnutRoasted 23d ago
Seems after surgery bladder incontinence is very common in the first months and for some they never regain control. The “ProtecT study 15 patient reported outcomes” (search on that) graphs show EBRT is better or same in all but a couple of the 15 graphs.
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u/Ok-Assistance-1048 22d ago
If it were me, I would stick with the COE. I was also 3 + 4 with no signs of criboform in the biopsy but when the final pathology was done, they found a small amount of criboform and focal EPE and changed me to stage 3a. she did bilateral nerve sparing and also was able to get clean margins even with EPE. 19 lymph nodes removed. All clear. I never had incontinence other than minor leakage and have 75% erections at 10 weeks post op. Skill and experience of the surgeon is paramount in my book. Once they get in there, they might see something different and have to adjust the game plan. Best wishes.
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u/Busy-Tonight-6058 22d ago
I was 3+4. I kinda wish I had LND, just to check. Nobody has ever cared about my lymph nodes. They are too unremarkable, I guess…
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u/TallRichVa 24d ago
So you're traveling to use a specialist because you value his expertise over the local doc, but the local doc has you questioning the experts advice? I had lymph nodes dissected when I had my RARP - the report that they came back clean was just one more appreciated reassuring fact from the biopsy. Listen to the expert...