Surgery for Men with High Risk Prostate Cancer – Extended lymph node dissection

Birmingham Prostate Clinic has extensive experience in the treatment of men with high risk prostate cancer, undertaking a procedure called extended pelvic lymph node dissection performed at the same time as a Radical Prostatectomy.

Understanding high risk prostate cancer and micrometastases

A number of men with ‘high risk’ clinically organ confined prostate cancer will have a PSA level of 10 or above. This means the patient may have what is known medically as micrometastases.

Micrometastases occur in places where cancer has spread (metastasized). They are often too small to see, even in a scan. In prostate cancer, one of the first places where cancer spreads is the lymph nodes, which lie parallel to large blood vessels in the pelvis. A lymph node is a small, ball-shaped organ which is part of the immune system and found throughout the body.

Evidence has shown that in the field of prostate cancer, if the PSA is high, especially if 20 or above, there is a strong possibility of micrometastases in the pelvic lymph nodes. This group is said to have high risk prostate cancer.

What treatment is available to patients with high risk prostate cancer?

This is an area where there is still the need for extensive research and discussion. One treatment option is to combine hormone therapy with radiotherapy. Some surgeons are reluctant to operate on high prostate cancer risk patients because to do so is technically very challenging and a careful judgment needs to be made about whether surgery can be effective, or whether the cancer is likely to have spread too far to be surgically removed.

However there is a procedure called extended pelvic lymph node dissection (sometimes referred to as lymphadenectomy) which provides a surgical option for men with high risk prostate cancer. Pelvic lymph node dissection simply means the surgical removal of the lymph nodes.

What is extended pelvic lymph node dissection?

This is a procedure which is carried out during a prostatectomy – the surgical removal of the prostate. During the operation, the surgeon seeks to remove as many of the lymph nodes as possible. The lymph nodes are carefully dissected of the major pelvic vessels and they are sent to the laboratory for analysis. A suctioning device can also be used to complete a comprehensive removal of tissue. An extended pelvic lymph node dissection is easier to perform as open surgery, rather than laparoscopic surgery. Evidence suggests that the larger the number of lymph nodes removed (ideally at least 20) the more effective the procedure.

What are the advantages and disadvantages of extended pelvic lymph node dissection?

If a patient has a prostatectomy with extended pelvic lymph node dissection, it is still possible for him to undergo radiotherapy and hormone therapy as second stage treatment. The reverse is not always the case; surgery cannot follow radiotherapy without a much higher risk of side effects. Many men find surgery a more active option in that it can take place quickly after diagnosis and provide accurate information regarding the likelihood of success (histology, margins, post-op PSA). In addition, surgical patients do not inevitably have hormone treatment which when combined with radiotherapy is usually given over a period of three years.

However, like hormone treatment, non nerve sparing radical prostatectomy with extended pelvic lymph node dissection will have a major impact upon erectile function. Erectile nerves are located in the same area as the pelvic lymph nodes and will be damaged during the process of removing lymph nodes.

“Extended lymph node dissection is a very important option for men with a very high PSA and wish to have a curative, surgical treatment option. Not all surgeons are prepared to undertake this procedure and it is very important that extended lymph node dissection is only carried out by surgeons with a large experience of prostatectomy.”
Mr Alan Doherty, Consultant Urologist, Birmingham Prostate Clinic