Patterns of Pelvic Lymph Node Dissection at the Time of Radical Prostatectomy for Low-risk Men

OBJECTIVE To examine nationwide patterns of lymph node dissection (LND) in men with D'Amico lowrisk prostate cancer, including the rate of detected lymph node metastasis and factors associated with the decision to perform LND. Existing guidelines recommend against LND at the time of radical prostatectomy (RP) in low-risk men, yet this is still a common practice. MATERIALS AND METHODS The 2013 National Cancer Database includes 1,208,180 cases of prostate cancer diagnosed between 2004 and 2013. Of these, 50,245 met D'Amico low-risk criteria, had complete clinicopathologic data, and underwent RP. Mixed effects multivariable logistic regression models were used to identify hospital and treatment characteristics independently associated with LND, extended LND, and the detection of lymph node metastasis. RESULTS A total of 20,556 men (40.9%) underwent LND and 4360 (8.7%) had extended LND. Lymph node metastasis was present in 76 cases (0.37%). On multivariable analysis, robotic vs open RP had odds ratio (OR) = 0.16 (0.14-0.17), P <.0001, for LND, and surgery at an academic center had OR = 1.76 (1.33-2.33), P <.0001, for LND. Men on Medicaid were less likely than the privately insured to undergo LND, and the highest earners were most likely to undergo LND. In multivariable analysis, race was significantly associated with lymph node metastasis, with black men having the highest rates (P <.0001). CONCLUSION LND is performed in nearly half of low-risk men, more commonly during open surgery at academic centers, yet metastasis is discovered less than 1% of the time. Guidelines suggest that percentage core involvement should be considered, but if the overall risk of metastasis is low, LND should not be performed. (C) 2017 Elsevier Inc.