Complications of Robotic Pelvic Lymph Node Dissection for Prostate Cancer: An Analysis of the National Surgical Quality Improvement Program Targeted Prostatectomy Database

TL;DR

This study finds that removing lymph nodes during prostate cancer surgery increases minor risks like infections and readmissions but not major complications.

Contribution

The study provides real-world data on the incremental risks of robotic pelvic lymph node dissection during prostatectomy.

Findings

PLND was associated with a 3-fold increased risk of lymphocele formation.

Patients with PLND had higher rates of unplanned readmission and surgical site infections.

No significant differences were found in major postoperative complications between groups.

Abstract

Prostate cancer is often treated with surgery to remove the prostate, sometimes along with nearby lymph nodes, to check if the cancer has spread. While removing these lymph nodes helps with cancer staging, it is uncertain whether the procedure improves survival, and it may carry additional risks. Using a large national database, we compared patients who had prostate surgery with and without lymph node removal to understand the added risks. We found that those who had lymph node removal had a small risk of developing fluid collections (lymphoceles), surgical site infections, and requiring hospital readmission, but they did not experience higher rates of serious complications. These findings suggest that while lymph node removal provides staging information, it adds small short-term risks. This information can help doctors and patients make better decisions about when lymph node removal is truly necessary.

Introduction/Background: Treatment of localized prostate cancer includes radical prostatectomy (RP) with or without pelvic lymph node dissection (PLND). While multiple guidelines recommend PLND for staging purposes, recent data has shown questionable therapeutic benefit. Thus, understanding the morbidity associated with PLND is important for counseling patients. We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted prostatectomy database to quantify real-world 30-day postoperative outcomes of patients undergoing contemporary robot-assisted PLND at the time of RP for prostate cancer to quantify the incremental morbidity. Methods: We conducted a retrospective cohort study using the NSQIP database of adult patients undergoing radical prostatectomy from 2019 to 2022. The primary outcomes were procedure-specific outcomes such as lymphocele and rectal injury. Secondary outcomes included a composite of any of the following 30-day major postoperative outcomes: mortality, reoperation, cardiac or neurologic event, as well as the individual components of this outcome, as well as infectious and other complications. We also analyzed yearly trends associated with PLND. Groups were balanced using propensity score matching (PSM) with a 1:1 ratio using demographic characteristics, prior medical history, and cancer staging data. Likelihood of complications was assessed by conditional logistic regression. Results: We identified 13,413 patients between 2019 and 2022 who underwent robotic prostatectomy: 11,341 (85%) had PLND while 2072 (15%) did not. After PSM, our cohort included 2071 matched pairs of patients with and without PLND. Patients who underwent PLND were more likely to be diagnosed with lymphocele (2.14% vs. 0.68%, OR 4.17; 95% CI 2.00, 8.68), have unplanned readmission (4.22% vs. 3.27%, OR 1.31; 95% CI 1.03, 1.65), and develop organ-site/space SSI (1.18% vs. 0.60%) (OR 1.97, 95% CI 1.20, 3.23). There was no significant association between the receipt of PLND and the likelihood of urinary leak or fistula, or ureteral obstruction. There were no significant differences between the two groups with respect to secondary outcomes of interest. Conclusion: Contemporary robotic PLND is associated with a 3-fold increased likelihood of lymphocele, as well as increased likelihood of unplanned readmission and organ-site SSI, though no significant differences in major postoperative complications were identified. We found that the odds of lymphoceles, readmission, and SSI in our study are lower than previously reported. These data provide real-world data to guide patient counseling and optimize patient selection for PLND at the time of RALP.