EURURO Vol. 71 No. 4

569 692

with positive nodes (9%) compared with patients with
negative nodes (27%). Similar to the current study, they
concluded that LND performed during cytoreductive
nephrectomy is not associated with a survival benefit.
However, they found that patients with positive nodes have
a worse prognosis and the staging information gained by
LND may be useful in planning clinical trials.
Current guidelines recommend LND during radical
nephrectomy if there is lymph node enlargement . Re-
moving lymph nodes in cancers like bladder and penile is
based on the theory of stepwise progression where the
disease goes from primary organ to nodes and then
metastasizes. This may not apply to RCC where hematoge-
nous spread is common and lymphatic involvement almost
never precedes metastatic disease . If that is the case, the
disease may have progressed too far by the time there is
lymph node enlargement and removing nodes based on size
may have little impact on the course of the disease.
The authors state, based on two referenced studies, that
LND during radical nephrectomy does not increase morbid-
ity, although there is no complication data presented in the
current study. While this might be true with a limited
retroperitoneal LND, an extended LND may be associated
with complications. In patients undergoing both limited
and extended pelvic lymph node dissection for clinically
localized prostate cancer, Clark found complications oc-
curred three times more often with the extended technique
. Lymphadenectomy for RCC requires dissection around
the great vessels with the risk of major vascular injury.
Others have reported a higher rate of chylous ascites in
patients undergoing LND with laparoscopic nephrectomy
compared with patients undergoing nephrectomy alone
. Given the lack of oncologic benefit demonstrated in the
current study and EORTC 30881, the decision to perform
LND during nephrectomy must be weighed against the risk
of potential complications.
The end result of this analysis is that the question it
set out to answer, namely, does LND during radical
nephrectomy impact cancer control, remains unanswered.
What the study does remind us is that there remains a need
for a well-designed randomized study in patients with
high-risk RCC where lymph node removal may impact the
disease course. Ideally, this future study would account for
the stage migration of contemporary patients, standardize
the indications for LND during nephrectomy and employ
agreed upon boundaries for lymph node removal. Even
with a well-designed randomized trial, the answer may
remain that there is no oncological benefit for LND during
radical nephrectomy and RCC will remain an unpredictable
cancer.
Conflicts of interest: Intuitive surgical: Proctor, instructor.
References
[1]
.
[2]
.
[3]
.
[4]
.
[5] National Comprehensive Cancer Network Clinical Practice Guide-
lines in Oncology. Kidney Cancer, Version 1.2017. September 26,
2016.
[6]
[7]
[8]
.
E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 5 6 8 – 5 6 9 569