机器人辅助根治性前列腺切除术时的盆腔淋巴结清扫术：在全州质量改进联盟内评估利用情况和淋巴结转移。
Pelvic lymph node dissection at robot-assisted radical prostatectomy: Assessing utilization and nodal metastases within a statewide quality improvement consortium.
机构信息
Divison of Urology, Spectrum Health Hospital System, Grand Rapids, MI; Central Michigan University College of Medicine, Mt. Pleasant, MI.
Henry Ford Hospital, Vattikuti Institute, Detroit, MI.
出版信息
Urol Oncol. 2020 Apr;38(4):198-203. doi: 10.1016/j.urolonc.2019.09.026. Epub 2019 Nov 15.
PURPOSE
Several guidelines recommend pelvic lymph node dissection (PLND) at robot-assisted radical prostatectomy (RARP) only when lymph node involvement (LN+) is >2%. Individual surgeon use of PLND is not well-known. We sought to examine variability in PLND performance and detection of LN+ across the Michigan Urological Surgery Improvement Collaborative.
METHODS
Data regarding all RARP (3/2012-9/2018) were prospectively collected, including patient and surgeon characteristics. Univariable and multivariable analyses of PLND rate and LN+ rate were performed.
RESULTS
Among 9,751 men undergoing RARP, 79.8% had PLND performed (n = 7,781), of which 5.2% were LN+ (n = 404). In univariate and multivariable analyses, predictors of PLND included higher Prostate-Specific Antigen (PSA), biopsy Gleason grade (bGG), number of positive cores, and maximum core involvement at P < 0.05 for each. Higher PSA, cT stage, bGG, number of positive cores, and maximum core involvement predicted LN+ when PLND was performed (P < 0.05 for each). There was significant surgeon variation in the proportion of PLND performed at RARP, yet neither surgeon-annualized RARP volume nor % of PLND performed was associated with LN+ disease (P > 0.05). Grade was associated with PLND (60.0%, 77.6%, 91.0%, 97.3%, and 98.5%; P < 0.001) and LN+ (0.7%, 2.5%, 5.8%, 8.6%, and 19.9%; P < 0.001) for bGG 1,2,3,4,5, respectively. Maximum core involvement also strongly predicted LN+ with rates of 1.5%, 3.8%, and 9.4% for <35%, 35% to 65%, and >65%, respectively (P < 0.001).
CONCLUSIONS
Nearly 80% of RARP in Michigan Urological Surgery Improvement Collaborative were performed with PLND, including 60% of bGG1 patients (with LN+ in only 0.7%), but significant variability exists between surgeons. Our data indicate limited benefit for favorable-risk CaP patients and support efforts to decrease PLND use going forward.
目的
有几项指南建议，只有在淋巴结受累（LN+）>2%时，才在机器人辅助根治性前列腺切除术（RARP）中进行盆腔淋巴结清扫术（PLND）。但个人外科医生对 PLND 的使用情况尚不清楚。我们试图在密歇根州泌尿外科学术改进协作组中检查 PLND 执行情况和 LN+检测的变异性。
方法
前瞻性收集了所有 RARP（2012 年 3 月至 2018 年 9 月）的数据，包括患者和外科医生的特征。进行了 PLND 率和 LN+率的单变量和多变量分析。
结果
在 9751 例接受 RARP 的男性中，有 79.8%（n=7781）进行了 PLND，其中 5.2%（n=404）为 LN+。在单变量和多变量分析中，前列腺特异性抗原（PSA）较高、活检 Gleason 分级（bGG）较高、阳性核心数较多以及核心最大受累程度较高均为 PLND 的预测因素（每个因素的 P<0.05）。当进行 PLND 时，更高的 PSA、cT 分期、bGG、阳性核心数和核心最大受累程度预测 LN+（每个因素的 P<0.05）。外科医生在 RARP 中进行 PLND 的比例存在显著差异，但外科医生的年度 RARP 量和 PLND 执行比例与 LN+疾病均无关（P>0.05）。bGG 分别为 1、2、3、4、5 时，分级与 PLND（60.0%、77.6%、91.0%、97.3%和 98.5%；P<0.001）和 LN+（0.7%、2.5%、5.8%、8.6%和 19.9%；P<0.001）有关。核心最大受累程度也与 LN+密切相关，<35%、35%-65%和>65%的比率分别为 1.5%、3.8%和 9.4%（P<0.001）。
结论
密歇根州泌尿外科学术改进协作组中近 80%的 RARP 均进行了 PLND，包括 60%的 bGG1 患者（仅 0.7%的患者有 LN+），但外科医生之间存在显著差异。我们的数据表明，PLND 对低危前列腺癌患者的获益有限，支持今后减少 PLND 使用的努力。
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