The rationale for locoregional staging lymphadenectomy in prostate and bladder cancer lies in the accurate diagnosis of occult micrometastases in order to stratify patients who might benefit from adjuvant therapeutic measures.

In prostate cancer, pelvic lymph node dissection (PLND) is considered the most reliable procedure for the detection of lymph node metastases in prostate cancer. However, the role of PLND in prostate cancer management is currently under debate. Despite recent advances in imaging techniques, PLND remains the most accurate staging procedure for the detection of lymph node invasion (LNI) in prostate cancer. Moreover, the rate of LNI virtually linearly increase with the extent of PLND.

It has been shown that extended pelvic lymphadenectomy including the lymphatic tissue along the common iliac region with the ureteral crossing as cranial margin, external and internal iliac region and the obturator fossa has been shown to significantly increase the yield of both total lymph nodes and lymph node metastases. The frequency of observed positive lymph nodes in clinically localized and locally advanced prostate cancer is significantly higher than predicted by nomograms such as Partin tables and CART analysis. However, not all patients with prostate cancer are at the same risk of harbouring nodal metastases. In order to identify those patients candidates to PLND, several nomograms and tables have been developed and validated. All these tools indicated that a staging PLND might be omitted in low risk prostate cancer patients due to the low rate of lymph node metastases found both in limited and extended dissections (<10%). 

Although there are no prospective randomized trials demonstrating a survival benefit associated with EPLA, there might be an advantage for those with minimal lymph node involvement. Various studies have documented an equal risk of cancer associated mortality in patients with no or only 1-2 positive lymph nodes. Since the surgery associated morbidity of EPLA is not increased as compared to standard lymphadenectomy, EPLA should be favoured for all patients undergoing radical prostatectomy. For the future, ongoing prospective trials such as the initiated SEAL trial have to demonstrate a benefit in terms of biochemical free and cancer specific survival.