Original Study

A Better Understanding of Lymphatic Drainage

of the Prostate With Modern Imaging and
Surgical Techniques
Gregory P. Swanson,1 John K. Hubbard2
Abstract
Because they are commonly involved and easily sampled, lymph nodes along the obturator artery are often
considered to be representative of the lymph node status of patients with prostate cancer. We performed a
comprehensive review of the historical anatomic descriptions in conjunction with modern imaging and surgical
information, and this characterization appears an oversimplification and may actually be misleading.
Purpose: In prostate cancer, the spread of cancer to the lymph nodes is often determined by sampling lymph nodes
from the obturator region. Historical findings from this area are often used as the basis for calculating the risk of lymph
node metastasis in patients with prostate cancer. Therefore, it is of utmost importance to determine whether this
sampling is a realistic representation of actual risk of lymphatic spread. This is important for risk assessment as well as
for targeting lymphatics in treatment. Materials and Methods: We attempted to reconcile historical anatomic de-
scriptions with contemporary imaging and surgical experience to try to obtain an accurate description of the lymphatic
drainage of the prostate. Results and Conclusions: Although obturator lymph nodes are clearly one of the possible
sites of spread of prostate cancer, their sampling was never intended to be a definitive description of the routes of
lymphatic cancer or the absolute incidence of lymph node metastasis. There are multiple other lymphatic areas at risk,
with drainage primarily from the periprostatic area to the deep branches of the internal iliac lymphatics. The subse-
quent spread is to the perirectal and lower sacral vessel lymphatics, the proximal external iliac, the obturator, the upper
sacral, common iliacs, and, ultimately, the para-aortic lymphatics. Describing the risk of lymphatic spread of prostate
cancer based on obturator lymph node dissection alone is not totally accurate and probably underestimates the actual
risk by 50% or more. A better understanding of the routes of drainage should make therapy that targets the lymphatics
more effective.

Clinical Genitourinary Cancer, Vol. 11, No. 4, 431-40 ª 2013 Elsevier Inc. All rights reserved.
Keywords: Anatomy, Lymph nodes, Sentinel lymph nodes, Prostate cancer

Introduction are several sources that provide some information on lymphatic

An accurate understanding of the routes of lymphatic drainage is drainage from this gland. Classically, this comes from anatomy
important in the staging and treatment of cancer. From a surgical dissection, but additional information can be gained from imaging
oncology standpoint, there appears to be a lack of comprehensive (contrast and radioisotope based) and surgical experience. Our goal
information on the lymphatic drainage of the prostate. There is to try to definitively define the lymphatic drainage of the prostate
from all of these available sources.
1
Department of Radiation Oncology, Texas A&M College of Medicine, Scott and
White Healthcare, Temple, TX Classic Anatomy
2
Department of Neuroscience and Experimental Therapeutics, Texas A&M College The classic anatomy texts form our basic understanding of the
of Medicine, Texas A&M Health Science Center College of Medicine/Scott and White
Hospital, Temple, TX routes of lymphatic drainage. Anatomists from the 19th and early
20th centuries supplanted previously published historical observa-
Submitted: Dec 19, 2012; Revised: Apr 23, 2013; Accepted: Apr 24, 2013; Epub: Jun
29, 2013 tion with their own observations. Sobotta1 described the lymphatic
system as being predominantly a network of interconnected capil-
Address for correspondence: Gregory P. Swanson MD, Department of Radiation
Oncology, Texas A&M College of Medicine, Scott and White Healthcare, laries that form lymphatic plexuses composed of stems and trunks
2401 South 31st Street, Temple, TX 76508 with interposition of nodes at the root of the main stems and
Fax: 254-724-0078; e-mail contact: [email protected]
trunks. Because it was generally accepted that the larger lymphatic

1558-7673/$ - see frontmatter ª 2013 Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.clgc.2013.04.031 Clinical Genitourinary Cancer December 2013 - 431
 Lymphatic Drainage of the Prostate
vessels accompany blood vessels, he did not describe the lymphatic These patterns of blood supply and the accompanying lymphatic
drainage in detail. He, however, gave a detailed accounting of the vessels have repeatedly been replicated by modern anatomists. In
arterial and venous prostate vascular supply. In the pelvis, Sobotta1 addition, the physician and medical illustrator Frank Netter shows
described viscera such as the prostate draining to the internal iliac the urethral branch coming from the penile artery, which is a deep
lymphatics, presumably along the visceral branches of the arteries. branch of the internal pudendal artery.4 He also delineates the
With that, there are several named arteries that go to the prostate.1 inferior vesicle artery as having a prostate branch with sub-branches
These include the inferior vesical artery, which supplies the base of to the urethra and prostatic capsule with perforators to the prostate
the bladder along with the prostate and seminal vesicles. The middle itself (Figure 3).
hemorrhoidal (rectal) artery not only supplies the rectum and le- In summation from the above anatomic descriptions, the arteries
vator ani but also sends branches to the prostate and seminal vesi- that supply the prostate gland are primarily branches of the internal
cles. Importantly, the middle hemorrhoidal vessels anastomose at iliac, including the inferior vesical artery, the middle hemorrhoidal
the rectum with the inferior hemorrhoidal, the inferior vesical and artery, the internal pudendal artery, and the prostatovesical artery
the superior hemorrhoidal artery (which is a branch of the inferior (which has variable branches). Additional anastomotic connections
mesenteric), which would put them in the continuum with the arise from the superior and the inferior hemorrhoidals and the
accompanying lymphatics. This would suggest a significant posterior penile artery (due to a urethral branch). The Netter illustration
venous and lymphatic drainage pattern from the prostate. In addi- (Figure 3) dramatically depicts the posterior sweep of blood vessels.
tion, the distal branch of the internal iliac (the internal pudendal) We should be reminded that these descriptions are of the larger
also anastomoses with the middle hemorrhoidal artery (Figure 1). blood vessels. With modern vascular mapping5 (Figure 4), it is clear
Similarly, in his classic text on human anatomy, Gray2 stated that that the blood supply is actually very extensive and complicated.
“the arteries supplying the prostate are derived from the internal The lymphatic drainage is likely as complicated.
pudendal, inferior vesical, and middle hemorrhoid arteries.” He There have been some focused attempts to describe the actual
further stated that “its veins form a plexus around the sides and base lymphatic drainage from the prostate gland. In his directed review of
of the gland; they receive in front the dorsal vein of the penis, and lymphatic drainage, which is generally quoted as the definitive
end in the hypogastric veins.”2 He also made specific statements evaluation, Rouvière6 published The Anatomy of the Human
about the lymphatic drainage and described a plexus around the Lymphatic System. In addition to his own investigations, he cited the
prostate, with drainage posterior toward the rectum, along the work of researchers from the preceding centuries. For the prostate
coccyx into the presacral hollow, and superiorly to the external and gland, these works range from years 1787 to 1924. Unfortunately,
internal iliac vessels (Figure 2). He identified recognizable lymph there has been a paucity of work on the subject since that time.
nodes from the prostate along the external iliac, the middle Although the basic techniques of dissection and identification of
hemorrhoidal (perirectal), the internal iliac vessels and their branches lymphatics has changed little, it is difficult to believe that the
to the prostate, and to the lateral sacrum and sacral vessels (Figure 2). accumulation of knowledge due to the effort of those previous re-
In a more contemporary analysis that presents additional detail searchers combined with better preservation of cadavers and modern
on the vascular supply of the prostate, Clegg3 performed postmor- technology would not lead to better insight of this drainage system.
tem injections of the internal and external iliac arteries with As it is, these ancient works remain the primary basis of our
Micropaque (Villepinte, France). He found that the prostatovesical understanding.
(inferior vesical) artery arises from the distal internal iliac, usually at The following is paraphrased from Rouvière’s text.6 Regarding
or below the obturator about where the umbilical artery originates. the prostate, “it is permeated by draining lymphatics that subse-
Occasionally it arises below the takeoff of the gluteal branches (the quently collect into a subcapsular lymphatic network. This network
inferior gluteal and internal pudendal arteries). The prostatovesical gives rise to the collecting vessels, which wholly or in part follow the
artery splits into 2 branches: the inferior vesicle and prostatic arteries numerous arteries that supply blood to the prostate. Because most of
(as with all branches of the internal iliac system, this is variable, eg, those arteries enter the prostate posteriorly and superiorly (base),
there can be no, or several, inferior vesicular arteries). The prostatic which is the location of the majority of the collecting lymphatics,
artery goes to the anterior lateral portion of the prostate and then but that does not mean there are none from the lateral and anterior
down the lateral aspect of the gland, with perforating branches to part of the gland. The drainage of the superior (base) prostate in-
the prostate; it then terminates in small vessels to the pelvic floor cludes the upper posterior surface of the prostate. These lymphatics
and can even have branches that extend to the rectum and the anal track up along the medial border of the seminal vesicles, move
canal. Another branch of the prostate artery goes to the posterior medially, and then above the insertion of the ureters before passing
aspect of the seminal vesicle. An additional possible branch of laterally over the umbilical artery before terminating in the middle
prostatovesical artery is the vesico deferential artery, which usually prevenous nodes” (the exact anatomic location is not stipulated).
has 3 branches. Noteworthy is that the superior rectal artery (the Rouvière6 notes that some researchers cite that there are up to 6 or 8
terminal branch of the inferior mesenteric artery) can also send separate lymphatics that originate in front or behind the seminal
branches to provide vascular supply the gland. These branches come vesicles, which converge and pass above the ureter and the umbilical
off the superior rectal in mid rectum, passing laterally to the upper artery with termination in the external iliac nodes. Again para-
lateral angle of the gland, communicating with other vessels in the phrasing, “the lymphatic drainage of the inferior portion of the
region. Although there is some debate about whether the prostatic prostate passes along the posterior surface of the gland to the base.
artery even exists, there is little debate about the middle rectal and They then follow the prostatic branches of the middle hemorrhoidal
inferior vesical arteries that supply blood to the gland. artery to the hypogastric nodes. For the posterior prostate, 2 or 3

432 - Clinical Genitourinary Cancer December 2013

 Gregory P. Swanson, John K. Hubbard
Figure 1 Lateral Pelvis With Vascular Supply to the Prostate Primarily From the Inferior Vesical (With Branches) and Middle
Hemorrhoidal Vessels

Reprinted From Ref. 1 (Figure 569).

draining lymphatics course along the rectovesical fascia before there are a large number of lymph nodes along the lymphatic vessels
eventually terminating in the parasacral nodes at the level of S2 and that lie between the rectum and the prostate. The lymphatics of the
in nodes that reside at the sacral promontory. Noteworthy is that prostate communicate with those of the rectum which then pass on

Clinical Genitourinary Cancer December 2013 - 433

 Lymphatic Drainage of the Prostate
Figure 2 Vessels of the Prostate Terminate Chiefly in the Hypogastric and Sacral Glands, but One Trunk From the Posterior
Surface Ends in the External Iliac Glands and Another From the Anterior Surface Joins the Vessels That Drain the
Membranous Part of the Urethra

Reprinted From Ref. 2 (Figure 619). Digital art Used With Permission From bartleby.com.

both the anterior and posterior surfaces of the rectum and involve information, an attempt was made to directly visualize the
the pararectal lymph nodes.”6 lymphatic drainage of the prostate. By using a vital blue dye, Smith7
“Lymphatics from the anterior portion of the prostate descend first experimented in dogs and then was able to glean information
downward to the floor of the perineum at the prostate apex and on a small number of patients who had surgery. After injecting the
then follows the internal pudendal artery all the way to where it prostate, he was able to observe that the primary lymphatic drainage
originates from the internal iliac. There are additional lymphatic was to the obturator-hypogastric and presacral lymph nodes.7
vessels and nodes from the anterior and lateral prostate that drain to
the paravesicular lymph nodes, which then drain with the bladder Imaging (Contrast)
lymphatics.”6 In all cases in which the lymphatic channels pass, More contemporarily, attempts have been made at actually
there are undoubtedly small lymphatic branches. mapping the prostate lymphatic drainage. In a classic evaluation,8
Although we can describe some of the more major trunks, these prostate glands in humans were injected with contrast (Ethiodol,
small lymphatics would be innumerous. To try to gain more specific Villepinte, France) to study the lymphatic drainage (Figure 5).

434 - Clinical Genitourinary Cancer December 2013

 Gregory P. Swanson, John K. Hubbard
Figure 3 The Urethral Branch Coming From the Penile Artery

Reprinted From Ref. 4. ª2012 With Permission From Netter.com.

Clinical Genitourinary Cancer December 2013 - 435

 Lymphatic Drainage of the Prostate
contrast density, and the resolution of the imaging modality.
Figure 4 Reconstruction of the Blood Vessels of the Pelvis
Therefore, small lymphatic vessels may not be well visualized
through this technique. As can be seen, there is significant peri-
prostatic spread, and the researchers describe this spread as the 2 or
3 primary routes of lymphatic flow. The major route originates from
the superolateral angle of the prostate to the lateral pelvic wall,
following the inferior vesical and middle hemorrhoidal vessels. A
second route (vasculature not speculated) goes directly to the pre-
sacral lymph nodes at approximately S2 and the third (although less
frequently seen) route is from the prostate apex, following the in-
ternal pudendal vessels. These studies have been replicated by later
investigators with remarkably similar findings but with more
detail.9,10 In those studies, after contrast was injected bilaterally into
the prostate, it was also noted that there appeared to be 3 routes of
spread: (1) superior-laterally from the prostatic angle to the pelvic
sidewall and the internal-external iliac lymph nodes, and subse-
quently to common iliac lymph nodes; (2) drainage via the perineal
floor to internal pudendal vessels; and (3) drainage via the sacral
lymphatics (which was seen only 24 hours after injection).9 They
Reprinted From Ref. 5 (Figure 2b). ª2008 With Permission From Springer. subsequently verified that all the patients had drainage via sacral
lymphatics to the S2-5 (mostly S3-4) levels. (Figure 6A-C).10
Figure 5 Anteroposterior View of the Pelvis After Intraprostate
Contrast Radioisotope Imaging
A variation on injection of the prostate with contrast is the use of
radioactive technetium nanocolloid. This was pioneered in studies
of breast cancer and melanoma, and was developed as an adjunct to
using blue dye. The goal was to use a gamma probe during surgery
to locate lymph nodes that accumulated radioactivity, with the
thinking that those same lymph nodes would also be more likely to
trap cancer cells. The premise was that the cancer status of these
initial sites (sentinel lymph nodes) would most likely represent the
risk to the entire lymphatic drainage. Optimally, one has to allow
enough time for the isotope colloid to spread from the site of in-
jection but only long enough to detect it in those initial (sentinel)
lymph nodes. Like lipiodol injection, only lymphatics large enough
can accumulate the nanocolloid. Even then, in breast cancer, it was
shown that, if the particles were too small, then there were too many
routes of lymphatic spread, which made mapping them impractical,
so particles of a minimal size have to be used.11 The nanocolloid
studies do not always detect all the sentinel lymph nodes at risk, so
most surgeons still use blue dye. Clearly, these issues prevent these
studies from being definitive as to the actual lymphatic drainage but
do give some further insight into lymphatics at risk in prostate
cancer. It is important to remember that they do not map the routes
of spread directly but identify apparent lymph nodes along the way.
Most of these studies were done in Europe. Initially, the technetium
nanocolloid was primarily used with the gamma probe during sur-
gery. With this better imaging technique, there have been further
attempts to map the sentinel lymph nodes that drain the prostate
gland with preoperative imaging.
One of the first studies in prostate cancer was performed by
Wawroschek et al12 in Germany. Twenty minutes after injection of
Reprinted From Ref. 8 (Figure 3). ª2008 With Permission From Elsevier. radioisotope into the prostate gland, lymphoscintigraphy was per-
Abbrevations: CI ¼ common iliac; II ¼ internal iliac; IP ¼ internal pudendal; PS ¼ presacral;
PL ¼ posterior-lateral; P ¼ prostate. formed. The first limitation of this technique was the demonstration
that the immediate periprostatic (including the posterior-perirectal)
What may be most important is that these studies show the actual tissue could not be evaluated due to wash out by the high prostate
routes of spread but are limited by the contrast particle size and doses. Therefore, the prostate was blocked out, which negated the

436 - Clinical Genitourinary Cancer December 2013

 Gregory P. Swanson, John K. Hubbard
Figure 6 (A) Anteroposterior View. Reprinted From Ref. 9. ª2001 With Permission From Elsevier. (B) Lateral View With
Posterior-Lateral Flow of Contrast. Reprinted From Ref. 10. ª2008 With Permission From John Wiley and Sons.
(C) Computed Tomography Reconstruction. I [ Intraforamen Lymph Node (LN) @ S3 II [ Presacral LN; III [ Bony Pelvis;
IV [ Iliac Vessels

Reprinted From Ref. 10. ª2008 With Permission From John Wiley and Sons

ability to immediately see adjacent and posterior drainage. With injection, 78% (21/27) had positive sentinel lymph nodes along the
their first 11 patients, the sentinel lymph nodes frequently were hypogastric artery, 19% (5/27) along the external iliac artery, and
found in the classic lymph node distribution of the obturator and 41% (11/27) in the obturator fossa.15 They concluded that half of
external iliac vessels.12 In spite of the limitations from having to the sentinel lymph nodes would have been missed on standard
block out the prostate, 4 patients were found to have their sentinel dissection. Four patients had presacral uptake, but the uptake was
lymph nodes in the periprostatic area, 2 of which contained fainter. With the gamma probe at the time of exploration, many
metastasis. The only other positive sentinel lymph node was along more “hot” nodes were identified, with 60% deep along the internal
the external iliac vessels. iliac, 12% along the external iliac, and 23% in the obturator fossa.
The researchers have subsequently updated their experience, with In a similarly sized study from Germany (25 patients), more detailed
more than 1000 patients.13 From these studies, they were able to lymph node mapping (Figure 7) was undertaken.16 A total of 142
make several interesting observations. In total, 207 (20%) of their sentinel lymph nodes were identified, with 35% (50/142) located
patients had positive lymph nodes. The mean number of sentinel along the external iliac, 18% (26/142) along the internal iliac, 11%
lymph nodes was 7. In almost every case (99%, 2/207), the positive (16/142) on the common iliac, 8% (11/142) perirectal, 6% (9/142)
nodes found were detectable on lymphoscintigraphy. By using what sacral, 6% (9/142) left para-aortic, 4% (6/142) in the seminal
they considered the standard lymph node dissection (ie, the obtu- vesical lymphatic plexus, 3% (4/142) in the right para-aortic area,
rator fossa and along the external iliac vein), 63% (131/207) of the 2% (3/142) in the deep inguinal, and 1% (1/142) for each of the
positive nodes were outside that standard lymph node template internal pudendal, paravesical, inferior rectal, superior rectal, and
(internal iliac region, presacral, pararectal, paravesical space, other). superficial inguinal nodes. They also noted that, with tracer accu-
Despite the limitations in identifying posterior lymph nodes, the mulation in the bladder, immediate periprostatic areas (paravesical
incidence of positive presacral, pararectal, and/or paravesical lymph and seminal vesicle) were not well visualized.
nodes was 8% (n ¼ 16). In a separate analysis of high-risk patients A study from Switzerland provides a detailed map of sentinel
(Gleason 8-10 or prostate-specific antigen level > 20 ng/mL), 42% lymph node location and is probably the best summary of their
(96/228) had lymph node metastasis, with almost a third (27%, location.17 Given the known difficulty of routine evaluation of
26/96) having involvement of nonsentinel lymph nodes.14 As nodes deep in the pelvis (ie, below the sacral promontory and
before, the most common sites were along the external and internal posterior to the bladder and prostate), they made a special effort to
iliac-obturator arteries. They were able to detect 12 (13%) patients evaluate the presacral and perineal area. The surgeons identified 317
with sites from other areas like the presacral, pararectal, and para- sentinel lymph nodes in 34 patients. A total of 120 of 317 lymph
vesical nodes. Again, this is likely an underestimation. nodes were in the external iliac-obturator fossa, 81 of 317 were in
There are numerous smaller studies that describe the location of the external iliac, 38 of 317 were para-aortic, 50 of 317 were in the
sentinel lymph nodes from the prostate that provide some further common iliac, 2 (< 1%) were in the inguinal, and 26 of 317 were
information. In 1 study from France, in 27 patients, 2 hours after presacral (Figure 8). In their figure, the authors outline that most

Clinical Genitourinary Cancer December 2013 - 437

 Lymphatic Drainage of the Prostate
node status in patients.21 This was facilitated in the 1970s as radical
Figure 7 Anatomic Distribution of Sentinel Nodes (SN) as
Detected by Single Photon Emission Computed retropubic prostatectomy gradually became the preferred surgical
Tomography in 25 Patients approach, at least in part because it enabled at least some lymph
node sampling as part of the same procedure. Subsequently, the
incidence and location of surgically staged positive lymph nodes has
been reported numerous times. Given that the obturator and
external iliac nodes are usually the only ones sampled, most reports
are limited to reporting their incidence of involvement. In general,
for patients who are node positive, the obturator and/or hypogastric
nodes were the most commonly involved (occurring 30%-60% of
the time) and then the external iliac (20%-50% of the time). Later,
there were some exceptions to these observations, such as a study
from MD Anderson in which almost all the positive nodes (90%,
86/96) were in the obturator-hypogastric areas, with only 10%
(10/96) having external iliac involvement.22 In a series with a slightly
wider dissection, the common iliac lymph nodes were involved in
15% (9/60) of the patients.23 Although these researchers and others
acknowledged that the common routes of spread to the presacral
lymph nodes were not sampled, the findings in these commonly
dissected areas became synonymous with the actual risk of metastatic
spread.24 It was observed, however, that the absolute incidence of
positive lymph nodes increases as the total number of lymph nodes
removed increases.25
Eventually, contemplative urologists began to be concerned
Reprinted From Ref. 16. ª2007 With Permission From Elsevier. about the limited information available from the standard lymph
node sampling. In an early study, in recognizing that there were
other areas (eg, presacral) of known routes of spread that were not
dissections involve only what the authors designate as area I. Those sampled, Golimbu et al26 made an attempt to expand the dissection
with expanded dissections may include part of area II and/or IV. As to include these. They found a very high incidence of positive nodes
could be predicted by anatomic studies, there are a significant outside the standard obturator (53%, 8/15), external iliac (60%,
number of sentinel lymph nodes deep in the pelvis along the in- 9/15), and external iliac-obturator (86%, 13/15) areas; with 27%
ternal iliac, its branches, and the lower sacral and perirectal vessels. (4/15) of the common iliac, 14% (2/15) of the hypogastric, and
In a similar study from Italy, 20% (4/20) of the patients actually 80% (12/15) of the presacral and/or sciatic areas involved (a small
had metastatic disease in the presacral and/or perirectal area (albeit, number of patients had these dissected). They concluded that, in
it was a small number of patients, n ¼ 4).18 prostate cancer, the initial lymph nodes involved were the obturator,
external iliac, presacral, and presciatic. Subsequently, numerous
Historical Surgical Insights into the studies support that a more extensive dissection results in a higher
Routes of lymphatic spread detection of positive lymph nodes. One approach was to simply try
Surgical resection of the prostatic lymphatics was never intended to remove more nodes from the area being dissected. In one
to map the lymphatics but to detect malignant spread to given areas. example, with the removal of an average of 11 lymph nodes, the
In the early days of radical prostatectomy, it was thought that pelvic positive rate was 12% (12/100), and, with more extensive dissection
lymph node dissection was not of much utility because the data (28 lymph nodes), the rate was 26% (27/103).27 At least half of the
from autopsy series suggested that there was a higher incidence of patients with positive lymph nodes had the lymph nodes deep along
extra pelvic than pelvic lymph node metastasis. When taken to the internal iliac or in other nonstandardly dissected locations.
living patients, Whitmore and Mackenzie19 in the mid 1950s cited These observations have been corroborated by other researchers.28
that the most common and earliest sites of involvement were the At Johns Hopkins, although they seldom found positive nodes,
obturator and external iliac nodes. It is clear that this was not they were able to demonstrate that a more extended dissection
intended to be a thorough evaluation of the lymphatics at risk but a resulted in an average of 3 more lymph nodes removed but with a
readily achievable sampling, with tolerable morbidity; a view held by tripling in the number of positive nodes from 1.1% (22/1865) to
other researchers.20 This became, and still is, the standard approach 3.2% (71/2135).29 It is worth noting that no study has seriously
in the United States. It was almost a moot issue in the 1960s pursued lymph nodes deeper in the pelvis, such as in the perirectal,
because the most standard surgical technique was the perineal pudendal, and lower sacral areas. Overall, these findings would serve
prostatectomy. If lymph node sampling was done, then it had to be as a word of caution for those using tables, formulas, and nomo-
done as a separate procedure. grams to estimate the risk of positive lymph nodes. Because they are
Given the long-standing perception that patients with positive based on surgical cohorts that mostly consisted of obturator area
lymph nodes are not curable, as cancer treatment became more only dissection, the risk of actual lymph node involvement is likely
formalized, there was renewed interest in documenting the lymph underestimated by at least a factor of 2.

438 - Clinical Genitourinary Cancer December 2013

 Gregory P. Swanson, John K. Hubbard
Figure 8 A Detailed Map of Sentinel Lymph Node (LN) Locations

Reprinted From Ref. 17. ª2008 With Permission From Elsevier.

Most of these extended lymph node studies have been done in the contention that the drainage of the prostate comes primarily
Europe. In the United States, in general, the lymph node risk from the periprostatic area and involves the internal iliac with
has been less, partially because our surgical series contain lower-risk its deep branches as the primary route of spread. Subsequently, the
patients.30 In those patients, extending the dissection does not show perirectal and lower sacral vessel lymphatics are involved and then
a difference. In addition, there is minimal proof that a wider the proximal external iliac, the obturator, the upper sacral, common
dissection benefits the patient but does increase the risk of iliacs, and, ultimately, the para-aortic lymphatics. The figure
morbidity. These include an increased risk of lymphocele, lower (Figure 7) from Mattei et al17 seems to represent an accurate
extremity edema, and thrombophlebitis.30 Therefore, if done at all, depiction of the known lymphatic drainage patterns and areas of
there is still a tendency to limit dissections only to the obturator risk. This information should improve the targeting of the areas at
fossa itself. In addition, most risk assessment tools in use currently risk with treatment (ie, radiotherapy) designed to treat potential
are based on obturator node only dissections, so cannot give a totally areas of metastasis in the lymphatics. It should also point out the
accurate estimate of risk. limitation of currently available risk assessment tools.
Overall, the information from the surgical series does not really
give us a map of the lymphatic drainage of the prostate but does Clinical Practice Points
demonstrate where positive lymph nodes can be found. This serves  Most texts base the description of the lymphatic drainage of the
as histologic validation of the proposed routes of lymphatics prostate on historical anatomic dissection data. With the advent
described by the anatomists and imagers. and evolution of radical retropubic prostatectomy, lymph nodes
along the obturator artery have been standardly accepted as
Conclusion representing the primary lymphatic drainage. Their involvement
Lymphatic drainage of the prostate is often discussed as being or noninvolvement with cancer is considered to be indicative of
fairly simplistic; but, as we have shown, it is quite complex. Other the overall lymph node status of the patient.
than those few studies that used contrast, most reports do not  Newer imaging techniques and imaging directed dissection have
actually map the lymphatics but point out the location of identifi- added new information about the lymphatic drainage and have
able lymph nodes. The bulk of the available information supports called into question whether the obturator lymph nodes accurately

Clinical Genitourinary Cancer December 2013 - 439

 Lymphatic Drainage of the Prostate
portray the overall lymph node status. We performed a compre- 11. Paganelli G, De Cicco C, Cremonesi M, et al. Optimized sentinel node scintig-
raphy in breast cancer. Q J Nucl Med 1998; 42:49-53.
hensive review and union of historical and current data to provide 12. Wawroschek F, Vogt H, Weckermann D, et al. The sentinel lymph node concept
a more detailed description of the lymphatic drainage than in prostate cancer: first results of gamma probe-guided sentinel lymph node
identification. Eur Urol 1999; 36:595-600.
currently exists in the literature. The primary lymphatic drainage 13. Weckermann D, Dorn R, Trefz M, et al. Sentinel lymph node dissection for prostate
is along the deep branches of the internal iliaceassociated lym- cancer: experience with more than 1,000 patients. J Urol 2007; 177:916-20.
14. Weckermann D, Dorn R, Holl G, et al. Limitations of radioguided surgery in
phatics and then to multiple nodal areas in addition to those of the high-risk prostate cancer. Eur Urol 2007; 51:1549-56.
obturator artery. It is now clear that the obturator lymph node 15. Brenot-Rossi I, Bastide C, Garcia S, et al. Limited pelvic lymphadenectomy using
the sentinel lymph node procedure in patients with localised prostate carcinoma: a
status alone does not completely describe the lymphatic status. pilot study. Eur J Nucl Med Mol Imaging 2005; 32:635-40.
 This information enables a more complete and accurate discus- 16. Ganswindt U, Paulsen F, Corvin S, et al. Optimized coverage of high-risk adjuvant
lymph node areas in prostate cancer using a sentinel node-based, intensity-
sion of lymphatic failure patterns and, with it, allows for more modulated radiation therapy technique. Int J Radiat Oncol Biol Phys 2007; 67:
accurate targeting of the lymphatics with treatment modalities 347-55.
17. Mattei A, Fuechsel FG, Bhatta Dhar N, et al. The template of the primary
such as surgery and radiation. It will also serve as a starting point lymphatic landing sites of the prostate should be revisited: results of a multi-
for more detailed investigation into prostate lymphatic drainage. modality mapping study. Eur Urol 2008; 53:118-25.
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