Pelvic lymph node dissection during radical cystectomy for muscle-invasive bladder cancer

Abstract

Radical cystectomy is the gold-standard treatment option for muscle-invasive and metastatic bladder cancer. At the time of cystectomy, up to 25% of patients harbour metastatic lymph node deposits. These deposits most frequently occur in the obturator fossa, but can be as proximal as the interaortocaval region. Thus, the use of concurrent pelvic lymph node dissection (PLND) with cystectomy has been increasingly reported. Data from studies including many patients suggest substantial oncological benefit in PLND cohorts versus non-PLND cohorts, irrespective of pathological nodal status. Additionally, PLND provides useful prognostic information, including disease burden, lymph node density, and extracapsular extension of metastatic lymph nodes. Accordingly, the National Comprehensive Cancer Network guidelines advocate the use of PLND during radical cystectomy for muscle-invasive bladder cancer. Despite this recommendation, a lack of consensus exists regarding the optimal PLND template. Comparative series suggest that extended PLND provides improved recurrence-free survival and cancer-specific survival compared with more limited PLND templates. More extensive templates (such as super-extended PLND) provide no additional survival benefit at the potential cost of increased operative time and patient morbidity. In addition to extended PLND templates, increased nodal harvest confers an oncological benefit in patients with node-positive disease or in patients with node-negative disease. Accordingly, recommendations for a minimum nodal yield have been proposed. Despite the growing body of evidence, formal recommendations by oncological and urological authoritative bodies have been limited owing to the lack of randomized data and level I evidence.

Role of lymph node dissection in radical cystectomy

“…Abol-Enein et al (30) demonstrated that the 5 year disease-free survival rate of patients undergoing extended LND in a non-randomized prospective cohort study was 66.6% (extended lymphadenectomy) vs. 54.7% (standard lymphadenectomy). In addition, extended LND can also reduce the probability of pelvic organ metastasis (27,31). Although numerous studies reported this result, some controversies exist.…”

“…extended LND and super-extended LND (15). Previous studies reported that expanding the extent and number of LNDs has a crucial impact on the prognostic significance, not only for lymph node-positive patients but also for the postoperative prognosis of lymph node-negative patients (26,27). In addition, it was reported that LND might be an independent prognostic factor for the prognosis of patients with BCa, since extended LND can reduce micrometastasis (28).…”

Plasmacytoid Urothelial Carcinoma: Response to Chemotherapy and Oncologic Outcomes

“…Positive surgical margins have a reported incidence of 1-10% in conventional UC across stages [15], and up to 12% in cases of extravesical disease extension [16]. Nodal-positive disease at RC can be found in approximately 25% in general, and up to 34% in patients with advanced pT stage [16,17].…”

“…11 (17) 82 (20 Each histology subgroup received a median of four NAC cycles. In the PUC subgroup, using chi squared test, no significant association was identified between NAC and pT0N0 (p = 0.96), extravesical disease at surgery, (p = 0.84), pN+ status (p = 0.72), margin positivity (p = 0.93), LVI+ (p = 0.33) or CIS+ (p = 0.14).…”

Timing of lymphadenectomy during robot-assisted radical cystectomy: before or after cystectomy? Fifteen cases with totally intracorporeal urinary diversions.

“…Publications strongly suggest that all patients undergoing radical cystectomy for bladder cancer should undergo concomitant extended pelvic lymph node dissection (ePLND) because of the positive effect on correct staging and survival [5]. Although controversy surrounds PLND levels, many researchers agree that ePLND shows superior survival rates and correct staging compared to limited PLND [6,7] and superextended PLND provides no additional survival benefits due to the potential for increased operation time and patient morbidity [8]. In addition, it is reported that meticulous dissection is more important than the number of nodes removed [7,8].…”