Technique, role of extended lymphadenectomy in bladder cancer

October 1, 2007

Lymphadenectomy in conjunction with radical cystectomy (RC) is the standard approach for surgical management of high-grade, invasive bladder cancer. Approximately 25% of patients undergoing RC will be found to have lymph node-positive disease.

In one of the largest retrospective series of patients with advanced bladder cancer undergoing RC, 246 of 1,054 patients (24%) who underwent RC had lymph node metastases (J Clin Oncol 2001; 19:666-75). The likelihood of lymph node involvement correlated with increasing primary tumor stage.

Although regional lymphadenectomy has been performed for bladder cancer since the 1950s, there is still no consensus in the urologic community on the borders or extent of the lymph node dissection necessary for adequate staging and possible therapeutic benefit. Two templates, a standard and an extended dissection, have been described in the literature.

Understaging of bladder cancer

Lymphadenectomy for invasive urothelial carcinoma of the bladder provides important staging and prognostic information. The presence of lymph node metastases at the time of surgery is one of the most important predictors of disease-free survival. Unfortunately, approximately 25% of patients undergoing RC have lymph node metastases at the time of surgery (J Clin Oncol 2001; 19:666-75; BJU Int 2005; 95:786-90).

Suboptimal performance of lymphadenectomy during RC is a major source of inaccurate staging. Even in randomized clinical trials, up to 25% of patients undergo either minimal or no lymph node dissection at the time of RC. In a review of the Surveillance, Epidemiology, and End Results (SEER) cancer registry, Badrinath et al reported that of 1,923 patients undergoing RC between 1988 and 1996, 40% of patients underwent no lymph node dissection and only 22% had greater than 10 lymph nodes removed (J Urol 2003; 169:946-50).

s-PLND and e-PLND defined

Although there is no universal definition of an e-PLND, most surgeons would agree that, in addition to the standard template, the lymph nodes in the presacral region and those surrounding the common iliac vessels to the level of the aortic bifurcation should be harvested, as well. In addition, some argue that in high-risk patients, the dissection may be extended cephalad to the inferior mesenteric artery (figures 1, 2, and 3).