Current Status of Pelvic Lymph Node Dissection in Disease Management

Review of contemporary cystectomy series demonstrates a lymph node positive rate of ~25% (28,29). There is evidence to support the therapeutic role of pelvic lymph node dissection in bladder cancer.

In a large cohort of patients undergoing radical cystectomy and pelvic lymph node dissection, patients with pN+ disease (N = 244), experienced 5- and 10-year recurrence-free survival rates of 35% and 34%, respectively (28). Both the anatomic extent of lymphadenectomy (30-32) and the number of nodes involved with metastatic disease are regarded as important independent factors (32-34). Patients with fewer than four lymph nodes involved with metastases fare better than those with five or more positive nodes (33).

Classically, the boundaries of a pelvic lymph node dissection for bladder cancer include the genitofemoral nerve laterally, bladder medially, node of Cloquet distally and the bifurcation of the common iliac artery proximally. Skinner described an extended dissection that includes the lymphatic tissue 2-3 cm above the aortic bifurcation (35).

Although the proximal extent of lymphadenectomy for bladder cancer continues to be debated, all patients undergoing cystectomy with curative intent should have a bilateral pelvic lymph node dissection since bladder tumors metastasize bilaterally even if they are focal and unilateral (36,37).

In an anatomic mapping study of lymph nodes removed during extended pelvic lymph node dissection for bladder cancer, it was demonstrated that in 29 patients who only had metastases to one lymph node, this solitary involved node was never in the presacral, paracaval, interaortocaval or paraaortic areas (37). Furthermore, metastases to the paraaortic, interaortocaval, or paracaval regions only occurred when nine or more lymph nodes from more distal landing zones were positive (37). Thus, the majority of patients with proximal lymph node metastases have more distal disease.

Recently, there has been an attempt to determine the minimum number of lymph nodes that should be removed and examined. An earlier report, demonstrated a cancer-specific survival of 65% versus 51% when 15 lymph nodes or more were removed at cystectomy compared to 15 or less, respectively (31). More recent studies have also found that the number of lymph nodes retrieved, regardless of whether metastases were diagnosed, correlated with survival (32,34). Herr et al. (32) demonstrated improved local control and an overall survival advantage for both pN+ and pN0 patients when more than 11 and 8 lymph nodes were removed, respectively.

The rate of complications associated with laparoscopic pelvic lymph node dissection ranges from 0% to 22% as opposed to 0% to 13% for open pelvic lymph node dissection. However, these reports were published between 1992 and 1997 and with greater laparoscopic experience, one would anticipate diminished complication rates.

Review of contemporary cystectomy series demonstrates a lymph node positive rate of ~25%. There is evidence to support the therapeutic role of pelvic lymph node dissection in bladder cancer.

Although the proximal extent of lymphadenectomy for bladder cancer continues to be debated, all patients undergoing cystectomy with curative intent should have a bilateral pelvic lymph node dissection since bladder tumors metastasize bilaterally even if they are focal and unilateral.

There is evidence to support a more extensive lymphadenectomy and thus, patients undergoing laparoscopic radical cystectomy with curative intent should have a meticulous pelvic lymph node dissection with at least 15 lymph nodes removed and examined.

We elect to perform pelvic lymph node dissection after cystectomy in order not to compromise tissue planes.

A review of patients undergoing radical cystectomy and pelvic lymph node dissection from the National Cancer Institute Surveillance, Epidemiology and End Results database confirmed the correlation between number of lymph nodes removed and survival (34). The authors concluded that a minimum of 10 to 14 nodes should be examined (34). To further discriminate survival and local control outcomes, the concepts of ratio-based lymph node staging (38) and lymph node density (28) were proposed. A cut-point of 20% correlated with a statistically significant improvement in recurrence-free survival at 10 years. Furthermore, improved survival has been reported in patients with grossly positive nodes undergoing an extended pelvic lymph node dissection (39).

There is evidence to support a more extensive lymphadenectomy and thus, patients undergoing laparoscopic radical cystectomy with curative intent should have a meticulous pelvic lymph node dissection with at least 15 lymph nodes removed and examined.

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