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

Nature Reviews Urology volume 15, pages 686–692 (2018)Cite this article

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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.

Key points

  • Pelvic lymph node dissection (PLND) during radical cystectomy for bladder cancer seems to provide oncological benefit.

  • PLND also provides useful prognostic information, such as tumour burden, lymph node density, and extracapsular extension of metastatic lymph nodes, which can guide management.

  • Extended PLND templates seem to provide optimal recurrence-free and cancer-specific survival, whereas the use of super-extended PLND provides no added benefit.

  • Increased nodal yield improves oncological outcomes in patients with node-negative or node-positive disease.

  • Despite the current evidence, recommendations for optimal PLND techniques during radical cystectomy for muscle-invasive bladder cancer are limited.

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Fig. 1: Limited, standard, extended, and super-extended templates for PLND.
Fig. 2: Location of metastatic deposits from muscle-invasive bladder cancer.

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Authors and Affiliations

  1. Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia

    Marlon Perera, Shannon McGrath, Shomik Sengupta, Jack Crozier, Damien Bolton & Nathan Lawrentschuk

  2. Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia

    Damien Bolton & Nathan Lawrentschuk

  3. Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia

    Nathan Lawrentschuk

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Contributions

S.M. and J.C. researched data for the article; M.P. and D.B. made substantial contributions to discussions of content; M.P., S.M., S.S., and J.C. wrote the article; and M.P., S.S., D.B., and N.L. reviewed and edited the manuscript before submission.

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Correspondence to Marlon Perera.

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Perera, M., McGrath, S., Sengupta, S. et al. Pelvic lymph node dissection during radical cystectomy for muscle-invasive bladder cancer. Nat Rev Urol 15, 686–692 (2018). https://doi.org/10.1038/s41585-018-0066-1

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