Balancing risk and benefit of extended pelvic lymph node dissection in patients undergoing radical cystectomy

Impact of Extended Versus Limited Lymph Node Dissection on Surgical Outcome, Recurrence Patterns and Survival After Radical Cystectomy

BACKGROUND

The aim of our study is to evaluate the impact of extended versus limited lymph node dissection (LND) in patients undergoing radical cystectomy (RC) on survival, perioperative outcomes and pattern of recurrence.

PATIENTS AND METHODS

We reviewed our charts to identify patients who underwent RC and LND with curative intent between January 2003 and November 2022. Standard open RC with limited or extended LND was routinely performed, depending on surgeon's preference. The upper limit of extended LND is usually the ureteral crossing with the common iliac artery, unless further extension to the aortic bifurcation or inferior mesenteric artery is clinically indicated. Whereas limited LND includes removal of external and internal iliac and obturator Lymph nodes (LNs). The primary outcome was to compare the 2 patient groups in terms of cancer-specific survival (CSS) and overall survival (OS). The secondary outcome was to assess the impact of the extent of LND on the pattern of recurrence (local and distant metastasis free-survival) and perioperative complications.

RESULTS

Of 642 patients, 439 and 203 underwent limited and extended LND, respectively. In the extended LND group, the median number of LNs removed was 23 compared to 8 in the limited LND group (P < .001), which was associated with higher median positive LNs in the extended group (3 vs. 2, P = .05). Extended LND was associated with longer operative time (300 vs. 250 min., P < .001), but not with blood loss, postoperative hemoglobin drop, hospital stay, 90-days major complications and hospital readmission rates. Lymphocele requiring surgical intervention was higher in extended group (7.4% vs. 1.8%, P = .001). The median follow-up time of survivors was 41 months in the limited group and 52 months in the extended group, (P = .1). Overall, 127 (29%) and 52 (26%) patients in the limited and extended groups experienced clinical recurrence (P = .39). At multivariable Cox regression analysis, LND template was not associated with either local and distant metastasis-free survival or CSS, while resection of ≥16 LNs was an independent predictor of local recurrence-free survival (HR 0.54; P = .01) and CSS (HR 0.6; P = .002), regardless of the dissected template. Both extended LND (HR 0.63; P = .004) and resection of ≥16 LNs (HR 0.66; P = .003) were associated with improved OS.

CONCLUSION

The number of LNs removed appears to be more important than the LN template in patients undergoing RC. Resection of at least 16 LNs is associated with better cancer control and oncologic outcome.

Standard Versus Extended Pelvic Lymphadenectomy in Patients With Bladder Cancer: A Systematic Review and Meta-analysis

OBJECTIVES

For decades, pelvic lymph node dissection (PLND) has been a critical component of radical cystectomy in patients with bladder cancer. Although its role in curative surgery for high-risk non-muscle-invasive and muscle-invasive cases is well-established, the therapeutic advantages of extended PLND remain a topic of ongoing debate.

METHODS

A comprehensive literature search of major bibliographic databases was performed from inception to November 2024. Studies comparing extended PLND (extended or super extended) with standard PLND were identified. Data for clinical outcomes was extracted and pooled estimates were calculated using a random effects model with RevMan 5.4.

RESULTS

A total of 11 studies (2 RCTs and 9 observational) were included reporting data for 4001 patients. The pooled analysis demonstrated that extended PLND was associated with significantly better recurrence-free survival (HR=0.67, 95% CI: 0.60-0.74). Standard PLND led to significantly higher 5-year recurrence rates (RR=1.44, 95% CI: 1.28-1.62) compared with the extended approach. The pooled estimates for disease-specific survival (HR=0.86, 95% CI: 0.62-1.19), overall survival (HR=0.99, 95% CI: 0.86-1.16), and complications remained comparable.

CONCLUSIONS

Extended PLND can lead to favorable recurrence-free survival and 5-year recurrence rates. However, retrospective observational studies mainly drive the evidence, and additional RCTs are required to reach a definitive conclusion.

Perioperative outcomes using template mapping after radical cystectomy and extended lymph node dissection

BACKGROUND

To evaluate oncologic and perioperative outcomes of extended pelvic lymph node dissection (PLND) during robot-assisted radical cystectomy (RARC) based on the location of lymph node positivity (LN+).

METHODS

We reviewed a tertiary center database of patients with bladder cancer who underwent extended PLND during RARC from 2004 to 2020. Patients were assigned to a standard (sPLN+) or extended (ePLN+) cohort based on LN+ location. ePLN+ patients were LN+ in one or more of the following: common iliac, presacral, aortic bifurcation, or paracaval packets. The Kaplan-Meier method estimated recurrence-free survival (RFS) and overall survival (OS). Perioperative 90-day complications were identified using the Clavien-Dindo system.

RESULTS

Ninety patients were included; 43 (48%) were sPLN+, and 47 (52%) were ePLN+. The median follow-up for sPLN+ and ePLN+ patients was 14.9 and 20.0 months, respectively. ePLN+ patients were older than sPLN+ patients (median age 75 vs. 68 years, p = 0.019). There were more ≤ cT1 LN+ patients in the sPLN+ cohort compared to the ePLN+ cohort (26% vs. 9%, p = 0.037). We recorded no differences in 90-day mortality or in RFS or OS between baseline and 12-year follow-up between groups (all, p > 0.05). Overall, the grade II or higher complication rate was 71%, with similar rates for the sPLN+ and ePLN+ (77% vs. 66%, p = 0.26) cohorts.

CONCLUSION

Location of LN+ does not affect oncologic outcomes in patients who underwent extended PLND. This underscores the lack of a notable therapeutic benefit beyond the standard dissection template.

CLINICAL TRIAL NUMBER

Not applicable.

Which lymph node dissection template is optimal for radical cystectomy? A systematic review and Bayesian network meta-analysis

Objective

This study aims to determine the optimal pelvic lymph node dissection (PLND) template for radical cystectomy (RC).

Methods

A systematic search was conducted using the PubMed, Embase and Cochrane Library database in December 2021. Articles comparing recurrence-free survival (RFS), disease-specific survival (DSS), overall survival (OS), and postoperative complications among patients undergoing limited PLND (lPLND), standard PLND (sPLND), extended PLND (ePLND), or super-extended PLND (sePLND) were included. A Bayesian approach was used for network meta-analysis.

Results

We included 18 studies in this systematic review, and 17 studies met our criteria for network meta-analysis. We performed meta-analyses and network meta-analyses to investigate the associations between four PLND templates and the RFS, DSS, OS, or postoperative complications. We found that the ePLND group and the sePLND group were associated with better RFS than the sPLND group (Hazard Ratio [HR]: 0.65, 95% Credible Interval [CrI]: 0.56 to 0.78) (HR: 0.67, 95% CrI: 0.56 to 0.83) and the lPLND group (HR: 0.67, 95% CrI: 0.50 to 0.91) (HR: 0.70, 95% CrI: 0.49 to 0.99). For RFS, Analysis of the treatment ranking revealed that ePLND had the highest probabilities to be the best template. There was no significant difference between the four templates in DSS, however, analysis of the treatment ranking indicated that sePLND had the highest probabilities to be the best template. And We found that the sePLND group and the ePLND group were associated with better OS than lPLND (HR: 0.58, 95% CrI: 0.36 to 0.95) (HR: 0.63, 95% CrI: 0.41 to 0.94). For OS, analysis of the treatment ranking revealed that sePLND had the highest probabilities to be the best template. The results of meta-analyses and network meta-analyses showed that postoperative complications rates did not differ significantly between any two templates.

Conclusion

Patients undergoing sePLND and ePLND had better RFS but not better DSS or OS than those undergoing lPLND or sPLND templates, however, RFS did not differ between patients undergoing sePLND or ePLND. Considering that sePLND involves longer operation time, higher risk, and greater degree of difficulty than ePLND, and performing sePLND may not result in better prognosis, so it seems that there is no need for seLPND. We think that ePLND might be the optimal PLND template for RC.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022318475.

Extent of lymph node dissection and impact on survival in radical cystectomy for advanced bladder cancer

PURPOSE OF REVIEW

In patients with muscle invasive bladder cancer (MIBC) or unresectable non-MIBC, radical cystectomy is routinely combined with bilateral pelvic lymph node dissection (LND) owing to the oncological benefits found in recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS) compared with radical cystectomy alone. However, the optimal anatomic extent of LND is still unclear.

RECENT FINDINGS

Retrospective studies were consistent in reporting oncological benefits of extended LND over nonextended LND. A recent RCT (the LEA trial) failed to demonstrate any benefit in terms of RFS, CSS and OS of super-extended LND over standard LND. Several confounding factors hindered the interpretation of the results, leaving the question of the right extent for LND still open. Results of a similar study, the SWOG S1011 are, therefore, highly anticipated. This study differed from the LEA study in several aspects but might also turn out to be a negative study.

SUMMARY

There are still no firm data on the oncological benefit brought by more extended LND in patients with MIBC. Survival benefits seem limited, at least in the general population. Other factors could influence the impact of LND on survival, including the administration of adjuvant and neoadjuvant chemotherapies.

The Adequacy of Pelvic Lymphadenectomy During Radical Cystectomy for Carcinoma Urinary Bladder: A Narrative Review of Literature

An adequate pelvic lymph node dissection (PLND) is an essential part of radical cystectomy for muscle invasive bladder cancer. However, the definition of what constitutes an adequate PLND is often shrouded in controversy. Various authors have defined different anatomic templates of PLND based on levels of pelvic lymph nodes. Some have suggested other surrogate markers of the adequacy of PLND, namely lymph node count and lymph node density. While individual studies have shown the efficacy and reliability of some of the above markers, none of them have been recommended forthright due to the absence of robust prospective data. The use of non-standardized nomenclature while referring to the above variables has made this matter more complex. Most of older data seems to favor use of extended template of PLND over the standard template. On the other hand, one recent randomized controlled trial (RCT) did not show any benefit of one template over the other in terms of survival benefit, but the study design allowed for a large margin of bias. Therefore, we conducted a systematic search of literature using EMBASE, Medline, and PubMed using PRISMA-P checklist for articles in English Language published over last 20 years. Out of 132 relevant articles, 47 articles were included in the final review. We have reviewed existing literature and guidelines and have attempted to provide a few suggestions toward a uniform nomenclature for the various anatomical descriptions and the extent of PLND done while doing a radical cystectomy. The results of another large RCT (SWOG S1011) are awaited and until we have a definitive evidence, we should adhere to these suggestions as much as possible and deal with each patient on a case to case basis.

Lymph node dissection for bladder cancer: Current standards and the latest evidence

Lymph node dissection is an indispensable component of radical cystectomy for bladder cancer. Information obtained with lymph node dissection is highly predictive of patient survival, affecting decision-making for adjuvant therapy (diagnostic role). Also, lymph node dissection provides survival benefits in certain patients by removing metastasized nodes (therapeutic role). However, an optimal extent of lymph node dissection has not been established yet. Data from surgical mapping studies showed that approximately 10% of the primary lymphatic landing sites were common iliac nodes, suggesting that lymph node dissection below the common iliac bifurcation is suboptimal. Several retrospective studies have shown a possible survival advantage with more extended lymph node dissection. However, the results of the first prospective randomized controlled trial failed to prove the survival advantage of extended lymph node dissection up to the level of the inferior mesenteric artery, compared with lymph node dissection below the bifurcation of the common iliac artery. Currently, lymph node dissection templates recommended by major guidelines are not consistent with each other. Furthermore, the evidence is limited in the settings of neoadjuvant chemotherapy, robot-assisted surgery and high-risk non-muscle-invasive disease. Physicians need to decide the extent of lymph node dissection for each patient, taking into account the potential survival benefit and possible harms of extended lymph node dissection. Another randomized controlled trial is currently underway and will provide further evidence shortly.

Extended versus non-extended lymphadenectomy during radical cystectomy for patients with bladder cancer: a meta-analysis of the effect on long-term and short-term outcomes

BACKGROUND

Pelvic lymphadenectomy (PLND) is an integral part of curative surgery for high-risk non-muscle invasive and muscle-invasive bladder cancer. The therapeutic value of extended PLND is controversial.

METHODS

We conducted a comprehensive online search in PubMed, EMBASE, and the Cochrane Library databases for relevant literature directly comparing extended PLND (e-PLND) with non-extended PLND (ne-PLND) from database inception to June 2019. We performed the meta-analysis to evaluate the impact of PLND templates on recurrence-free survival (RFS), disease-specific survival (DSS), overall survival (OS), rates of postoperative major complications, and mortality within 90 days of surgery.

RESULTS

A total of 10 studies involving 3979 patients undergoing either e-PLND or ne-PLND were included. The results showed that e-PLND was significantly associated with better RFS (HR 0.74, 95% CI 0.62-0.90, p = 0.002) and DSS (HR 0.66, 95% CI 0.55-0.79, p < 0.001). However, no correlation was found between e-PLND template and a better OS (HR 0.93, 95% CI 0.55-1.58, p = 0.79). Postoperative major complications were similar between e-PLND group and ne-PLND group, as was mortality within 90 days of surgery.

CONCLUSION

e-PLND template is correlated with favorable RFS and DSS outcomes for patients with bladder cancer. e-PLND did not have more postoperative major complications than did ne-PLND.

Eligibility and Radiologic Assessment in Adjuvant Clinical Trials in Bladder Cancer

Objective

To harmonize eligibility criteria and radiographic disease assessments in clinical trials of adjuvant therapy for muscle-invasive bladder cancer (MIBC).

Methods

National experts in bladder cancer clinical trial research, including medical and urologic oncologists, radiologists, biostatisticians, and patient advocates, convened at a public workshop on November 28, 2017, to discuss eligibility, radiographic entry criteria, and assessment of disease recurrence in adjuvant clinical trials in patients with MIBC.

Results

The key workshop conclusions for adjuvant MIBC clinical trials included the following points: (1) patients with urothelial carcinoma with divergent histologic differentiation should be allowed to enroll; (2) neoadjuvant chemotherapy is defined as at least 3 cycles of neoadjuvant cisplatin-based combination chemotherapy; (3) patients with muscle-invasive, upper-tract urothelial carcinoma should be included in adjuvant trials of MIBC; (4) patients with severe renal insufficiency can enroll into trials using agents that are not renally excreted; (5) patients with microscopic surgical margins can be included; (6) patients should undergo a standard bilateral lymph node dissection prior to enrollment; (7) computed tomographic (CT) imaging should be performed within 4 weeks prior to enrollment. For patients with renal insufficiency who cannot undergo CT imaging with contrast, noncontrast chest CT and magnetic resonance imaging of the abdomen and pelvis with gadolinium should be done; (8) biopsy of indeterminate lesions to evaluate for malignant disease should be done when feasible; (9) a uniform approach to evaluate indeterminate radiographic lesions when biopsy is not feasible should be included in any trial design; (10) a uniform approach to determining the date of recurrence is important in interpreting adjuvant trial results; and (11) new high-grade, upper-tract primary tumors and new MIBC tumors should be considered recurrence events.

Conclusions and Relevance

A uniform approach to eligibility criteria, definitions of no evidence of disease, and definitions of disease recurrence may lead to more consistent interpretations of adjuvant trial results in MIBC.

Multidisciplinary Management of Muscle-Invasive Bladder Cancer: Current Challenges and Future Directions

The treatment of muscle-invasive bladder cancer (MIBC) is complex and requires a multidisciplinary collaboration among surgery, radiation, and medical oncology. Although neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) and lymph node dissection has been considered the standard treatment for MIBC, many patients are unfit for surgery or cisplatin-ineligible, and considerations for bladder-preservation strategies not only are increasingly recognized as optimal treatment alternatives, but also should feature in the range of management options presented to patients at the time of diagnosis. Apart from chemotherapy, immunotherapy has also been used with success in locally advanced and metastatic bladder cancer and is moving into the MIBC space. Prospective studies addressing trends in management that span systemic, surgical, and radiation options for patients are discussed in this article.

Gender Specific Differences in Disease-Free, Cancer Specific and Overall Survival after Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis

PURPOSE

We summarize the evidence on gender specific differences in disease-free, cancer specific and overall survival after radical cystectomy for bladder cancer.

MATERIALS AND METHODS

We performed a systematic literature search of MEDLINE®, Embase® and the Cochrane Library in July 2017. Studies evaluating gender specific differences in disease-free, cancer specific or overall survival after radical cystectomy for bladder cancer were included in study. Analyses included random effect meta-analysis, subgroup analyses, meta-influence and cumulative meta-analyses. Funnel plots and the Egger test were used to assess publication bias.

RESULTS

Of the 3,868 studies identified during the literature search 59 published between 1998 and 2017 were included in analysis. Of the studies 30 in a total of 38,321 patients evaluated disease-free survival, 44 in a total of 69,666 evaluated cancer specific survival and 26 in a total of 30,039 evaluated overall survival. Random effect meta-analyses revealed decreased disease-free, cancer specific survival and overall survival in female patients than in their male counterparts. Pooled estimates showed a HR of 1.16 (95% CI 1.06-1.27, p = 0.0018) for disease-free survival, 1.23 (95% CI 1.15-1.31, p <0.001) for cancer specific survival and 1.08 (95% CI 1.03-1.12, p = 0.0004) for overall survival. Subgroup analyses confirmed impaired disease-free, cancer specific and overall survival in female patients in all strata. Publication bias was evident only for studies of cancer specific survival (Egger test p = 0.0029). After adjusting for publication bias by the trim and fill method the corrected pooled estimated HR of cancer specific survival was 1.13 (95% CI 1.05-1.21, p = 0.0012).

CONCLUSIONS

Female patients who underwent radical cystectomy for bladder cancer demonstrated worse disease-free, cancer specific and overall survival than their male counterparts. The multifactorial etiology might include epidemiological differences, gender specific health care discrepancies and hormonal influences.

Lymphadenectomy for Muscle-Invasive Bladder Cancer and Upper Tract Urothelial Cell Carcinoma

There are currently no reported randomized trials that characterize the staging or therapeutic benefit of performing a lymph node dissection in either bladder cancer or upper tract urothelial carcinoma. Several unanswered questions remain in this domain focused on the indications and patient selection for pelvic lymph node dissection, extent of dissection, its impact on outcome, and potential risks. However, the results of observational studies suggest that the burden of metastasis is high in both diseases when muscle invasive and performing a lymphadenectomy can provide prognostic information and yield therapeutic benefit.

Patterns and predictors of recurrence after open radical cystectomy for bladder cancer: a comprehensive review of the literature

Purpose

To review the currently available literature reporting the patterns of recurrence and their predictive factors after open radical cystectomy (RC) for bladder cancer.

Methods

A review of the literature was performed using the MEDLINE, Scopus and Web of Sciences databases from January 1997 to May 2017. The PRISMA guidelines were followed for the conduct of the study.

Results

Local recurrence rate ranges between 30 and 54%. Distant recurrence is not often standardized and is reported in up to 50% of cases. The overall 5-year recurrence-free survival rates from 58 to 81%. The mean follow-up of studies included in the analysis ranged from 18 to 350 months. Details on the most important demographic and epidemiological, clinical, histologic and pathologic predictors of recurrence after radical cystectomy are provided through an evidence-based approach. The impact of the extension of lymph node dissection on recurrence after RC is investigated.

Conclusions

A correct prognostic assessment is essential for patients undergoing radical cystectomy for bladder cancer, thereby potentially improving their oncologic outcomes.

Electronic supplementary material

The online version of this article (10.1007/s00345-017-2115-4) contains supplementary material, which is available to authorized users.

Risks and benefits of pelvic lymphadenectomy in octogenarians undergoing radical cystectomy due to urothelial carcinoma of the bladder

OBJECTIVES

According to current guidelines, radical cystectomy (RC) should be combined with an extended pelvic lymphadenectomy (PLND) as therapeutic and staging instrument. Objective of this study was to analyze the influence of PLND on survival rates and complication rates in a selected group of elderly patients with a minimum age of 80 years.

MATERIALS AND METHODS

In this single-center retrospective analysis, we evaluated 102 patients who underwent RC due to UCB from 2004 to 2015 at our institution. In 74 patients (73%), RC was combined with PLND; in 28 cases (27%), RC was performed without PLND. Impact of PLND on cancer specific survival (CSS), overall survival (OS) and progression-free survival (PFS) was analyzed using log-rank test and COX regression model.

RESULTS

In univariate analysis of the data, we were not able to show a significant impact of PLND on CSS (p = 0.606), OS (p = 0.979) or PFS (p = 0.883). Also in multivariate analysis of the data, we were not able to identify PLND as an independent prognostic parameter on survival rates of patients undergoing RC, neither for CSS (p = 0.912) nor OS (p = 0.618) or PFS (p = 0.900).

CONCLUSIONS

Our small and single-center study was not able to demonstrate a significant independent influence of PLND on CSS, OS and PFS in octogenarians undergoing RC due to UCB. There is no doubt that RC should usually be combined with PLND, but the results of this small data set with a selected patient cohort indicate that RC without PLND might be an option in selected cases of elderly patients.

Advances in surgical management of muscle invasive bladder cancer

INTRODUCTION

Bladder cancer remains a disease of the elderly with relatively few advances that have improved survival over the last 20 years. Radical cystectomy (RC) has long remained the principal treatment for muscle-invasive bladder cancer (MIBC).

METHODS

A literature search of PubMed was performed. The content was reviewed for continuity with the topic of surgical advances in MIBC. Articles and society guidelines were included in this review.

RESULTS

Despite the associated morbidity, even in the elderly, RC is still a reasonable option. Modifications during RC may have a positive or negative impact on survival and quality of life. The extent of pelvic lymph node dissection is one such factor which may positively impact survival outcomes. In addition, preservation of pelvic organs, robotic surgery and the adoption of enhanced recovery after surgery principles continues to improve the postoperative recovery and quality of life in RC patients.

CONCLUSION

There are some ongoing studies in many of these areas, but overall the new advances in MIBC may improve patient quality and quantity of life. The advances in surgical treatment of MIBC are important and the focus of the review here.