Main Determinants of the Extent of Lymphadenectomy in Radical Cystectomy: A Study Based on Clinical Practice

  • Luís Vale Serviço de Urologia, Centro Hospitalar São João, Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
  • Filipa Mendes Faculdade de Medicina da Universidade do Porto, Porto, Portugal
  • Luís Pacheco-Figueiredo Serviço de Urologia, Centro Hospitalar São João, Porto, Portugal
  • Tiago Antunes-Lopes Serviço de Urologia, Centro Hospitalar São João, Porto, Portugal
  • João Alturas-Silva Serviço de Urologia, Centro Hospitalar São João, Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Porto, Portugal
  • Carlos Martins-Silva Serviço de Urologia, Centro Hospitalar São João, Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Porto, Portugal
Keywords: Cystectomy, Lymph Node Excision, Urinary Bladder Neoplasms, Urinary Diversion


Introduction: During radical cystectomy of patients with muscle-invasive bladder cancer, pelvic lymphadenectomy is used not only for an accurate staging, but also to provide local and regional control of the disease. Although recent studies evaluating the anatomical extent of lymphadenectomy recommend an extended template, the relation between the extent of lymphadenectomy and the number of dissected nodes remains controversial. The aim of this study was to determine the main predictors of the extent of lymphadenectomy in patients with bladder cancer submitted to radical cystectomy.

Material and Methods: Retrospective analysis of 119 patients with muscle-invasive or selected high-risk non-muscle invasive bladder cancer submitted to radical cystectomy between 2010 and 2015 at our institution.

Results: Standard and extended lymphadenectomy was performed in 87 and 22 patients, respectively. Extended template was statistically associated with a higher number of lymph nodes dissected when compared to standard lymphadenectomy, (14 vs 11 lymph nodes; p < 0.05) and showed a trend toward better overall survival, although without statistical significance (HR = 0.52, 95% CI 0.23-1.21). Extended lymphadenectomy was performed preferentially in patients undergoing an orthotopic bladder substitution (47.8%) relatively to other types of urinary diversion (around 10% - 11%). These patients had more lymph nodes dissected relatively to cutaneous ureterostomy (15 vs 8 lymph nodes), on average.

Conclusion: The surgeon’s decision about the type of urinary diversion to be performed is the main determinant of the extent of lymphadenectomy in patients with bladder cancer undergoing radical cystectomy The number of retrieved lymph nodes was associated with the extent of lymphadenectomy and with a trend toward better overall survival.


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1. Weisbach L, Dahlem R, Simone G, Hansen J, Soave A, Engel O, et al. Lymph node dissection during radical cystectomy for bladder cancer treatment: considerations on relevance and extent. Int Urol Nephrol.
2013;45:1561-7. doi: 10.1007/s11255-013-0503-2.

2. Bi L, Huang H, Fan X, Li K, Xu K, Jiang C, et al. Extended vs non-extended pelvic lymph node dissection and their influence on recurrence-free survival in patients undergoing radical cystectomy for bladder cancer: a systematic review and meta-analysis of comparative studies. BJU Int. 2014;113:E39-48. doi: 10.1111/bju.12371.

3. Stein JP, Lieskovsky G, Cote R, Groshen S, Feng AC, Boyd S, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol. 2001;19:666-75.

4. Dhar NB, Klein EA, Reuther AM, Thalmann GN, Madersbacher S, Studer UE. Outcome after radical cystectomy with limited or extended pelvic lymph node dissection. J Urol. 2008;179:873-8; discussion 8.

5. Herr HW, Bochner BH, Dalbagni G, Donat SM, Reuter VE, Bajorin DF. Impact of the number of lymph nodes retrieved on outcome in patients with muscle invasive bladder cancer. J Urol. 2002;167:1295-8.

6. Leissner J, Ghoneim MA, Abol-Enein H, Thüroff JW, Franzaring L, Fisch M, et al. Extended radical lymphadenectomy in patients with urothelial bladder cancer: results of a prospective multicenter study. J Urol.

7. Davies JD, Simons CM, Ruhotina N, Barocas DA, Clark PE, Morgan TM. Anatomic basis for lymph node counts as measure of lymph node dissection extent: a cadaveric study. Urology. 2013;81:358-63. doi: 10.1016/j.urology.2012.10.025.

8. Seiler R, Thalmann GN, Zehnder P. Pelvic lymph node dissection in the context of radical cystectomy: a thorough insight into the connection between patient, surgeon, pathologist and treating institution. Res Rep Urol. 2013;5:121-8. doi: 10.2147/RRU.S32333.

9. Abol-Enein H, Tilki D, Mosbah A, El-Baz M, Shokeir A, Nabeeh A, et al. Does the extent of lymphadenectomy in radical cystectomy for bladder cancer influence disease-free survival? A prospective single-center study.
Eur Urol. 2011;60:572-7. doi: 10.1016/j.eururo.2011.05.062.

10. Heidenreich A, Pfister D. Anatomic extent of pelvic lymphadenectomy in bladder cancer. Eur Urol Suppl. 2010;9:419-23.

11. Tilki D, Brausi M, Colombo R, Evans CP, Fradet Y, Fritsche HM, et al. Lymphadenectomy for bladder cancer at the time of radical cystectomy. Eur Urol. 2013;64:266-76. doi: 10.1016/j.eururo.2013.04.036.

12. Bochner BH, Herr HW, Reuter VE. Impact of separate versus en bloc pelvic lymph node dissection on the number of lymph nodes retrieved in cystectomy specimens. J Urol. 2001;166:2295-6.

13. Madersbacher S, Hochreiter W, Burkhard F, Thalmann GN, Danuser H, Markwalder R, et al. Radical cystectomy for bladder cancer today--a homogeneous series without neoadjuvant therapy. J Clin Oncol.2003;21:690-6.
doi: 10.1200/JCO.2003.05.101.

14. Shariat SF, Rink M, Ehdaie B, Xylinas E, Babjuk M, Merseburger AS, et al. Pathologic nodal staging score for bladder cancer: a decision tool for adjuvant therapy after radical cystectomy. Eur Urol. 2013;63:371-8. doi:
15. Kassouf W, Svatek RS, Shariat SF, Novara G, Lerner SP, Fradet Y, et al. Critical analysis and validation of lymph node density as prognostic variable in urothelial carcinoma of bladder. Urol Oncol. 2013;31:480-6. doi:

16. Rink M, Hansen J, Cha EK, Green DA, Babjuk M, Svatek RS, et al. Outcomes and prognostic factors in patients with a single lymph node metastasis at time of radical cystectomy. BJU Int. 2013;111:74-84.

17. Stenzl A, Cowan NC, De Santis M, Jakse G, Kuczyk MA, Merseburger AS, et al. Actualizacion de las Guias Clinicas de la Asociacion Europea de Urologia sobre el carcinoma vesical musculo-invasivo y metastasico.
Actas Urol Esp. 2010;34:51-62.

18. Cowan NC, Crew JP. Imaging bladder cancer. Curr Opin Urol. 2010;20:409-13.

19. Whitmore WF, Jr., Marshall VF. Radical total cystectomy for cancer of the bladder: 230 consecutive cases five years later. J Urol. 1962;87:853-68.

20. Koppie TM, Vickers AJ, Vora K, Dalbagni G, Bochner BH. Standardization of pelvic lymphadenectomy performed at radical cystectomy: can we establish a minimum number of lymph nodes that should be removed?
Cancer. 2006;107:2368-74.

21. Konety BR, Joslyn SA. Factors influencing aggressive therapy for bladder cancer: an analysis of data from the SEER program. J Urol. 2003;170:1765-71.

22. Herr HW. Superiority of ratio based lymph node staging for bladder cancer. J Urol. 2003;169:943-5.

23. Abdel-Latif M, Abol-Enein H, El-Baz M, Ghoneim MA. Nodal involvement in bladder cancer cases treated with radical cystectomy: incidence and prognosis. J Urol. 2004;172:85-9.

24. Stein JP, Skinner DG. Results with radical cystectomy for treating bladder cancer: a ‘reference standard’ for high-grade, invasive bladder cancer. BJU Int. 2003;92:12-7.

25. Leissner J, Hohenfellner R, Thuroff JW, Wolf HK. Lymphadenectomy in patients with transitional cell carcinoma of the urinary bladder; significance for staging and prognosis. BJU Int. 2000;85:817-23.

26. Mitra AP, Quinn DI, Dorff TB, Skinner EC, Schuckman AK, Miranda G, et al. Factors influencing post-recurrence survival in bladder cancer following radical cystectomy. BJU Int. 2012;109:846-54. doi: 10.1111/j.1464-410X.2011.10455.x.

27. Capitanio U, Suardi N, Shariat SF, Lotan Y, Palapattu GS, Bastian PJ, et al. Assessing the minimum number of lymph nodes needed at radical cystectomy in patients with bladder cancer. BJU Int. 2009;103:1359-62.
doi: 10.1111/j.1464-410X.2008.08212.x