Anatomic Extent of Pelvic Lymphadenectomy in Bladder Cancer

ContextThe rationale for locoregional staging lymphadenectomy in bladder cancer lies in the accurate diagnosis of occult micrometastases to stratify patients who might benefit from adjuvant therapeutic measures. In bladder cancer, pelvic lymphadenectomy (PLA) as a common procedure of radical cystectomy has not been standardized, although evidence supports a relationship between the extent of lymph node dissection and therapeutic outcome.Evidence acquisitionRecent retrospective and prospective clinical trials have carefully analyzed the distribution of lymph node metastases at time of radical cystectomy, thereby identifying those regions that should be included in a standard pelvic lymph node dissection.Evidence synthesisDissecting all lymphatic tissue along the common iliac region—with the aortic bifurcation as cranial margin—along the external, internal iliac region, and the obturator fossae bilaterally will completely clear 80% of all positive nodes. Only if frozen section examination will demonstrate micrometastases at these regions will extending lymphadenectomy further cranially be worthwhile.ConclusionsCurrently, extended PLA in bladder cancer has been shown to improve progression-free survival if >14 lymph nodes are removed. For the future, prospective trials have to demonstrate a benefit with regard to cancer-specific and overall survival and in terms of regional versus distant recurrences.