The Role of Lymphadenectomy in Radical Cystectomy

Detection of lymph node metastases in patients undergoing radical cystectomy and pelvic lymph node dissection (PLND) for bladder cancer indicates poor prognosis. For pretreatment assessment of lymph node status, computed tomography and magnetic resonance imaging are generally performed, both of which show a low sensitivity of approximately 30%. Newer imaging techniques are being developed; however, it will take time until they can be used in everyday clinical practice. Therefore, PLND remains the only reliable method for lymph node staging in the pelvis. The extent of PLND remains a matter of discussion, but a recent study mapping the lymphatic drainage from the bladder suggests that the template for an appropriate PLND at cystectomy should include the external iliac, obturator, and internal iliac region (lateral and medial to the internal iliac vessels) as well as the common iliac vessels up to the uretero-iliac junctions bilaterally. Additionally, the lymph nodes of the fossa of Marcille should be removed. Questions remain about whether it is worthwhile to resect the few draining lymph nodes between the uretero-iliac junctions and the inferior mesenteric artery with regard to both the increased risk of complications and the injury to the autonomic sympathetic nerves. In addition, PLND at the time of radical cystectomy not only is associated with more accurate staging but also allows removal of undetected micrometastases in patients with bladder cancer. Evidence is growing that extended PLND in patients with bladder cancer may confer a survival benefit for node-positive and node-negative patients without increasing morbidity.