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

Rahul Jena,Gautam Ram Choudhary,Aditya Prakash Sharma,Aneesh Srivastava,Nikita Shrivastava

doi:10.3389/fsurg.2021.687636

Abstract

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.

Highlights

Each year, more than 400,000 patients worldwide are diagnosed with bladder cancer of which ∼30% are muscle invasive [1]
The question arises as to how should one assess the adequacy of pelvic lymph node dissection (PLND)? Whether it is the levels of pelvic lymph nodes removed, the anatomical template of dissection followed, the lymph node count or the lymph node density remains a bone of contention? Adding to this confusion, is the frequent use of non-standardized nomenclature in denoting the extents of PLND across various studies
We suggest certain points which can bring a uniformity to this procedure and facilitate better reporting of the outcomes of PLND for muscle invasive bladder cancer (MIBC)

Summary

Introduction

More than 400,000 patients worldwide are diagnosed with bladder cancer of which ∼30% are muscle invasive [1]. Radical cystectomy (RC) with bilateral pelvic lymph node dissection (PLND) is the standard of care for recurrent high risk non muscle invasive bladder cancer (NMIBC) and muscle invasive bladder cancer (MIBC) [2, 3]. A thorough bilateral PLND increases the staging procedure’s accuracy and provides a probable survival benefit in patients of MIBC irrespective of the nodal involvement [7, 8]. We attempted to review the existing literature related to the levels of pelvic lymph nodes and the various templates of PLND defined by different authors to bring clarity to this issue.

Methods

Results

Conclusion