Abstract
Radical cystectomy has become a standard and effective treatment for muscle-invasive bladder cancer, however, the role and appropriate extent of a concomitant lymphadenectomy continues to evolve. We performed a detailed review of the English medical literature pertaining to the historical development and rationale for an extended lymphadenectomy in patients undergoing radical cystectomy. An historical perspective of lymphadenectomy and an anatomic account of bladder lymphatic drainage are presented. The boundaries and technique of an extended lymphadenectomy are also highlighted. Autopsy and contemporary survival data are presented to suggest that a more extensive lymphadenectomy has both prognostic and therapeutic utility. Furthermore, the stage of the primary bladder tumor, total number of lymph nodes removed, and the lymph node tumor burden are shown to be important prognostic variables in patients undergoing cystectomy with pathologic evidence of lymph node metastasis. Radical cystectomy provides not only excellent local cancer control with low pelvic recurrence rates, but also the best long-term survival. Radical cystectomy with an appropriate extended lymphadenectomy, while surgically more challenging, does not significantly increase the morbidity or mortality of the procedure. Although the absolute limits of the lymph node dissection remain to be determined, there is an evolving body of data to support that an extended lymphadenectomy provides further diagnostic and therapeutic benefit.
Highlights
Bladder transitional cell carcinoma (TCC) makes up nearly 90% of all primary bladder tumors
This study demonstrated lymph node metastases in 19% of cases to the common iliac lymph node packet
Understanding that a lymph node dissection is important in the management of patients undergoing radical cystectomy for bladder cancer, coupled with the fact that a more extensive lymphadenectomy may provide more accurate pathologic staging and survival benefits, one must carefully evaluate the risks associated with an extended lymph node dissection
Summary
Bladder transitional cell carcinoma (TCC) makes up nearly 90% of all primary bladder tumors. 70% of patients with bladder cancer initially present with superficial disease that has not invaded through the lamina propia. One-fourth of patients will either present with or subsequently develop muscle-invasive disease. TheScientificWorldJOURNAL (2005) 5, 891–901 invasive bladder cancer[3], nearly 25% of patients demonstrate pathologic evidence of lymph node metastases at the time of cystectomy[4,5,6,7]. High-grade, muscle-invasive bladder cancer is typically regarded as a potentially lethal disease with high propensity for spread despite definitive therapy. The rational for an extended lymphadenectomy in high-grade, invasive bladder cancer is based on the natural history of the disease process. Tumor cells have access to blood vessels and lymphatics through which they may metastasize to regional lymph nodes or distant sites. This review will evaluate historical and contemporary aspects of the role of a lymphadenectomy in patients undergoing radical cystectomy for invasive TCC of the bladder
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