Lymph node dissection during nephroureterectomy: Establishing the existing evidence based on a review of the literature

Abstract

To determine the role of lymph node dissection (LND) in the treatment of upper tract transitional cell carcinoma (UTTCC), as the role of LND along with nephroureterectomy in treating UTTCC is unclear and several retrospective studies have been published on this topic with conflicting results. Methods: The Medical Literature Analysis and Retrieval System Online (MEDLINE), the Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials database (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Clinicaltrials. gov, Google Scholar, and individual urological journals, were searched for all studies investigating the role of LND in the treatment of UTTCC. Of the studies identified, those that met inclusion criteria were included in this review. Results: In all, 27 studies were included in this review, with 9303 patients who underwent LND. No randomised controlled trials (RCTs) were identified. Tumours were located in the renal pelvis in 62% of patients, in the ureter in 35.5%, and multifocal in 2.3%. In total: 77.1% were LN-negative and 22.9% had LN metastasis. For all patients undergoing LND, the 5-year recurrence-free survival (RFS) and cancer-specific survival (CSS) rates were 27-65.4% and 32.3-95%, respectively. For patients who underwent a LND in accordance with a standardised anatomical template, the 5-year RFS and CSS rates were 84.3-93% and 83.5-94%, respectively. Conclusion: LND may provide a survival benefit in patients undergoing nephroureterectomy for UTTCC, particularly if following a standardised anatomical template and in those patients with muscle-invasive disease; however, a prospective RCT is required to confirm this.

Survival Benefits Based on the Number of Lymph Nodes Removed during Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: Systematic Review and Meta-Analysis

“…Feared morbidity might be, at least in part, the reason most surgeons hesitate to perform LNDs [ 8 ]. However, perioperative mortality and morbidity due to LND are not serious, reported to be 0% and 14.2% (Clavien–Dindo classification ≥ grade 3 = 3.9%), respectively [ 3 ]. In another study, only chylous lymphatic leaks were directly attributable to the extended LND component of the procedure, occurring in only one of 19 patients [ 29 ].…”

“…Upper tract urothelial carcinoma (UTUC) is a relatively rare neoplasm that accounts for approximately 5–10% of all urothelial carcinoma (UC), and the annual incidence in Western countries is one to two cases per 100,000 inhabitants [ 1 , 2 ]. However, UTUC is a highly aggressive malignancy that tends to present with lymph node (LN) metastasis in 20–40% of the patients as early as the initial diagnosis with invading musculature [ 3 , 4 ]. LN metastasis is a well-established poor prognostic factor with a five year survival rate of 10–30% [ 5 ].…”

“…Currently, there are no guidelines regarding its role [ 2 ]. This may be due to the difficulty of establishing evidence because of its low incidence [ 3 ]. Therefore, it is a suitable subject for a systematic review and meta-analysis.…”

Complications and their management following retroperitoneal lymph node dissection in conjunction with retroperitoneal laparoscopic radical nephroureterectomy

“…Similar to bladder cancer, which is also an urothelial cancer, LND is expected to improve prognosis. The utility of LND for UTUC has been recently reported via systematic reviews and meta‐analyses 2–5 . The evidence level is considered low because of the lack of randomized trials.…”

“…The utility of LND for UTUC has been recently reported via systematic reviews and meta-analyses. [2][3][4][5] The evidence level is considered low because of the lack of randomized trials. However, various guidelines recommend LND for UTUC.…”