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

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.

Minimizing the learning curve for robotic-assisted radical cystectomy

“…Our mean lymph node count was above the minimum suggested number of 12, and modern nomograms did not identify any correlation between lymph node count and cancer specific survival. [16,17] Our results demonstrate that we had achieved lower There are several limitations to our study. Follow-up was limited to the first 90-days post-operatively, and as such long term surgical (stoma revision, stricture formation) and oncologic outcomes are not reported.…”

Extent of lymph node dissection and impact on survival in radical cystectomy for advanced bladder cancer

“…The definition of the boundaries of different LND templates was rather inconsistent across studies. Most comparative studies arbitrarily used the terms 'limited' and 'extended' to define the narrower and wider extent of the LNDs [26].…”

Extended pelvic lymph node dissection in muscle invasive bladder cancer

“…Using standardized terminology has become important following various definitions for differing extent of dissections. In this review, we will utilize the following terminology described by the EAU Working Group on MIBC [4,[6][7][8][9][10][11].…”