The role of lymph node dissection in the management of urothelial carcinoma of the upper urinary tract

Abstract

Urothelial carcinoma of the upper urinary tract (UCUUT) is a disease with poor prognosis and a high incidence of lymphatic metastasis at 30-40%. Lymphadenectomy may be a possible surgical strategy to control the spread of lymphatic cancer, but its therapeutic benefit in UCUUT has remained controversial in contrast to bladder cancer in which consensus has been almost reached with respect to the necessity of extended lymphadenectomy. We hypothesized that radical lymphadenectomy may also be important for UCUUT since UCUUT is histologically similar to bladder cancer. One of the major reasons for uncertainty about whether lymphadenectomy has any therapeutic value may have resulted from an incomplete understanding of the regional nodes. Thus, we started our analyses by clarifying this issue, and found that the primary sites of lymphatic metastases encompassed a relatively wide area, especially on the right side, when compared with the conventional recognition. We further reported complete lymphadenectomy in which all regional sites which were dissected appeared to provide a survival benefit for patients with UCUUT at an advanced stage. To date, several studies from the other institutes have added supportive evidence for the therapeutic role of lymphadenectomy. Although there are several points to be determined such as the extent of the template, the minimum number of lymph nodes removed, or the candidate for lymphadenectomy, performing lymphadenectomy is unlikely to have a negative effect on the patient. In the future, we expect that controlled prospective studies will further clarify the potential role of lymphadenectomy in UCUUT.

The role of adjuvant chemotherapy for lymph node‐positive upper tract urothelial carcinoma following radical nephroureterectomy: a retrospective study

“…The impact of a LN dissection on UTUC‐related mortality is currently unknown. Patients with ≥pT2 stage seem to benefit most from a LN dissection . In our present study, LN density was an independent prognostic factor, but it did not impact the effect of AC.…”

Risk of Cancer-specific Mortality following Recurrence After Radical Nephroureterectomy

“…Based on the cumulative data from the literature, it seems that lymphadenectomy could offer a more accurate staging and also may remove (micro-)metastasis thereby resulting into improved outcomes[20, 24]. However, we did not control for the lymph node count nor for the anatomical template of lymphadenectomy, both of which might have influenced our results[20, 27]. Only a prospective study with standardized criteria and a clearly defined template may shed more light on the value of lymph node dissection.…”

Radical nephroureterectomy for pathologic T4 upper tract urothelial cancer: can oncologic outcomes be improved with multimodality therapy?

“…Similarly, a Japanese group found that more complete LnD was associated with survival benefits compared to incomplete or no LnD (24). Moreover, retrospective data suggests that LnD may have more significant staging and therapeutic impact on outcome in patients with locally advanced disease compared to those with localized UTUC (16,24,25). However, even at the high volume academic centers included in this collaboration, LnD was performed only in 40-50% of cases (25).…”

“…Brausi et al demonstrated that LnD performed at the time of RnU significantly improved the survival of patients with invasive UTUC (23). Similarly, a Japanese group found that more complete LnD was associated with survival benefits compared to incomplete or no LnD (24). Moreover, retrospective data suggests that LnD may have more significant staging and therapeutic impact on outcome in patients with locally advanced disease compared to those with localized UTUC (16,24,25).…”