What is the role of bilateral pelvic lymphadenectomy during radical cystectomy?

Updated: Nov 27, 2016
  • Author: Michael Christopher Large, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

A lymph node dissection must be bilateral and should include either a standard or extended template. A standard pelvic lymph node dissection generally includes removal of the bilateral external iliac, obturator, internal iliac (hypogastric), and common iliac lymph node chains. An extended dissection includes all nodes from the standard template plus paracaval, interaortocaval, para-aortic, and presacral lymph nodes.

Two recent studies have detailed the pattern of lymphatic spread for bladder cancer. A group from Mansoura, Egypt performed pelvic lymph node dissections (extending cranially to the inferior mesenteric artery) in 200 consecutive patients and harvested a mean of 50 lymph nodes per patient. Twenty-three of the patients had only one positive lymph node. Twenty-two of the positive lymph nodes were located in the obturator or hypogastric region. Based on these data, the obturator and hypogastric region may represent sentinel regions. Thus, the authors suggest that a pelvic lymph node dissection should include the obturator and hypogastric regions and that, if the frozen sections are negative for metastatic deposits, extending the lymphadenectomy to other regions may be of limited utility.

A separate analysis of 290 lymphadenectomies from a European multicenter trial identified 7% of patients with metastases in only the external iliac/internal iliac/obturator region, 7% of patients with metastases in only the common iliac region, and no patient with metastases more proximal to the common iliac region without also having more caudal regions of metastases. [15]

In concert with the previously detailed study, these findings suggest that the lymph node regions caudal to the aortic bifurcation may represent the initial areas of metastatic spread. Because some patients have a solitary positive lymph node in the common iliac region, this area should be included in the pelvic lymphadenectomy. In 2008, a retrospective study compared patients who underwent cystectomy plus limited pelvic lymph node dissection in the United States with a matched group who underwent cystectomy and extended lymph node dissection in Europe. [16] The group who underwent limited pelvic lymphadenectomy were found to have suboptimal staging, a higher rate of local progression, and a lower recurrence-free survival at 5 years (7% vs 35% for N+; 67% vs 77% for T2N0). While stage migration may be a confounding factor in this analysis, the study reflects a growing trend in oncologic surgery toward more extensive lymphadenectomies.

Always attempt a thorough lymph node dissection; however, dissection cannot be safely performed in some rare circumstances, such as the following:

  • Extensive radiation changes

  • Prior pelvic surgery

  • Large arterial aneurysms

  • Severe patient comorbidities that limit the length of surgery

  • Large volume, fixed lymphadenopathy


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