How is lymphadenectomy performed during a radical cystectomy?

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

Dissect the adventitia from the external and common iliac vessels and isolate all of the perivascular lymphatic tissue. Enter the obturator space, being cognizant of accessory obturator vessels and the obturator nerve. Most surgeons clip all lymphatics to limit the incidence and size of lymphoceles. Standard lymphadenectomy template borders are typically as follows:

  • Lateral - Genitofemoral nerve on the psoas muscle

  • Superior - Aortic bifurcation

  • Inferior - Inguinal ligament, including the node of Cloquet

  • Medial - Perivesical tissue

As detailed in Surgical therapy, if the standard template is without gross or microscopic disease, stopping the lymph node dissection is reasonable. Recently, some surgeons have adopted an extended lymph node dissection, including the distal paracaval, distal paraaortic, and presacral regions, in all patients. Studies have shown that the survival rate is related to the total number of lymph nodes removed, regardless of the number of positive lymph nodes (for further detail, see Outcome and Prognosis). [18]

The survival rate is likely related to more accurate pathologic staging and the removal of lymph nodes with micrometastatic disease that the pathologist does not identify; therefore, a more extensive lymph node dissection is often advocated. Another rationale for an extended lymph node dissection is that more limited templates (caudal to the bifurcation of the iliac vessels) are associated with pelvic recurrence rates as high as 30%.

If grossly positive lymph node disease is encountered, consider whether the lymph nodes can be safely and completely resected. If this can be fully achieved, proceed with the lymphadenectomy. Up to 25% of patients with lymph node–positive disease survive long-term, as detailed in Outcome and Prognosis.


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