What is the role of lymph node dissection in the surgical treatment of urothelial tumors of the renal pelvis and ureters?

Updated: Aug 07, 2020
  • Author: Kyle A Richards, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Several studies have demonstrated a significant survival advantage in patients undergoing extensive regional lymphadenectomy at the time of open nephroureterectomy. In a retrospective analysis of 169 patients who underwent nephroureterectomy for non-metastatic upper tract urothelial carcinoma, Kondo et al reported a definite survival advantage in lymph node–positive patients with higher T stages, namely pT3 and above, who underwent a complete lymphadenectomy. Multivariate analysis showed that complete lymphadenectomy was a significant prognostic factor for cancer-specific survival (P = 0.009) as well as T stage (pT3 or less, P = 0.0004) and tumor grade (G3, P = 0.0001). [59]

A multi-institutional retrospective study by Matin et al identfied characteristic patterns of lymph node metastasis in upper tract urothelial carcinoma, depending on the side and anatomical location (eg, renal pelvis; proximal, mid-, or distal ureter) of the primary tumor. On the basis of those data, these authors constructed standardized templates for lymph node dissection. [60] See the image below.

Graphic representation of templates for lymph node Graphic representation of templates for lymph node dissection in patients with upper tract urothelial carcinoma, as proposed by Matin et al. For tumors in the right pelvis and upper ureter, dissection encompassing the right hilar, paracaval, and retrocaval regions (orange) will remove 82.9% of the involved lymph nodes. Adding the inter-aortocaval region (green) will improve coverage to 95.8%. For left-sided pelvic tumors, removal of hilar and para-aortic lymph nodes (violet) will ensure removal of 86.9% of the involved nodes. Adding inter-aortocaval lymph nodes (green) will increase the coverage to 90.2% of involved nodes. The level of dissection along the great vessels varies for pelvic tumors. The lower limit is the inferior mesenteric artery. For upper ureteric tumors, dissection should extend up to the aortic bifurcation. For distal ureteric tumors, pelvic template dissection involving the common iliac, external iliac, obturator, and internal iliac nodes will remove 75% of involved nodes on the right side and 83.3% of involved nodes on the left side (orange and violet circles). However, adding paracaval groups for tumors on the left side (orange rectangle) and para-aortic groups for those on the right side (violet rectangle) will improve coverage to almost 100%.

For tumors in the right pelvis and upper ureter, Matin et al concluded that a dissection template encompassing the right hilar, paracaval, and retrocaval regions will remove 82.9% of the involved lymph nodes. Adding the inter-aortocaval region to the template will improve coverage to 95.8%. [60]

For left-sided pelvic tumors, removal of hilar and para-aortic lymph nodes will ensure removal of 86.9% of the involved nodes. Adding inter-aortocaval lymph nodes will increase the coverage to 90.2% of involved nodes. [60]

The level of dissection along the great vessels varies for pelvic tumors. The lower limit is the inferior mesenteric artery. For upper ureteric tumors, dissection should extend up to the aortic bifurcation. [60]

For distal ureteric tumors, pelvic template dissection involving the common iliac, external iliac, obturator, and internal iliac nodes will remove 75% of involved nodes on the right side and 83.3% of involved nodes on the left side. However, adding paracaval groups for tumors on the left side and para-aortic groups for those on the right side will improve coverage to almost 100%.The final decision regarding the utility and extent of lymphadenectomy is at the discretion of the surgeon and can be modified by the intraoperative findings. [60]

Lymphadenectomy has both diagnostic and therapeutic purposes. In the TALL (T staging, architecture [papillary vs sessile],  lymphovascular invasion, lymphadenectomy) multivariable prognostic variable created by Youssef et al, absence of lymphadenectomy  is a poor prognostic factor. [61]


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