Extended lymphadenectomy to the lower paraaortic nodes during radical cystectomy

Evaluation of the diagnostic, prognostic and possible therapeutic role of extended lymphadenectomy to lower para-aortic area in operable bladder cancer patients.

One hundred and nine patients were subjected to the procedure in the National Cancer Institute of Cairo University, and in Minea Oncology Center, Ministry of Health by the same group of surgeons, during the period from September 2000 to March 2003. The lymph nodes dissected were labeled to the following groups: perivesical, lymph node of Cloquet, external iliac, internal iliac and obturator, common iliac and paraaortic groups both right and left. These nodes were subjected with the primary tumor to serial sectioning for histopathologic examination. Preoperatively, all patients were subjected to routine laboratory investigations. In addition to cystoscopy, biopsy and histologic examination, bone scan, chest X-ray and computerized tomography with I.V. contrast examination for the abdomen and pelvis were done for clinical staging of the disease.

34.4% of the node positive patients have been found to harbor the disease in the para-arotic lymph nodes above the common iliac bifurcation. Obturator, external iliac, internal iliac, para-aortic, common iliac, perivesical and lymph node of Cloquet are the higher incidence groups of positive lymph nodes sequentially. The clinical and C.T. staging are inaccurate methods of diagnosis due to high overall error up to 70.6% of patients. There is no higher incidence of morbidity, mortality, operative time or intraoperative blood loss related to the addition of lower para-arotic dissection to the routine radical cystectomy.

Extension of lymphadenectomy to include the lower para-arotic area in addition to the standard pelvic lymphadenectomy during radical cystectomy for bladder cancer is a more accurate technique for diagnosis and staging of bladder cancer patients and it may help in determining the benefit of adjuvant chemotherapy +/- radiotherapy. By itself, it gives a better recurrence-free survival rate without adding higher morbidity or mortality than the standard pelvic lymphadenectomy.