Clinical outcome after cystectomy in patients with lymph node-positive bladder cancer

Whereas radical cystectomy is the standard of care in high-grade, invasive bladder tumors, the extent of lymphadenectomy and its diagnostic and/or therapeutic potential is controversial. Independent predictors for lymph node involvement are T-stage, histological grading and lymphovascular invasion. Preoperative assessment, including 3D magnetic resonance imaging and sentinel node detection, are promising concepts for the future. The extension of lymphadenectomy is not yet defined, although prospective data regarding the absence of skipped lesions in the case of pelvic lymphadenectomy and the damage of autonomic nerves in the case of extensive lymphadenectomy are arguments for a limited or stepwise approach. Outcome of N1 patients appears to be nearly equivalent to N0 patients in organ-confined tumors, whereas the outcome of N3 patients is poor in all studies presented to date. Therefore, it has been suggested that a meticulous lymphadenectomy in N1 patients, with positive lymph nodes almost exclusively localized within the endopelvic region, has a long-term therapeutic impact in terms of an improvement in the patient's clinical prognosis. For N2 patients, a long-term survival benefit from extensive lymphadenectomy remains to be demonstrated. Recognizing the inevitably poor clinical prognosis in cases with gross nodal involvement (N3), the clinical value of an extended lymph node dissection in these patients is very questionable.