Does extended lymphadenectomy preclude laparoscopic or robot-assisted radical cystectomy in advanced bladder cancer?

Open radical cystectomy with an appropriate bilateral lymph node dissection (LND) is currently the standard treatment for patients with muscle-invasive bladder cancer. Approximately 25% of patients with stages T1-T4 N0 M0 harbour metastatic lymph nodes at the time of radical cystectomy. Results from open high volume radical cystectomy series suggest that a more extended LND provides the best survival outcomes and the lowest local recurrence rates. Currently, there is controversy whether laparoscopic or robot-assisted extended LND at radical cystectomy is technically feasible and whether it can provide oncological control equivalent to open LND series at the time of radical cystectomy.

Laparoscopic LND is technically demanding and requires prolonged operation time. Most studies to date indicate that fewer nodes are removed than with an open approach, putting a question mark to this surgical approach from an oncological point of view. Limited data on lymph node yield using a robot-assisted approach are available; however, several series found similar results as in open series.

At present, there is no conclusive evidence showing that laparoscopic LND gives similar results than open LND. Robot-assisted LND is still in its learning curve and more patient series are needed.