Stage-specific impact of extended versus standard pelvic lymph node dissection in radical cystectomy

To evaluate the impact of an extended versus a standard pelvic lymph node dissection on disease-free survival and cancer-specific survival of patients with non-metastatic muscle-invasive urothelial carcinoma of the bladder treated with radical cystectomy.

We retrospectively analyzed data of 933 patients collected in two prospectively-maintained institutional databases between 2002 and 2010. Patients who met inclusion criteria (high-grade urothelial carcinoma, have not undergone neoadjuvant treatments, have not undergone salvage cystectomy) were included for analysis. The upper boundary was the iliac bifurcation for standard lymph-node dissection and the aortic bifurcation for the extended lymph node dissection, respectively. Univariable and multivariable Cox regression analyses were carried out to identify independent predictors of disease-free survival and cancer-specific survival and, subsequently, the effect of extended lymph node dissection was determined with a multivariable Cox analysis after stratifying for significant covariates.

At multivariable analysis, once adjusted for the effect of the other covariates, extended lymph node dissection was an independent predictor of disease-free survival (hazard ratio 1.95, P < 0.001) and cancer-specific survival (hazard ratio 1.80, P < 0.001). The benefit of an extended pelvic lymph node dissection on disease-free survival and cancer-specific survival was significant across all pT stages (all P < 0.05) except for pT <2 and across all pN stages (pN = 0, P = 0.011 and P = 0.034 for disease-free survival and cancer-specific survival, respectively; pN1 and pN2, all P < 0.001).

The staging accuracy and the survival benefit provided by extended pelvic lymph node dissection suggests the adoption of this template as the standard template for patients with muscle-invasive urothelial carcinoma of the bladder undergoing radical cystectomy.