Is there an oncological benefit to extended lymphadenectomy for muscle-invasive bladder cancer?

The full optimal extent of a pelvic lymph node dissection (PLND) at time of radical cystectomy (RC) has not yet been determined. The diagnostic role of LND is clear and is extremely important for identifying those who may benefit from adjuvant therapy. While retrospective analyses have demonstrated improved survival when the number of lymph nodes is increased and extended LNDs (eLNDs) are performed, these results have yet to be borne out in prospective randomized phase III trials. The recently published LEA AUO AB 25/02 trial is a promising attempt to determine the efficacy of eLND, but unfortunately falls short because of its limited design and therefore, did not demonstrate an improvement in recurrence-free survival (RFS). In an era of increased utilization of neoadjuvant chemotherapy (NAC) providing survival benefit, the ability to demonstrate improved survival with eLND is even more challenging. Currently, we are awaiting the results of SWOG S1011, expectations of achieving a positive trial with improved RFS remains unlikely.