Lymph node dissection during cystectomy for non-muscle-invasive bladder cancer: A systematic review

Radical cystectomy (RC) is standard for muscle-invasive disease (MIBC) and utilised frequently in high-risk non-muscle-invasive bladder cancer (NMIBC). Pelvic lymph node dissection (PLND) is routinely performed during RC for MIBC, demonstrating a survival benefit. However, the oncologic value in NMIBC remains uncertain. As such, a systematic review was conducted to determine whether PLND confers an oncologic benefit in NMIBC patients undergoing RC.

A systematic search of MEDLINE, Embase and PubMed (January 1989-January 2025) was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (CRD42023443011). Eligible studies included NMIBC patients undergoing RC with or without PLND. Data extraction and quality assessment (ROBINS-I, MINORS) were performed independently by two reviewers.

Twenty-one retrospective studies (n = 35 793) met inclusion criteria. Lymph node positivity ranged from 0% to 13%. Comparative studies consistently demonstrated improved overall survival and cancer-specific survival with PLND, particularly among pT1 subgroups (pooled 5-year OS = 71.8%, 95% CI 59.3-84.3). Several studies demonstrated a dose-response association between lymph node yield or dissection extent and improved outcomes. Benefits were inconsistent for Ta/Tis disease. Pathological upstaging occurred in 16%-36% of clinically staged cohorts. However, study quality was moderate, with heterogeneity in PLND definitions, staging methods and adjuvant treatment use.

PLND appears to improve staging and survival in high-risk NMIBC, especially pT1 disease. Routine PLND for low-risk Ta/Tis disease is unsupported. Standardised definitions of PLND extent and prospective evaluation are needed to confirm its therapeutic role.