What Is the Proper Extent of Lymph Node Dissection During a Radical Cystectomy for Bladder Cancer?

Radical cystectomy with pelvic lymph node dissection remains the standard of care for muscle-invasive and high-risk nonmuscle-invasive bladder cancer. Lymphatic mapping studies demonstrate that primary drainage traverses the true pelvis, with most metastatic nodes located below the aortic bifurcation. Two randomized trials failed to show a survival benefit from extended dissection, though both were limited by enrolment of lower-risk populations and underpowered to detect true treatment effects. A risk-adapted approach is recommended, reserving extended dissection for higher-risk patients while recognizing that a subset of node-positive patients can achieve long-term disease-free survival with surgery alone.