Management of invasive bladder cancer: a meticulous pelvic node dissection can make a difference

During an 8-year period 159 patients with primary epithelial carcinoma of the bladder were operated upon in anticipation of cure. At the operation 6 patients (4 per cent) were found to be inoperable because of extensive disease above the aortic bifurcation. Therefore, 153 patients underwent a meticulous bilateral pelvic iliac lymph node dissection with en bloc radical cystectomy and urinary diversion as a single stage procedure. Of these 153 potentially curable patients 36 had positive nodes histologically. Analysis of these 36 patients revealed that the presence or absence of nodal metastases cannot be predicted accurately on the basis of T or P category of the primary tumor, although the frequency of nodal disease increased with deeper penetration of the bladder wall. The incidence of positive pelvic nodes is 5 to 10 per cent in patients with P1 tumors, 30 to 35 per cent in those with P2 or P3A tumors and 50 to 66 per cent in those with P3B and P4 tumors. The presence of positive pelvic nodes does not mean incurability since the 2, 3 and 5-year survival rates for these patients are 46, 36 and 36 per cent, respectively. In this small series of patients with nodal metastases the extent of the primary tumor (P stage) did not relate to survival. Pelvic recurrence as the first site of failure was noted in only 2 of 22 patients with metastatic disease. Experience indicates that pelvic node dissection does not increase the morbidity associated with cystectomy, can cure some patients with metastatic disease, effectively controls pelvic disease and indicates which patients are at substantial risk for systemic metastatic disease, implying the need for development and use of systemic chemotherapy.