Surgical and chemotherapeutic management of regional lymph nodes in bladder cancer

Purpose: While approximately 25% of patients undergoing radical cystectomy for bladder cancer have nodal metastases, the role and extent of pelvic lymphadenectomy remain controversial. Patients with lymph node metastases have a poor prognosis despite increases in the use of an extended lymphadenectomy template and in the administration of systemic chemotherapy. We summarize the surgical and chemotherapeutic approaches to the regional spread of disease in patients with muscle invasive bladder cancer.

Materials and methods: We performed a PubMed® search to identify relevant bladder cancer studies, focusing on those published between 2001 and 2011.

Results: There remains substantial disagreement regarding the anatomical extent of lymphadenectomy, including whether presacral and retroperitoneal lymph nodes above the aortic bifurcation should be included. Extended lymphadenectomy has been associated with improved survival in multiple studies. However, whether this relates to improved staging or a true therapeutic benefit is currently difficult to discern. In addition, given that neoadjuvant chemotherapy likely benefits patients with occult nodal metastases to a greater extent than those with organ confined disease, the ability to accurately predict nodal status before surgery would help to selectively tailor the use of neoadjuvant chemotherapy in patients undergoing cystectomy.

Conclusions: Recent findings have continued to lend strong support to the value of extended lymphadenectomy, and 2 ongoing phase III trials will help determine the survival benefit of extended lymphadenectomy. Further improvements in preoperative risk stratification, including advances in imaging technology, may help refine decisions regarding the extent of surgery and the use of neoadjuvant chemotherapy in these individuals.