The Role and Extent of Pelvic Lymphadenectomy in Patients with Grossly Node Positive Bladder Cancer

Objective:Should the surgeon proceed with surgery when grossly positive lymph nodes are found at surgery? To answer this question, we evaluated the outcome of patients after radical cystectomy and extended pelvic lymph node dissection for grossly node positive bladder cancer. Patients and methods.- A total of 56 patients with grossly node positive bladder cancer (N2-3) found at surgery underwent radical cystectomy (for males) and anterior pelvic excentration (for females) with bilateral extended pelvic lymph node dissection at National Cancer institute, Cairo University between March 2004 and November 2009. Of these patients, 48 were males and 8 were females with a mean age of 61.8 years (range 39-78). The median and overall 5-year survival rates were evaluated demonstrating their relation to the primary bladder tumour stage, pathological subgroups, lymph node (LN) capsular perforation, lymph node density (total number of positive LNs /total number of LNs removed) as well as the administration of adjuvant chemotherapy. Results: The overall 5-year survival rate was 27%. The median overall survival was 18 months. Patients with grossly node positive bladder cancer and organ confined bladder tumour had significantly better 5-year survival compared with those with extravesical tumour extension (47.6% versus 14.3% P=0.025 ). The 5-year survival of 24 patients ( 43%) with no lymph node capsular perforation was 46% compared with 12.5% for 32 patients (57%) with capsular perforation (P=0.0027 ). The concept of lymph node density was also a significant prognostic factor. Patients with a lymph node density of 20% or less had a 36% 5-year survival rate compared with 13% survival at 5 years when lymph node density was greater than 20% (P=0.004). Again, patients who received postoperative adjuvant chemotherapy showed a better 5-year survival rate compared with those who did not receive (43% versus 17% P= 0.033). Conclusion: long term survival is possible in patients with grossly node positive bladder cancer. A proportion of those patients can be cured with radical cystectomy and thorough extended pelvic lymph node dissection especially those in whom the primary tumour is confined to the bladder, without lymph node capsular perforation and with low lymph node density.