UROLOGICAL ONCOLOGY

Extended radical lymphadenectomy in patients with urothelial bladder cancer: results of a prospective multicenter study
Leissner J, Ghoneim MA, Abol-Enein H, Thuroff JW, Franzaring L, Fisch M, Schulze H, Managadze G, Allhoff EP, el-Baz MA, Kastendieck H, Buhtz P, Kropf S, Hohenfellner R, Wolf HK
Department of Urology, Otto-von-Guericke-University, Magdeburg, Germany
J Urol. 2004; 171: 139-44

• Purpose: Previous studies demonstrate a positive correlation between postoperative survival and the extent of pelvic lymphadenectomies in patients with bladder cancer. However, the distribution of nodal metastases has not been examined in sufficient detail. Therefore, we conducted a comprehensive prospective analysis of lymph node metastases to obtain precise knowledge about the pattern of lymphatic tumor spread.
• Materials and Methods: Between 1999 and 2002 we performed 290 radical cystectomies and extended lymphadenectomies. Cranial border of the lymphadenectomy was the level of the inferior mesenteric artery, lateral border was the genitofemoral nerve and caudal border was the pelvic floor. We made every effort to excise and examine microscopically all lymph nodes from 12 well-defined anatomical locations.
• Results: Mean total number and standard deviation of lymph nodes removed was 43.1 +/- 16.1. Nodal metastases were present in 27.9% of patients. The percentage of metastases at different sites ranged from 14.1% (right obturator nodes) to 2.9% (right paracaval nodes above the aortic bifurcation). By studying cases of unilateral primary tumors or with only 1 metastasis we observed a preferred pattern of metastatic spread. However, there were many exceptions to the rule and we did not identify a well-defined sentinel lymph node.
• Conclusions: We strongly recommend extended radical lymphadenectomy to all patients undergoing radical cystectomy for bladder cancer to remove all metastatic tumor deposits completely. The operation can be conducted in routine clinical practice and our data may serve as a guideline for future standardization and quality control of the procedure.
  
  
• Editorial Comment
  These authors performed a meticulous lymphadenectomy together with cystectomy in patients with bladder cancer. In analogy to previous approaches in retroperitoneal lymphadenectomy for testis cancer, the lymph nodes were sampled and ordered according to there anatomic origin.
  In general, these data provide interesting information on the rate and the extent of lymph nodular metastases in bladder cancer. Several issues however deserve comments. First, patients with pT1 category (n = 57) only had 1.8 % metastases, whereas pT2a patients had 10.7% and pT2b had 22.2% metastases. All other pT – categories had around 40%, whereas pT4b had 80 % metastases. The percentage of lymph node metastases on all 290 patients was around 3 – 8 % over all anatomical sides, with the exception of the ipsilateral and contralateral paravesical area (14% and 11%). If patients had nodal metastases at level 1 (next to the bladder) 57% of patients of group were also positive at level 2 and 31 % at level 3.
  In conclusion nodal metastases next to the bladder indicate systemic disease. To my opinion, this date would rather provide the rationale for systemic chemotherapy in nodular positive patients.

Dr. Andreas Böhle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany