RECONSTRUCTIVE UROLOGY

Lymphadenectomy with cystectomy: is it necessary and what is its extent?
Ghoneim MA, Abol-Enein H
Urology & Nephrology Center, Gomhouria Street, Mansoura, Dakahlia 35516, Egypt
Eur Urol. 2004; 46: 457-461

• No Abstract Available
  
  
• Editorial Comment
  Several decades ago, well known urologic surgeons in the field made it clear that lymphadenectomy is an important part of anterior exenteration. It was, however, thought to be useful only for staging. More recent reports, however, both from the USA and Europe have shown that patients with minimal involvement of lymph nodes and curable primary transitional cell cancer of the bladder may survive even without further adjuvant treatment. This means that nodal disease defined as N-1 in the TNM system can be cured surgically, at least in some cases. In one larger report the authors even found the T-stage to be more important and the actual prognostic factor for survival regardless whether patients were staged as N-0 or N-1 [1]. This prompted some authors to propose an extension of pelvic lymphadenectomy cranially to the common iliac and the para-aortic region.
  The para-aortic and especially the common iliac region were the main trunk of the sympathetic fibers supplying the hypogastric plexus could be found. The division of these fibers may lead to functional problems in the remnant urethra in patients undergoing an orthotopic neobladder after cystectomy [2]. The present paper by two well-known experienced surgeons is a well worked-up series of 200 patients undergoing radical cystectomy and extended lymphadenectomy. Only two surgeons performed all cystectomies, thereby reducing the possibility of an operator dependent variation. The nodes from each anatomic region were sent on a separate template for pathologic evaluation. It was demonstrated that none of the patients with minimal lymph node disease-and those were the ones that had a chance of cure-had nodal involvement outside the pelvic region. They did find extrapelvic nodal disease, but in all cases these pN2 patients. Most of us agree with the authors’ conclusion that these are not the patients which can be cured surgically.
  For reconstructive purposes it is important that we can limit our lymphadenctomy in certain patients to a level where we do not have to dissect the sympathetic autonomic nerve supply to the hypogastric plexus and pelvic floor. Thereby functional results of an orthotopic neobladder and vagina can be improved without compromising oncological results.

References
1. Vieweg J, Gschwend JE, Herr HW, Fair WR: The impact of primary stage on survival in patients with lymph node positive bladder cancer. J Urol. 1999; 161: 72-6.
2. Stenzl A, Colleselli K, Bartsch G: Update of urethra-sparing approaches in cystectomy in women. World J Urol. 1997; 15: 134-8.

Dr. Arnulf Stenzl
Professor and Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany