RADICAL CYSTECTOMY: EXTENDING THE LIMITS OF PELVIC LYMPH NODE DISSECTION IMPROVES SURVIVAL FOR PATIENTS WITH BLADDER CANCER CONFINED TO THE BLADDER WALL

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Abstract
Purpose: We assess the influence of the limits of pelvic lymph node dissection on survival following radical cystectomy for bladder cancer. Materials and Methods: From January 1990 to September 1997, 194 patients underwent radical cystectomy without prior treatment. Between March 1993 and September 1997, 126 consecutive patients underwent radical cystectomy with extended pelvic lymph node dissection beginning at the bifurcation of the aorta, including the common and external iliac vessels, presacral nodes and obturator fossa. Between January 1990 and March 1993, 68 consecutive patients underwent radical cystectomy, with limited pelvic lymph node dissection beginning at the bifurcation of the common iliac vessels, including the external iliac vessels and obturator fossa. The cystectomy procedure remained unchanged throughout this period and 1 surgeon performed all procedures. Results: A total of 117 patients had tumors confined to the bladder wall (stage pT3a or less) and 77 had tumors penetrating beyond the bladder into perivesical fat or adjacent structures (stage pT3b or greater). The prevalence of patients with tumors penetrating the bladder was higher in the extended dissection group (42.9 versus 33.8% limited dissection). The incidence of lymphatic involvement was 26.2% and slightly higher in the extended than the limited dissection group. There was a modest improvement in the 5-year recurrence-free survival for the extended dissection group (62 versus 56% limited dissection, p = 0.33), and a substantial improvement for the subgroups with tumors confined to the bladder wall (tumor stage pT3a or less) (85 versus 64%, p <0.02) and without lymph node metastasis (stage pT3a or less, pN0) (90 versus 71%, p <0.02). Accordingly, extended pelvic lymph node dissection reduced the 5-year probabilities for pelvic and distant metastasis (2 versus 7% limited dissection, p = 0.17 and 10 versus 21%, p = 0.15, respectively) for patients with tumors confined to the bladder wall (stage pT3a or less). Survival was similar for patients with pT3b or greater tumor. Conclusions: This retrospective analysis suggests that extending the limits of pelvic lymph node dissection from the bifurcation of the common iliac vessels to the bifurcation of the aorta improves the recurrence-free survival rate for patients undergoing radical cystectomy for bladder cancer confined to the bladder wall (stage pT3a or less).