Standard or Extended-the Controversy of Extent of Lymphadenectomy during Radical Cystectomy Continues

Radical cystectomy in patients with bladder cancer includes regional lymph node (LN) dissection. There is growing body of evidence suggesting that extended bilateral pelvic LN dissection may confer a survival benefit for surgically appropriate patients with bladder cancer. Accurate node status can only be ascertained by lymphadenectomy. Besides pathological tumor stage, lymph node status is the strongest prognostic factor. The pelvic lymphadenectomy (LND) during radical cystectomy for muscle invasive bladder cancer is now standard of care. However, the optimal extent of the LND remains dubitable. Some recent work from the mapping studies and retrospective analyses has shown that the extended LND up to the mid-upper third of the common iliac vessels appears to provide further prognostic and therapeutic benefit and therefore should be defined as standard LND. The extent of LND suggested is applicable to all form surgical extirpation of the urinary bladder i.e. open surgery, minimally invasive approach (laparoscopic and robot assisted). The role of LND is more controversial in non-muscle invasive cancer. The concept of total lymph node count is now not considered a quality criterion because nodal yield is overly influenced by the individual patient's anatomy, surgical technique, template applied and pathological work-up. Lymph node density is thought to be a superior prognostic factor, but it is similarly influenced by the above-mentioned factors. Concerning molecular techniques to improve the sensitivity of postoperative nodal staging further research is necessary. There are few ongoing prospective randomized trials will potentially help to further define the optimal LND template.