Pelvic lymph node dissection before or after laparoscopic radical cystectomy: An ambispective study comparing ease of surgery and operative outcomes

Introduction: It is unclear when pelvic lymph node dissection (PLND) should be performed during laparoscopic radical cystectomy. Proponents of PLND performed before cystectomy claim that early PLND skeletonizes the urinary bladder's vascular pedicles, making cystectomy easy. Others contend that an early cystectomy provides space and flexibility during subsequent PLND. This first-of-its-kind study compared PLND before and after cystectomy for the ease of performing surgery (total operative time, cystectomy time, and PLND time) and the operative outcomes (number of lymph nodes removed, blood loss, and complication rates). Methods: This ambispective cohort study included a predetermined sample size of 44 patients. The first 22 patients underwent PLND after cystectomy (Group 1), and the following 22 underwent PLND before cystectomy (Group 2). The primary outcome was total operative time. Secondary outcomes included cystectomy time, PLND time, number of lymph nodes removed, blood loss, and complication rates. Results: The baseline characteristics were similar in both groups. The total operative time (344.23 +/- 41.58 min vs. 326.95 +/- 43.63 min, P = 0.19), cystectomy time (119.36 +/- 34.44 min vs. 120.91 +/- 35.16 min, P = 0.53), PLND time (126.82 +/- 18.75 min vs. 119.36 +/- 23.34 min, 0.25), number of dissected lymph nodes (13.27 +/- 4.86 vs. 14.5 +/- 4.76, P = 0.40), and blood loss (620.45 +/- 96.23 ml vs. 642.27 +/- 131.8 ml, P = 0.20) were similar in the two groups. The complication rates categorized by Clavien-Dindo grading were identical in the two groups. Conclusions: PLND done after cystectomy was comparable to PLND done before cystectomy regarding the ease of surgery and the operative outcomes.