Extended versus limited lymph node dissection in radical cystectomy: Impact on recurrence pattern and survival

Objectives: To compare recurrence patterns and survival of patients with carcinoma of the urinary bladder undergoing radical cystectomy and extended or limited lymph node dissection. Methods: From a consecutive series of 469 patients undergoing radical cystectomy, two different historical cohorts were constructed; one with 265 patients intentionally undergoing extended lymph node dissection and one with 204 patients undergoing limited lymph node dissection. Results: Early lymph node recurrences were more frequently located outside the pelvic region in patients from the extended lymph node dissection cohort, whereas the overall risk of recurrence was not reduced by carrying out an extended lymph node dissection compared with the limited lymph node dissection cohort (8% vs 6%, P = 0.5). However, positive node patients had a significantly better prognosis after extended lymph node dissection (5-year disease-specific survival 29% vs 8%, P = 0.002). Improved survival was also found in negative node patients with non-organ confined tumors undergoing extended lymph node dissection compared with limited lymph node dissection (5-year disease-specific survival 76% vs 62%, P = 0.008). A total of 16 positive node patients (6%) in the extended lymph node dissection cohort were identified as possible stage migrators with metastasis exclusively in lymph nodes outside the limited template. A total of 5% of patients undergoing extended lymph node dissection had an evident survival benefit of an extended lymph node dissection compared with a limited lymph node dissection. Conclusions: Extended lymph node dissection provides more accurate nodal staging than a limited lymph node dissection. However, recurrence patterns are not significantly altered by extending the limits of lymph node dissection, suggesting a survival benefit only in a minority of patients. Improved survival is more likely in patients with locally advanced disease.