Standard or extended lymphadenectomy in radical cystectomy: what metric of surgical quality for lymph node dissections matters in improving patient outcomes?

摘要

In patients undergoing radical cystectomy (RC) for muscle-invasive urothelial carcinoma, there is widespread agreement that lymph node dissection (LND) is an integral part of the surgical paradigm. LND has been advocated because of the improved accuracy of pathologic staging in identifying patients at high risk for regional or distant recurrence who may benefit from adjuvant chemotherapy and possible resection of micrometastatic nodal lesions [1]. Previous studies have suggested that higher lymph node counts are also associated with improved survival [2,3].Despite this evidence, we have yet to develop a universally accepted metric of surgical quality for LND that reliably predicts survival in all bladder cancer (BCa) patients undergoing RC. Because of the marked variation in the performance and quality of LNDs, efforts to standardize this aspect of the surgery have focused primarily on improving the yield in lymph node counts, increasing attention to a meticulous anatomical dissection, or extending the standard template proximally to include the para-aortic and paracaval nodal regions [2-5].