Editing Muscle-Invasive Bladder Cancer (section)

==== Pelvic lymphadenectomy====

===== Indications =====
*'''<span style="color:#ff0000">Bilateral pelvic lymphadenectomy must be performed at the time of any surgery with curative intent[https://pubmed.ncbi.nlm.nih.gov/28456635/ ★]</span>'''
** Bilateral pelvic lymphadenectomy should be performed in ALL patients, including those with unilateral bladder wall involvement, due to documented crossover risk to the contralateral lymphatic chain.

===== Extent of lymphadenectomy =====
*'''<span style="color:#ff0000">When performing bilateral pelvic lymphadenectomy, at a minimum, the external and internal iliac and obturator lymph nodes should be removed[https://pubmed.ncbi.nlm.nih.gov/28456635/ ★]</span>'''
**'''To facilitate adequate staging, a standard lymphadenectomy''' (bilateral external iliac, internal iliac and obturator lymph nodes), at a minimum, '''needs to be completed with >12 lymph nodes evaluated'''
**Submission of separate nodal packets appears to facilitate identification of lymph nodes and is associated with an increased number of reported lymph nodes

====== <span style="color:#ff00ff">SWOG S1011 (NEJM 2024)  ======
* Population: 592 patients with localized muscle-invasive bladder cancer of clinical stage T2 (confined to muscle) to T4a (invading adjacent organs) with two or fewer positive nodes (N0, N1, or N2) 
* Randomized to: bilateral standard lymphadenectomy (dissection of lymph nodes on both sides of the pelvis) or extended lymphadenectomy involving removal of common iliac, presciatic, and presacral nodes.
* Primary outcome: disease-free survival
* Results:
** Median follow-up: 6.1 years
** Disease-free survival: no significant difference
** Overall survival: no significant difference
** Extended lymphadenectomy was associated with higher perioperative morbidity and mortality
* Standard or Extended Lymphadenectomy for Muscle-Invasive Bladder Cancer. Lerner et al. NEJM 2024.

====== <span style="color:#ff00ff">LEA AUO AB 25/02 (European Urology 2019)</span> ======

* Population: 401 patients with locally resectable T1G3 or muscle-invasive urothelial bladder cancer (T2-T4aM0)
* '''Randomized to limited''' (obturator, and internal and external iliac nodes) '''vs. extended LND''' (in addition, deep obturator, common iliac, presacral, paracaval, interaortocaval, and para-aortal nodes up to the inferior mesenteric artery).
* Primary outcome: recurrence-free survival
* Secondary outcomes: cancer-specific survival, overall survival, complications
* Results:
** Median number of dissected nodes: limited 19 vs. extended 31
** '''Primary outcome: no significant difference in recurrence-free survival''' (5-yr RFS 65% extended vs 59%; p=0.36)
** Secondary outcomes:
*** No significant difference in cancer-specific survival (5-yr CSS 76% vs 65%; p=0.10)
*** No significant difference in overall survival (5-yr OS 59% vs 50%; p=0.12)
*** Clavien grade ≥3 lymphoceles were more frequently reported in the extended LND group within 90 days after surgery.
* [https://pubmed.ncbi.nlm.nih.gov/30337060/ Gschwend, Jürgen E., et al.] "Extended versus limited lymph node dissection in bladder cancer patients undergoing radical cystectomy: survival results from a prospective, randomized trial." European urology 75.4 (2019): 604-611.