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==== Template ==== * '''<span style="color:#ff0000">Bilateral pelvic lymph node dissection should be performed with removal, at minimum, of the (3)</span>''' *#'''<span style="color:#ff0000">Obturator lymph nodes</span>''' *#'''<span style="color:#ff0000">Internal iliac lymph nodes</span>''' *#'''<span style="color:#ff0000">External iliac lymph nodes</span>''' ===== Boundaries ===== * '''<span style="color:#ff0000">Superiorly: ureter/bifurcation of the common iliac artery</span>''' * '''<span style="color:#ff0000">Inferiorly: circumflex iliac vein and Cloquet’s node/Cooper ligament at the femoral canal</span>''' * '''<span style="color:#ff0000">Laterally: genitofemoral nerve</span>''' * '''<span style="color:#ff0000">Medially: bladder and internal iliac artery</span>''' * '''<span style="color:#ff0000">Posteriorly: obturator nerve/fossa</span>''' ===== Extended lymph node dissection ===== *Many retrospective studies have suggested a survival benefit of extending the cystectomy lymph node dissection boundaries to a level as high as the inferior mesenteric artery. *'''<span style="color:#ff00ff">LEA AUO AB 25/02</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. ===== <span style="color:#ff0000">Lymph node count</span> ===== * '''<span style="color:#ff0000">To facilitate adequate staging, a standard lymphadenectomy </span>(bilateral external iliac, internal iliac and obturator lymph nodes), <span style="color:#ff0000">at a minimum, needs to be completed with >12 lymph nodes evaluated.</span>[https://www.auanet.org/guidelines/guidelines/bladder-cancer-non-metastatic-muscle-invasive-guideline]''' *'''Absolute number of nodes removed has been shown to provide important prognostic information and staging accuracy both in lymph node positive and lymph node negative patients''' ** Removing > 10 nodes is recommended ['''AUA MIBC Guidelines say >12'''] based on observational studies evaluating node count and survival
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