RADICAL CYSTECTOMY - EXTENDING THE LIMITS OF PELVIC LYMPH-NODE DISSECTION IMPROVES SURVIVAL FOR PATIENTS WITH BLADDER-CANCER CONFINED TO THE BLADDER WALL

Purpose: We assess the influence of the limits of pelvic lymph node di ssection on survival following radical cystectomy for bladder cancer. Materials and Methods: From January 1990 to September 1997, 194 patien ts underwent radical cystectomy without prior treatment. Between March 1993 and September 1997, 126 consecutive patients underwent radical c ystectomy with extended pelvic lymph node dissection beginning at the bifurcation of the aorta, including the common and external iliac vess els, presacral nodes and obturator fossa. Between January 1990 and Mar ch 1993, 68 consecutive patients underwent radical cystectomy, with li mited pelvic lymph node dissection beginning at the bifurcation of the common iliac vessels, including the external iliac vessels and obtura tor fossa. The cystectomy procedure remained unchanged throughout this period and 1 surgeon performed all procedures. Results: A total of 11 7 patients had tumors confined to the bladder wall (stage pT3a or less ) and 77 had tumors penetrating beyond the bladder into perivesical fa t or adjacent structures (stage pT3b or greater). The prevalence of pa tients with tumors penetrating the bladder was higher in the extended dissection group (42.9 versus 33.8% limited dissection). The incidence of lymphatic involvement was 26.2% and slightly higher in the extende d than the limited dissection group. There was a modest improvement in the Ei-year recurrence-free survival for the extended dissection grou p (62 versus 56% limited dissection, p = 0.33), and a substantial impr ovement for the subgroups with tumors confined to the bladder wall (tu mor stage pT3a or less) (85 versus 64%, p <0.02) and without lymph nod e metastasis (stage pT3a or less, pN0) (90 versus 71%, p <0.02). Accor dingly, extended pelvic lymph node dissection reduced the 5-year proba bilities for pelvic and distant metastasis (2 versus 7% limited dissec tion, p = 0.17 and 10 versus 21%, p = 0.15, respectively) for patients with tumors confined to the bladder wall (stage pT3a or less). Surviv al was similar for patients with pT3b or greater tumor. Conclusions: T his retrospective analysis suggests that extending the limits of pelvi c lymph node dissection from the bifurcation of the common iliac vesse ls to the bifurcation of the aorta improves the recurrence-free surviv al rate for patients undergoing radical cystectomy for bladder cancer confined to the bladder wall (stage pT3a or less).