Separate Submission Of Standard Lymphadenectomy In 6 Packets Versus En Bloc Lymphadenectomy In Bladder Cancer

Main Category: Urology / Nephrology
Also Included In: Cancer / Oncology
Article Date: 17 Aug 2008 - 0:00 PDT

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UroToday.com - The practice of lymphadenectomy during radical cystectomy for muscle invasive bladder cancer is not standardized. There is a wide variation in the number of nodes retrieved. Recent studies suggest that both the number of nodes removed and the method of submission of lymph node specimens affect the treatment outcome. Some recent papers have also indicated that the lymph node specimens separately retrieved and submitted for pathology have a greater number of nodes compared to en bloc resection. In the present study, we sought to identify if there was a difference in the number of nodes retrieved between separately retrieved and submitted pathologic specimens and specimens from en bloc resection.

Guidelines for the treatment of muscle-invasive bladder cancer by the European Association of Urology recommend limited pelvic node dissection, consisting of removal of the tissue in the obturator fossa in patients undergoing surgery with a curative intent.

Several authors have noted an improved 5-year survival rate with extensive pelvic lymph node dissection in the patients with node-involved bladder cancer. Some investigators have noted that the quality of radical cystectomy procedure is judged by number of nodes retrieved.

They found that a minimum of 9 nodes was needed to be examined to accurately assess nodal involvement. They also found that survival improved in both patients with and without node involvement as the number of the removed nodes increased.

They also evaluated the impact of submitting nodes en bloc or as separate packages and suggested that submitting nodes as separate packages not only is easier, but also optimizes the evaluation and number of the lymph nodes retrieved. Some studies indicate that lymphadenectomy in combination with RC can cure a small fraction of node-positive patients We evaluated data on 77 patients with radical cystectomy and either standard pelvic lymph node dissection or en bloc lymphadenectomy were reviewed. Nodal dissection specimens during standard lymphadenectomy were sent for pathology examination in 6 separate containers marked as external iliac, internal iliac, and obturator groups from both sides. en bloc dissection specimens were sent in 2 containers marked as the right and the left pelvic nodes. Clinical and pathological findings of these two groups were compared in terms of the number of dissected lymph nodes, number of nodes with metastasis, lymph node density, and clinical outcomes. There were 34 patients with standard lymph node dissection and 43 with en bloc lymphadenectomy. The median numbers of nodes removed per patient were 15.5 (range, 4 to 48) and 7.0 (range, 1 to 24) in those with standard and en bloc lymphadenectomy, respectively (P < .001). Nodal involvement was detected in 10 (29.4%) and 9 (20.9%) patients, respectively (P = .43). Although nodal involvement was not significantly different between the two groups, standard lymphadenectomy submitted in 6 different containers significantly improved the nodal yield over en bloc resection. Obturator nodes were the most commonly involved nodes in our study.

We found that the number of the nodes retrieved per specimen increases significantly if dissection and submission of the nodes is done in the anatomically defined areas rather than en bloc submission.

Written by M. Hammad Ather, FCPS (Urol.), as part of Beyond the Abstract on UroToday.com

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