Article

Radical Cystectomy and Lymphadenectomy for Invasive Bladder Cancer: Towards the Evolution of an Optimal Surgical Standard

Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
Seminars in Oncology (Impact Factor: 3.94). 05/2007; 34(2):110-21. DOI: 10.1053/j.seminoncol.2006.12.011
Source: PubMed

ABSTRACT The surgical management of invasive bladder cancer has undergone a significant evolution in technique since its initial introduction. Changes in the extent of surgery have largely reflected a better understanding of the natural history of bladder cancer and the recognized pathways of progression. Incorporation of contemporary surgical techniques that target the perivesical soft tissues, regional lymph nodes, and adjacent organs appear to enhance oncologic outcomes. A growing body of evidence indicates that the quality of radical cystectomy (RC) directly affects patient outcome. Recently, quality of life and functional considerations have led to surgical modifications such as nerve-, prostate-, vaginal wall-, and urethra-sparing approaches. While some modifications in appropriate candidates appear not to decrease cancer control, further studies will be needed to establish their role and safety. This ongoing evolution in the technique of RC and pelvic lymph node dissection (PLND) may help define a new surgical standard that provides optimal benefit in patients with invasive bladder cancer.

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    • "following surgical treatment [9]. Inaccurate clinical staging may lead to suboptimal treatment , particularly since extravesical disease at the time of surgical therapy is a known predictor of poor prognosis [10] and patients who are thought to have localized disease may not receive potentially beneficial neoadjuvant therapy. Increased accuracy of initial clinical staging would thus facilitate risk stratification and preoperative decision making. "
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    ABSTRACT: Approximately one third of patients diagnosed with muscle-invasive urinary bladder cancer (UBC) have undetected metastases at the time of treatment of the primary tumor. Currently there are no reliable specific serum markers for monitoring and evaluating risk profiles of urothelial cancers. Several studies suggest that detection of circulating tumor cells (CTCs) may correlate with the disease status and prognosis at baseline and early in the treatment of cancers. In this study a new way of isolation and in vitro cultivation of CTCs of urinary bladder cancer was introduced.
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    • "However, initial clinical staging can be imprecise and a considerable proportion of patients thought to have localized disease will be upstaged to extravesical cancer following surgical treatment [8]. Inaccurate clinical staging may lead to suboptimal treatment, particularly since extravesical disease at the time of surgical therapy is a known predictor of poor prognosis [9,10] and patients who are thought to have localized disease may not receive potentially beneficial neoadjuvant therapy. Increased accuracy of initial clinical staging would thus facilitate risk stratification and preoperative decision making. "
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    ABSTRACT: The diagnostic value and prognostic significance of circulating tumor cell (CTC) detection in patients with bladder cancer is controversial. We performed a meta-analysis to consolidate current evidence regarding the use of CTC detection assays to diagnose bladder and other urothelial cancers and the association of CTC positivity with advanced, remote disease. Studies that investigated the presence of CTCs in the peripheral blood of patients with bladder cancer and/or urothelial cancer were identified and reviewed. Sensitivities, specificities, and positive (LR+) and negative likelihood ratios (LR-) of CTC detection in individual studies were calculated and meta-analyzed by random effects model. Overall odds ratio of CTC positivity in patients with advanced disease versus those with organ-confined cancer was also calculated. Overall sensitivity of CTC detection assays was 35.1% (95%CI, 32.4-38%); specificity, LR+, and LR- was 89.4% (95%CI, 87.2-91.3%), 3.77 (95%CI, 1.95-7.30) and 0.72 (95%CI, 0.64-0.81). CTC-positive patients were significantly more likely to have advanced (stage III-IV) disease compared with CTC-negative patients (OR, 5.05; 95%CI, 2.49-10.26). CTC evaluation can confirm tumor diagnosis and identify patients with advanced bladder cancer. However, due to the low overall sensitivity, CTC detection assays should not be used as initial screening tests.
    BMC Cancer 08/2011; 11:336. DOI:10.1186/1471-2407-11-336 · 3.32 Impact Factor
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    • "Recent BCG or neoadjuvant chemotherapy might have an effect, probably by causing inflammation and fibrosis thus helping more nodal yield [4]. Sending LNs in separate packages was reported to increase the nodal yield [15] [34]. The method of pathologic evaluation including the use of fat-clearing solutions may play a role as well [2] [4]. While there were contradictory reports about the effect of surgeon volume on LN yield [4] [47], academic or teaching hospitals with a higher RC volume tend to report higher LN counts [4] [47] [53]. "
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    ABSTRACT: Radical cystectomy with pelvic lymphadenectomy represents the gold standard for treatment of muscle-invasive bladder cancer. Extent of the lymph node dissection and lymph node involvement during radical cystectomy are the most powerful prognostic factors associated with poor oncological outcome. However, the optimal boundaries of the lymph node dissection during a radical cystectomy are controversial. The published literature based mostly on retrospective studies suggests that increasing the number of nodes excised may have therapeutic and diagnostic benefits without significantly increasing the surgical morbidity. These conclusions are, however, influenced by selection and surgeon biases, inconsistencies in the quality of the surgery, and node count variability. In this paper, we establish the current understanding about the utility of lymphadenectomy during a radical cystectomy for muscle-invasive bladder cancer.
    International Journal of Surgical Oncology 06/2011; 2011:758189. DOI:10.1155/2011/758189
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