Radical cystectomy and lymphadenectomy for invasive bladder cancer: Towards the evolution of an optimal surgical standard
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.
SourceAvailable from: Vladimir Bobek[Show abstract] [Hide abstract]
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.
[Show abstract] [Hide abstract]
ABSTRACT: Radical cystectomy in patients with bladder cancer includes regional lymph node (LN) dissection. There is growing body of evidence suggesting that extended bilateral pelvic LN dissection may confer a survival benefit for surgically appropriate patients with bladder cancer. Accurate node status can only be ascertained by lymphadenectomy. Besides pathological tumor stage, lymph node status is the strongest prognostic factor. The pelvic lymphadenectomy (LND) during radical cystectomy for muscle invasive bladder cancer is now standard of care. However, the optimal extent of the LND remains dubitable. Some recent work from the mapping studies and retrospective analyses has shown that the extended LND up to the mid-upper third of the common iliac vessels appears to provide further prognostic and therapeutic benefit and therefore should be defined as standard LND. The extent of LND suggested is applicable to all form surgical extirpation of the urinary bladder i.e. open surgery, minimally invasive approach (laparoscopic and robot assisted). The role of LND is more controversial in non-muscle invasive cancer. The concept of total lymph node count is now not considered a quality criterion because nodal yield is overly influenced by the individual patient’s anatomy, surgical technique, template applied and pathological work-up. Lymph node density is thought to be a superior prognostic factor, but it is similarly influenced by the above-mentioned factors. Concerning molecular techniques to improve the sensitivity of postoperative nodal staging further research is necessary. There are few ongoing prospective randomized trials will potentially help to further define the optimal LND template