Management of Invasive Bladder Cancer: A Meticulous Pelvic Node Dissection Can Make a Difference

Abstract

During an 8-yr period 159 patients with primary epithelial carcinoma of the bladder were operated upon in anticipation of cure. At the operation 6 patients (4%) were found to be inoperable because of extensive disease above the aortic bifurcation. Therefore, 153 patients underwent a meticulous bilateral pelvic iliac lymph node dissection with en bloc radical cystectomy and urinary diversion as a single stage procedure. Of these 153 potentially curable patients, 36 had positive nodes histologically. Analysis of these 36 patients revealed that the presence or absence of nodal metastases cannot be predicted accurately on the basis of [stage] T or P category of the primary tumor, although the frequency of nodal disease increased with deeper penetration of the bladder wall. The incidence of positive pelvic nodes is 5-10% in patients with P1 tumors, 30-35% in those with P2 or P3A tumors and 50-66% in those with P3B and P4 tumors. The presence of positive pelvic nodes does not mean incurability since the 2, 3 and 5-yr survival rates for these patients are 46, 36 and 36%, respectively. In this small series of patients with nodal metastases the extent of the primary tumor (P stage) did not relate to survival. Pelvic recurrence as the 1st site of failure was noted in only 2 of 22 patients with metastatic disease. Apparently, pelvic node dissection does not increase the morbidity associated with cystectomy, can cure some patients with metastatic disease, effectively controls pelvic disease and indicates which patients are at substantial risk for systemic metastatic disease, implying the need for development and use of systemic chemotherapy.