Comparison of extended and standard lymph node dissection in radical cystectomy for urothelial bladder cancer: a systematic review and meta-analysis.

Purpose: Lymph node dissection (LND) is an essential part of radical cystectomy (RC) performed with curative intent for invasive urothelial bladder cancer (UBC). This meta-analysis synthesizes evidence from randomized controlled trials (RCTs) comparing outcomes of extended and standard LND during RC.

Methods: Systematic searches of PubMed, Scopus, and Web of Science, conducted on November 10, 2024, identified RCTs that compared outcomes of standard (removal of pelvic lymph nodes [LNs]) versus extended LND (removal of pelvic and retroperitoneal LNs) during RC. Intention-to-treat populations were analyzed. Primary outcomes were recurrence-free (RFS) and overall survival (OS).

Results: Two RCTs involved 993 patients, among whom 490 were randomized to extended and 503 to standard LND. We did not find evidence that RFS (hazard ratio [HR] 1.01, 95% confidence interval [CI] 0.83-1.24) and OS (HR 0.98, 95% CI 0.81-1.19) differed between patients undergoing extended and standard LND. The risk of local recurrence did not differ between extended and standard LND (relative risk [RR] 1.17, 95% CI 0.80-1.72). The risk of major complications (grade > 3) was higher for the extended template (RR 1.22, 95% CI 1.05-1.41), as was the 90-day postoperative mortality (RR 1.93, 95% CI 1.01-3.69). The limited number of studies and sample size constitute major limitations.

Conclusion: This meta-analysis demonstrates that extended LND was not associated with improved RFS or OS compared to standard LND, but was linked to increased morbidity. Therefore, pelvic lymphadenectomy up to the common iliac bifurcation should remain the standard of care during RC.