LAUSR

Lymph node dissection (LND) is widely acknowledged as a standard surgical procedure in conjunction with radical cystectomy (RC). Many previous studies addressed the potential benefit of LND in the management of bladder cancer, which supports the current clinical practice. However, there remained controversies, particularly related to the therapeutic role of LND and also its optimal extent. In this article, Nakagawa reviewed the latest evidence of LND for bladder cancer and discussed the controversies. Pathological lymph node (LN) metastasis is an established prognostic factor for bladder cancer patients. From this aspect, LND specimens are highly informative for disease management after surgery, and adjuvant chemotherapy is generally recommended for patients with pathologically positive LNs, which predict a significant risk of cancer recurrence. In contrast, the therapeutic role of LND has been more debatable. In clinically node-positive disease, although surgical removal of positive LNs might contribute to patient survival in a part of definitive surgery combined with induction chemotherapy, previous studies suggested that survival outcomes primarily depend on the response to chemotherapy. As for cN0 bladder cancer patients, current guidelines recommend neoadjuvant chemotherapy before RC. Importantly, as highlighted in this review article, there has been no clear evidence showing survival benefits of LND after neoadjuvant chemotherapy. Further studies are required to determine the impact of LND on patient survival in this setting. The present article also summarized previous studies addressing the optimal extent of LND, which has not been established to date. Although some thought leaders have explored the potential benefit of extended/super-extended LND, discouraging results in the first randomized trial recently published that compared extended versus limited LND made the pendulum swing back. In this trial, extended LND failed to show survival advantages over limited LND in patients undergoing RC. As stated in the present article, 10– 20% of primary LNs of bladder cancer are located in the common-iliac/presacral regions, suggesting that LND below the bifurcation of the common iliac artery might be suboptimal. Another randomized study (SWOG-1011) is ongoing, which will provide further knowledge regarding optimal templates of LND. Beside such unresolved controversies related to LND, recent advancements in the management of bladder cancer might change our principles of surgery. Immune checkpoint inhibitor could be the most significant game changer. Recently, a phase II trial (PURE-01) assessed the treatment efficacy of pembrolizumab in the neoadjuvant setting before RC, showing that 42% of patients achieved pathological complete response. A potential role of LND should be further evaluated in the new standard era.