Association of super-extended lymphadenectomy at radical cystectomy with perioperative complications and re-hospitalization

Lymph node metastasis in cancer progression: molecular mechanisms, clinical significance and therapeutic interventions

Lymph nodes (LNs) are important hubs for metastatic cell arrest and growth, immune modulation, and secondary dissemination to distant sites through a series of mechanisms, and it has been proved that lymph node metastasis (LNM) is an essential prognostic indicator in many different types of cancer. Therefore, it is important for oncologists to understand the mechanisms of tumor cells to metastasize to LNs, as well as how LNM affects the prognosis and therapy of patients with cancer in order to provide patients with accurate disease assessment and effective treatment strategies. In recent years, with the updates in both basic and clinical studies on LNM and the application of advanced medical technologies, much progress has been made in the understanding of the mechanisms of LNM and the strategies for diagnosis and treatment of LNM. In this review, current knowledge of the anatomical and physiological characteristics of LNs, as well as the molecular mechanisms of LNM, are described. The clinical significance of LNM in different anatomical sites is summarized, including the roles of LNM playing in staging, prognostic prediction, and treatment selection for patients with various types of cancers. And the novel exploration and academic disputes of strategies for recognition, diagnosis, and therapeutic interventions of metastatic LNs are also discussed.

Which lymph node dissection template is optimal for radical cystectomy? A systematic review and Bayesian network meta-analysis

Objective

This study aims to determine the optimal pelvic lymph node dissection (PLND) template for radical cystectomy (RC).

Methods

A systematic search was conducted using the PubMed, Embase and Cochrane Library database in December 2021. Articles comparing recurrence-free survival (RFS), disease-specific survival (DSS), overall survival (OS), and postoperative complications among patients undergoing limited PLND (lPLND), standard PLND (sPLND), extended PLND (ePLND), or super-extended PLND (sePLND) were included. A Bayesian approach was used for network meta-analysis.

Results

We included 18 studies in this systematic review, and 17 studies met our criteria for network meta-analysis. We performed meta-analyses and network meta-analyses to investigate the associations between four PLND templates and the RFS, DSS, OS, or postoperative complications. We found that the ePLND group and the sePLND group were associated with better RFS than the sPLND group (Hazard Ratio [HR]: 0.65, 95% Credible Interval [CrI]: 0.56 to 0.78) (HR: 0.67, 95% CrI: 0.56 to 0.83) and the lPLND group (HR: 0.67, 95% CrI: 0.50 to 0.91) (HR: 0.70, 95% CrI: 0.49 to 0.99). For RFS, Analysis of the treatment ranking revealed that ePLND had the highest probabilities to be the best template. There was no significant difference between the four templates in DSS, however, analysis of the treatment ranking indicated that sePLND had the highest probabilities to be the best template. And We found that the sePLND group and the ePLND group were associated with better OS than lPLND (HR: 0.58, 95% CrI: 0.36 to 0.95) (HR: 0.63, 95% CrI: 0.41 to 0.94). For OS, analysis of the treatment ranking revealed that sePLND had the highest probabilities to be the best template. The results of meta-analyses and network meta-analyses showed that postoperative complications rates did not differ significantly between any two templates.

Conclusion

Patients undergoing sePLND and ePLND had better RFS but not better DSS or OS than those undergoing lPLND or sPLND templates, however, RFS did not differ between patients undergoing sePLND or ePLND. Considering that sePLND involves longer operation time, higher risk, and greater degree of difficulty than ePLND, and performing sePLND may not result in better prognosis, so it seems that there is no need for seLPND. We think that ePLND might be the optimal PLND template for RC.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022318475.

Surgical intervention in patients with urothelial carcinoma of the bladder and lymph node metastasis

PURPOSE OF REVIEW

To systematically review the most recent evidence on the role of surgery in patients with urothelial carcinoma of bladder and lymph node metastasis.

RECENT FINDINGS

Patients with urothelial carcinoma of bladder and lymph node metastasis have a poor prognosis. The mainstay treatment for these patients is systemic chemotherapy. However, slowly growing body of literature suggests that multimodal therapy comprised of radical cystectomy, lymph node dissection, and perioperative chemotherapy is more effective than either chemotherapy or surgery alone. The timing of chemotherapy, whether preoperative or adjuvant chemotherapy, is still controversial, but the current evidence indicates that patients who achieve a major or complete response after induction chemotherapy appear to benefit from the surgical intervention in the form of radical cystectomy and pelvic lymph node dissection. The limit of lymph node dissection has to be determined.

SUMMARY

Multimodal therapy is associated with better survival outcomes in bladder cancer patients with lymph node metastasis. The current guidelines recommend systemic chemotherapy as the mainstay of treatment for these patients, and there is no convincing evidence on the efficacy of surgical intervention in isolation. Nonetheless, studies comparing multiple treatment modalities demonstrated that surgical salvage therapy is beneficial only when combined with chemotherapy. The methodological limitations of the current literature preclude a robust conclusion of survival advantage. Further studies are needed to help improve imaging for detecting lymph node metastasis and novel strategies to enrich our multimodal therapeutic implementation.

Utility of lymphadenectomy in bladder cancer: where do we stand?

PURPOSE OF REVIEW

The aim of this review is to provide insight into the current state of lymph node dissection (LND) during radical cystectomy in patients with bladder cancer (BCa).

RECENT FINDINGS

The first prospective, multicenter, randomized, phase III trial to assess the therapeutic benefit of extended versus limited LND at the time of radical cystectomy failed to demonstrate relevant improvement with extended LND, but showed that this approach does not increase overall complications. Although contemporary rate of LND during radical cystectomy has increased, it remains suboptimal. Minimally invasive radical cystectomy with LND is feasible in most patients and has similar lymph node yields and complication rates compared with open procedures when performed by experienced surgeons. Overall major complication, readmission and mortality rates do not significantly differ according to extent of LND.

SUMMARY

Meticulous LND provides both diagnostic and potentially therapeutic benefits in patients with bladder cancer. Results of ongoing trials will provide additional insights regarding the anatomic extent and therapeutic benefit of extended versus standard true pelvic-only LND.

Complications and quality of life of ileal conduit, orthotopic neobladder and ureterocutaneostomy: systematic review of reports using the Clavien-Dindo Classification

INTRODUCTION

Radical cystectomy (RC) and urinary diversion (UD) are two steps of the same surgical procedure involving likely complications and important impact on quality of life (QoL). The literature was reviewed to identify recent studies reporting UDs complications occurred 90 days after surgery and graded by Clavien-Dindo Classification System (CCS).

EVIDENCE ACQUISITION

A comprehensive systematic Medline search was performed in PubMed/Medline, Embase and Scopus databases to identify reports published in English starting from 2013 using key words related to review outcome (i.e. neobladder, ileal conduct, ureterocutaneostomy, cystectomy, QoL). Complications were defined as minor or major whether the CCS grade was ≤2 or ≥3, respectively. Then, manuscripts references were screened to identify unfounded studies. Only studies using CCS to report surgical complications were considered.

EVIDENCE SYNTHESIS

Retrieved studies were reported according to two main items of complications and QoL. About UDs complications, fourteen studies were identified incorporating overall 4436 patients. Up to 50% of patients experienced at least one low-grade complications (CCS≤2) requiring pharmacological treatment to be healed. On the other hand, high-grade complications (CCS≥3) occurred in 0.7-42% of cases and required surgical interventions (CCS 3a and 3b) or life support (CCS=4). Finally, mortality (CCS=5) rated between 0.4-7%. Regarding QoL, six studies were analyzed with overall 445 patients. Most of them were retrospective and showed conflicting results whether the external UDs were better than neobladder in term of impact on QoL.

CONCLUSIONS

The use of a standardized system such as CCS improves analyses of literature. However, rigorous patient selection for UD type makes unable a randomized comparison between UDs in terms of complications and QoL impact.

Extended versus non-extended lymphadenectomy during radical cystectomy for patients with bladder cancer: a meta-analysis of the effect on long-term and short-term outcomes

BACKGROUND

Pelvic lymphadenectomy (PLND) is an integral part of curative surgery for high-risk non-muscle invasive and muscle-invasive bladder cancer. The therapeutic value of extended PLND is controversial.

METHODS

We conducted a comprehensive online search in PubMed, EMBASE, and the Cochrane Library databases for relevant literature directly comparing extended PLND (e-PLND) with non-extended PLND (ne-PLND) from database inception to June 2019. We performed the meta-analysis to evaluate the impact of PLND templates on recurrence-free survival (RFS), disease-specific survival (DSS), overall survival (OS), rates of postoperative major complications, and mortality within 90 days of surgery.

RESULTS

A total of 10 studies involving 3979 patients undergoing either e-PLND or ne-PLND were included. The results showed that e-PLND was significantly associated with better RFS (HR 0.74, 95% CI 0.62-0.90, p = 0.002) and DSS (HR 0.66, 95% CI 0.55-0.79, p < 0.001). However, no correlation was found between e-PLND template and a better OS (HR 0.93, 95% CI 0.55-1.58, p = 0.79). Postoperative major complications were similar between e-PLND group and ne-PLND group, as was mortality within 90 days of surgery.

CONCLUSION

e-PLND template is correlated with favorable RFS and DSS outcomes for patients with bladder cancer. e-PLND did not have more postoperative major complications than did ne-PLND.