title: Does increasing the nodal yield improve outcomes in patients without nodal metastasis at radical cystectomy?
abstract: OBJECTIVE
  To determine whether the number of lymph nodes (LNs) examined is associated with outcomes in patients without nodal metastasis after radical cystectomy (RC).
  
  
  METHODS
  We retrospectively analyzed data from 4,188 patients treated at 12 centers with RC and pelvic lymphadenectomy without neo-adjuvant chemotherapy for urothelial carcinoma of the bladder (UCB). Outcomes of patients without LN metastasis (n = 3,088) were examined according to the LN yield analyzed as continuous variable, tertiles, and using the cutoffs of ≥ 9 and ≥ 20.
  
  
  RESULTS
  The median nodal yield was 18 (range 1-123; IQR:20). A total of 2591 (84 %) and 1445 (47 %) patients had a LN yield ≥ 9 and ≥ 20, respectively. Median follow-up was 47 months (IQR:70). In multivariable analyses that adjusted for the standard clinicopathologic factors, higher LN yield was associated with a decreased risk of disease recurrence (continuous: HR = 0.996, p = 0.05; 3rd vs 1st tertile: HR = 0.853, p = 0.048; cutoff ≥ 20: HR = 0.851, p = 0.032). In the subgroups of patients with muscle-invasive UCB or those with ≥ 9 LN removed, LN yield was not associated with outcomes (p values >0.05).
  
  
  CONCLUSIONS
  In this large multicenter cohort of patients with node-negative UCB, higher nodal yield improved recurrence-free survival when all patients were analyzed. Patients with a high LN yield (≥ 20 LN removed or 3rd tertile) had the largest benefit. The lack of prognostic significance of LN yield in patients with muscle-invasive UCB or those stratified by 9 LNs removed suggests that this effect is weak. Further prospective studies are needed to help identify preoperatively the optimal template for each patient.
authors: Brady Urologic Health Center, Weill Cornell Medical College of Cornell University, New York Presbyterian Hospital, 525 East 68th Street, Box 94, Starr 900, New York, NY, USA.
authors: Michael
authors: M
authors: Rink
authors: Shahrokh F
authors: SF
authors: Shariat
authors: Evanguelos
authors: E
authors: Xylinas
authors: John P
authors: JP
authors: Fitzgerald
authors: Jens
authors: J
authors: Hansen
authors: David A
authors: DA
authors: Green
authors: Ashish M
authors: AM
authors: Kamat
authors: Giacomo
authors: G
authors: Novara
authors: Siamak
authors: S
authors: Daneshmand
authors: Yves
authors: Y
authors: Fradet
authors: Scott T
authors: ST
authors: Tagawa
authors: Patrick J
authors: PJ
authors: Bastian
authors: Wassim
authors: W
authors: Kassouf
authors: Quoc-Dien
authors: QD
authors: Trinh
authors: Pierre I
authors: PI
authors: Karakiewicz
authors: Hans-Martin
authors: HM
authors: Fritsche
authors: Derya
authors: D
authors: Tilki
authors: Felix K
authors: FK
authors: Chun
authors: Bjoern G
authors: BG
authors: Volkmer
authors: Marko
authors: M
authors: Babjuk
authors: Axel S
authors: AS
authors: Merseburger
authors: Douglas S
authors: DS
authors: Scherr
authors: Yair
authors: Y
authors: Lotan
authors: Robert S
authors: RS
authors: Svatek
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D015331:Cohort Studies; D015653:Cystectomy / Q000379:methods*; D005260:Female; D006801:Humans; D015994:Incidence; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology / Q000601:surgery*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D019459:Urothelium / Q000473:pathology