title: The impact of the extent of lymphadenectomy on oncologic outcomes in patients undergoing radical cystectomy for bladder cancer: a systematic review.
abstract: BACKGROUND
  Controversy exists regarding the therapeutic value of lymphadenectomy (LND) in patients undergoing radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC).
  
  
  OBJECTIVE
  To systematically review the relevant literature assessing the impact of LND on oncologic and perioperative outcomes in patients undergoing RC for MIBC.
  
  
  METHODS
  Medline, Medline In-Process, Embase, the Cochrane Central Register of Controlled Trials, and the Latin American and Caribbean Center on Health Sciences Information (LILACS) were searched up to December 2013. Comparative studies reporting on no LND, limited LND (L-LND), standard LND (S-LND), extended LND (E-LND), superextended LND (SE-LND), and oncologic and perioperative outcomes were included. Risk-of-bias and confounding assessments were performed.
  
  
  RESULTS
  Twenty-three studies reporting on 19,793 patients were included. All but one study were retrospective. Planned meta-analyses were not possible because of study heterogeneity; therefore, data were synthesized narratively. There were high risks of bias and confounding across most studies as well as extreme heterogeneity in the definition of the anatomic boundaries of LND templates. All seven studies comparing LND with no LND favored LND in terms of better oncologic outcomes. Seven of 14 studies comparing (super)extended LND with L-LND or S-LND reported a beneficial outcome for (super)extended LND in at least a subset of patients. No difference in outcome was reported in two studies comparing E-LND and S-LND. The comparative harms of different extents of LND remain unclear.
  
  
  CONCLUSIONS
  Although the quality of the data was poor, the available evidence indicates that any kind of LND is advantageous over no LND. Similarly, E-LND appears to be superior to lesser degrees of dissection, while SE-LND offered no additional benefits. It is hoped that data from ongoing randomized clinical trials will clarify remaining uncertainties.
  
  
  RESULTS
  The current literature suggests that removal of lymph nodes in bladder cancer surgery is beneficial and might result in better outcomes in terms of prolonging survival; however, the quality of the available studies is poor, and high-quality studies are needed.
authors: Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands. Electronic address: maxbruins@gmail.com.
authors: Harman M
authors: HM
authors: Bruins
authors: Department of Urology, Tampere University Hospital, Tampere, Finland.
authors: Erik
authors: E
authors: Veskimae
authors: Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain.
authors: Virginia
authors: V
authors: Hernandez
authors: Academic Urology Unit, University of Aberdeen, Scotland, UK.
authors: Mari
authors: M
authors: Imamura
authors: Department of Urology, University of Florida, Gainesville, FL, USA.
authors: Molly M
authors: MM
authors: Neuberger
authors: Department of Urology, University of Florida, Gainesville, FL, USA; Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, USA.
authors: Philip
authors: P
authors: Dahm
authors: Academic Urology Unit, University of Aberdeen, Scotland, UK.
authors: Fiona
authors: F
authors: Stewart
authors: Academic Urology Unit, University of Aberdeen, Scotland, UK.
authors: Thomas B
authors: TB
authors: Lam
authors: Academic Urology Unit, University of Aberdeen, Scotland, UK.
authors: James
authors: J
authors: N'Dow
authors: Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands.
authors: Antoine G
authors: AG
authors: van der Heijden
authors: Department of Pathology, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
authors: Eva
authors: E
authors: Compérat
authors: Department of Radiology, Queen Alexandra Hospital, Portsmouth, UK.
authors: Nigel C
authors: NC
authors: Cowan
authors: 3rd Medical Department/LBI-ACR VIEnna-LBCTO and ACR-ITR VIEnna, Kaiser Franz Josef Spital, Vienna, Austria.
authors: Maria
authors: M
authors: De Santis
authors: Department of Urology, Eberhard-Karls University, Tübingen, Germany.
authors: Georgios
authors: G
authors: Gakis
authors: Department of Urology, Foch Hospital, Suresnes, France.
authors: Thierry
authors: T
authors: Lebret
authors: Department of Urology, Hospital Clinic, University of Barcelona, Barcelona, Spain.
authors: Maria J
authors: MJ
authors: Ribal
authors: Department of Surgical and Perioperative Science, Umeå University, Umeå, Sweden.
authors: Amir
authors: A
authors: Sherif
authors: Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands.
authors: J Alfred
authors: JA
authors: Witjes
mesh_terms: D002294:Carcinoma, Squamous Cell / Q000473:pathology / Q000601:surgery*; D015653:Cystectomy; D006801:Humans; D008197:Lymph Node Excision / Q000009:adverse effects / Q000379:methods*; D009361:Neoplasm Invasiveness; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000473:pathology / Q000601:surgery*
keywords: Bladder neoplasms; Lymph node dissection; Lymphadenectomy; Oncologic outcomes; Radical cystectomy; Standard; extended; or superextended dissection