Pelvic Lymphadenectomy In Bladder Cancer
Dr.Abdelazim Hussein Khalafalla Sudan - Khartoum
Invasive Bladder Cancer
Although the majority of patients with bladder cancer present with superficial bladder tumors, 20%to 40% will present with or subsequently have muscle invasive disease develop
LN metastasis in invasive bladder cancer
nearly 25% of patients have pathologic evidence of lymph node metastases at cystectomy
role of pelvic lymphadenectomy in the management of bladder cancer remain controversial.
Daughtry et al.  observed that no patients survived beyond 20 months after radical cystectomy if the pelvic lymph nodes were positive. They saw no justification for routine pelvic lymphadenectomy since this was believed to increase the morbidity and mortality of the procedure.
On the other hand, Skinner advocated meticulous pelvic lymph node dissection when performing radical cystectomy for bladder cancer. he found no association between pelvic lymphadenectomy and increased morbidity or mortality.
The role of a regional lymphadenectomy in the surgical treatment of high-grade, invasive transitional cell carcinoma of the bladder has evolved over the last several decades.
the absolute extent or level of proximal dissection of the lymphadenectomy remains a controversial issue ? Surgical boundaries of the lymphadenectomy extended vs. standard
all lymph nodes in the boundaries of the: - proximal -aortic bifurcation and common iliac vessels - Lateral - genitofemoral nerve - Distally - circumflex iliac vein and lymph node of Cloquet - posteriorly - hypogastric vessels NB : including the obturator fossa; and presacral lymph nodes It is noteworthy that an extended dissection may, in some cases, extend more superiorly to the level of the inferior mesenteric artery.
more limited: - cephalad - common iliac bifurcation. - Lateral - genitofemoral nerve - Distal -circumflex iliac vein and lymph node of Cloquet NB: The presacral lymph nodes are generally not removed in a standard lymphadenectomy
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the morbidity associated with an extended l lymphadenectomy is low and comparable to a o w more limited or standard lymph node a .dissection n
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Radical cystectomy with an appropriately performed lymphadenectomy provides the best survival outcomes and lowest local recurrence rates. Although the absolute limits of the lymph node dissection remain to be determined, evidence supports a more
extended lymphadenectomy to include the common iliac vessels and presacral lymph nodes at cystectomy in patients who are appropriate surgical candidates. When feasible, adjuvant chemotherapy is warranted in patients with positive nodal metastasis.
Radical cystectomy with bilateral pelvic iliac lymphadenectomy is a standard treatment for high-grade, invasive bladder cancer
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