Perioperative Outcomes Using Template Mapping after Radical Cystectomy and Extended Lymph Node Dissection

Bladder cancer is one of the most common genitourinary malignancies worldwide, and its management has evolved significantly over the past two decades. Robotic-assisted radical cystectomy (RARC) has become increasingly adopted as a minimally invasive surgical approach. This technique implies surgical removal of the bladder in conjunction with diversion of the urinary tract and pelvic lymph node dissection (PLND). While neoadjuvant chemotherapy is the standard of care for patients with muscle-invasive bladder cancer, as it targets micrometastatic disease not overly evident on initial clinical staging, surgical technique continues to play a critical role in local control and disease staging.

A previous area of controversy was whether an extended PLND template offered a meaningful oncologic advantage over a standard template. The recently published SWOG S1011 trial addressed this directly, finding no survival benefit from extended dissection and reported an increased perioperative morbidity and mortality in this group. In our study, we sought to validate these findings in a real-world setting.

We reviewed the oncologic and perioperative outcomes of 562 patients with bladder cancer who underwent RARC and extended PLND template at an NCI-designated cancer center. A total of 90 patients were found to have pathologically confirmed node-positive disease. Using a template-mapping approach, patients were grouped based on the location of nodal positivity, with 43 in the standard dissection cohort and 47 in the extended cohort.

We recorded no significant difference in pathologic lymph node yield between groups. There was a comparable rate of clinically significant complications (≥ grade II) between groups, with the most common being infectious in nature, followed by gastrointestinal, genitourinary, and cardiac. Notably, there was no significant difference in overall survival, 90-day mortality, or death from bladder cancer between groups, suggesting that the lymph node positivity template does not alter survival outcomes in patients.

Our findings further validate the real-world implications of the SWOG S1011 trial by demonstrating that the location of lymph node positivity does not appreciably affect oncologic outcomes, supporting the notion that extended PLND may not provide significant oncologic benefits over the standard approach for most patients.

Written by: Salvador Jaime-Casas,¹ Ahmad Imam,¹ Daniel J Lama,¹ Oluwatimilehin Okunowo,² Clayton S Lau,¹ Kevin G Chan,¹ Bertram E Yuh,¹

Division of Urology and Urologic Oncology, Department of Surgery, City of Hope Comprehensive Cancer Center, CA, USA.
Department of Computational and Quantitative Medicine, Division of Biostatistics, Beckman Research Institute of City of Hope, Duarte, CA, USA.

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