Key messages
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Removing more lymph nodes in the pelvis probably results in fewer deaths from bladder cancer, but may make no difference to death from any cause or the cancer coming back (all measured within five years).
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Removing more lymph nodes in the pelvis probably increases the risk of serious complications after surgery (like needing another procedure, returning to the operating room, or requiring intensive medical care).
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Future studies are needed to better understand how patients feel about their health and daily lives after undergoing these surgeries.
What is lymph node removal during bladder removal surgery?
When the bladder is surgically removed (an operation called radical cystectomy) to treat bladder cancer, surgeons also remove nearby lymph nodes, small glands that are part of the immune system. This is called lymph node dissection. This is done to find out whether the cancer has spread and to help prevent it from spreading further.
We compared two approaches in this review, as follows.
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Standard removal: lymph nodes are removed up to where two major blood vessels in the pelvis (the internal and external iliac arteries) branch apart.
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Extended removal: a larger area of lymph nodes is removed, reaching further up into the lower abdomen (up to a blood vessel called the inferior mesenteric artery).
In both approaches, the same lymph nodes are removed in the lower pelvis; the difference in approaches is how far upwards the removal occurs.
What did we want to find out?
We wanted to find out whether removing more lymph nodes during radical cystectomy reduces the risk of dying from any cause or from bladder cancer and reduces the risk of the cancer coming back, compared with standard lymph node removal. We also wanted to know whether removing more lymph nodes leads to more complications after surgery, and its effects on patient quality of life.
What did we do?
We searched for studies that compared extended lymph node removal with standard lymph node removal during bladder removal surgery. We compared and summarized the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes.
What did we find?
We found two studies including a total of 993 people. People in the studies were on average 67 to 69 years old and were followed for 58 to 73 months.
Main results
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People who had more lymph nodes removed lived about the same amount of time as those who had standard lymph node removal.
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Fewer people died from bladder cancer in the extended lymph node removal group in one study.
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There was no clear evidence of a difference in how often the cancer came back between groups.
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People who had extended lymph node removal had more serious complications after surgery, including need for additional surgery, readmission to the hospital, or admission to an intensive care unit (measured up to 90 days after surgery).
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Minor complications after surgery, such as wound infections, temporary urinary problems, or mild pain requiring additional medication, occurred at similar rates in both groups (measured up to 90 days after surgery).
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No study looked at how the treatment affected people’s daily lives or well-being.
What are the limitations of the evidence?
The two included studies used good-quality methods. However, we have only moderate to little confidence in the evidence, mainly because the number of people in the studies was small, and the results differed across studies. We found no information on quality of life. The true effects of extended lymph node removal may differ from those found in the current review, and further high-quality studies are needed.
How up-to-date is this evidence?
The evidence is current to 24 September 2025.
Pročitajte cijeli sažetak
In the treatment of urothelial carcinoma of the bladder, we are currently uncertain of the benefits and harms of standard pelvic lymph node dissection (PLND) compared to extended PLND.
Ciljevi
To assess the effects of extended versus standard PLND in people undergoing cystectomy to treat muscle-invasive (cT2 and cT4a) and treatment-refractory, non-muscle-invasive (cT1 with or without carcinoma in situ) urothelial carcinoma of the bladder.
Metode pretraživanja
We conducted a comprehensive literature search using multiple databases (CENTRAL, PubMed, Embase, Web of Science, and LILACS), trial registries, and conference proceedings published up to 24 September 2025, with no restrictions on language or publication status.
Kriteriji odabira
We included randomized controlled trials in which participants underwent radical cystectomy (RC) for muscle-invasive or therapy-refractory non-muscle-invasive urothelial carcinoma of the bladder with either an extended PLND with a superior extent reaching as far cranially as the inferior mesenteric vein, or a standard PLND with a superior extent of the bifurcation of the internal and external iliac artery, with otherwise the same anatomical boundaries.
Prikupljanje podataka i obrada
Two review authors independently assessed the included studies and extracted data from them for the primary outcomes: time to death from any cause, time to death from bladder cancer and Clavien-Dindo classification of surgical complications grade III-V, and the secondary outcomes: time to recurrence, Clavien-Dindo I-II complications and disease-specific quality of life.
We performed statistical analyses using a random-effects model and rated the certainty of evidence according to the GRADE approach.
Glavni rezultati
The search identified one multicenter trial based in Germany that enrolled 401 participants with histologically confirmed T1 grade 3 or muscle-invasive urothelial carcinoma. The median age was 67 years (range: 59 to 74) and the majority of participants were male (78.3%). No participant received neoadjuvant chemotherapy; a small subset received adjuvant chemotherapy (14.5%).
Primary outcomes
Our results indicate that extended PLND may reduce the risk of death from any cause over time as compared to standard PLND, but the confidence interval includes the possibility of no effect (hazard ratio [HR]: 0.78, 95% confidence interval [CI]: 0.57 to 1.07, 401 participants, low-certainty evidence). After five years of follow-up, this may result in 83 fewer deaths (95% CI: 174 fewer to 24 more overall deaths) per 1000 participants: 420 deaths for extended PLND compared to 503 deaths per 1000 for standard PLND. We downgraded the certainty of evidence by two levels due to study limitations and imprecision.
Our results indicate that extended PLND may reduce the risk of death from bladder cancer over time as compared to standard PLND but, again, the confidence interval includes the possibility of no effect (HR: 0.70, 95% CI: 0.45 to 1.07, participants = 401, low-certainty evidence). After five years of follow-up, this corresponds to 91 fewer deaths per 1000 participants (95% CI: 176 fewer to 19 more bladder cancer deaths): 264 deaths for extended PLND compared to 355 deaths per 1000 for standard PLND. We downgraded the certainty of evidence by two levels due to study limitations and imprecision.
Based on follow-up of up to 30 days, we are uncertain whether extended PLND leads to more grade III-V complications as compared to standard PLND, because of study limitations and imprecision (risk ratio [RR]: 1.13, 95% CI: 0.84 to 1.52, participants = 401, very low-certainty evidence).
Secondary outcomes
We are uncertain whether extended PLND reduces the risk of recurrence over time as compared to standard PLND, because of study limitations and imprecision (HR: 0.84, 95% CI: 0.58 to 1.22, participants = 401, very low-certainty evidence).
Based on follow-up of up to 30 days, we are uncertain whether extended PLND leads to similar grade I-II complications as compared to standard PLND because of study limitations and imprecision (RR: 0.94, 95% CI: 0.74 to 1.19, participants = 401, very low-certainty evidence).
We found no trials that reported on disease-specific quality of life.
Zaključak autora
This updated systematic review synthesizes the evidence from the two available RCTs in this field. We found that extended PLND likely improves bladder cancer-specific survival; however, it may result in little to no difference in overall survival or recurrence-free survival. Extended PLND likely increases severe complications (Clavien-Dindo grade ≥ 3), while likely showing similar rates of minor complications (grade ≤ 2) at 90-day follow-up compared to standard PLND. These findings underscore the trade-offs of potential oncologic benefits of extended PLND versus the increased risk of serious complications in patients undergoing radical cystectomy.
Funding
None
Registration
Protocol (2018) available via https://www.crd.york.ac.uk/PROSPERO/view/CRD42018116290
Original review (2019) DOI: 10.1002/14651858.CD013336
