Extended lymphadenectomy at radical cystectomy: longer operations, no clear survival gain

Design

Systematic review and random-effects meta-analysis with GRADE assessment

Population

15 studies, 5,671 patients (two randomised) having radical cystectomy for bladder cancer

Primary outcome

Operative time, overall, cancer-specific, disease-free and recurrence-free survival

Effect

Operative time +26.2 min; no significant overall or cancer-specific survival difference; recurrence-free survival HR 0.79 for non-extended

A meta-analysis of 15 studies with 5,671 patients, only two of them randomised, compared extended with non-extended pelvic lymphadenectomy during radical cystectomy for bladder cancer.

Extended lymphadenectomy added about 26 minutes of operating time (mean difference +26.2 minutes). The authors report improved disease-free survival with it (hazard ratio 1.47, as stated in the abstract) but no significant benefit in overall or cancer-specific survival, and higher recurrence-free survival with the non-extended approach (hazard ratio 0.79). Heterogeneity was moderate to high. Certainty of evidence was very low for most outcomes, and low for overall survival in randomised trials alone.

The survival hazard ratios point in different directions across end points, which the abstract does not reconcile, and the direction convention is not explained. The evidence does not clearly support a consistent oncological benefit. Extent of dissection is still a matter for guidelines and the surgical team.

• Extended dissection added about 26 minutes of operating time.
• No significant overall or cancer-specific survival benefit.
• Disease-free and recurrence-free survival results pointed in different directions.
• Only two of 15 studies were randomised.
• Certainty of evidence was very low for most outcomes.

Why it matters

Extent of lymph node dissection is a long-standing debate that randomised evidence has not settled.

Don't overread it

A meta-analysis mostly of observational studies with very low certainty cannot support a change from current guideline practice.

The statistics, in plain English

Hazard ratios for different end points can disagree when studies define them differently or when few studies contribute. Very low certainty means the true effect could be quite different from the estimate.

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