PURPOSE OF REVIEW: Although lymph node dissection (LND) during radical nephroureterectomy (RNU) is recommended for high-risk nonmetastatic upper tract urothelial carcinoma (UTUC), adherence to guidelines remains insufficient in clinical practice. Therefore, this review aims to comprehensively summarize the current evidence regarding the diagnostic, prognostic, and therapeutic impact of LND during RNU in UTUC patients. RECENT FINDINGS: Clinical nodal staging using conventional CT scan has low sensitivity (25%) and diagnostic accuracy [area under the curve (AUC): 0.58] in UTUC, suggesting the importance of LND for obtaining accurate N-staging. Patients with pathological node-positive (pN+) disease have poor disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS) compared with those with pN0. In addition, population-based studies showed that patients who underwent LND improved CSS and OS than those who did not, even in patients who received adjuvant systemic therapy. The number of lymph nodes removed has also been shown to be associated with improved CSS and OS, even in pT0 patients. Template-based LND should be performed as the extent of lymph node is more important than the number of lymph nodes. Robot-assisted RNU may facilitate performing a meticulous LND compared with a laparoscopic approach. Postoperative complications such as lymphatic and/or chylous leakage are increased but adequately manageable. However, the current evidence is not supported by high-quality studies. SUMMARY: Based on the published data, LND during RNU is a standard procedure for high-risk nonmetastatic UTUC, owing to its diagnostic, staging, prognostic, and, potentially, therapeutic benefits. Template-based LND should be offered to all patients who are planned for RNU for high-risk nonmetastatic UTUC. Patients with pN+ disease are optimal candidates for adjuvant systemic therapy. Robot-assisted RNU may facilitate meticulous LND compared with laparoscopic RNU.

• MeSH
• Carcinoma, Transitional Cell * pathology   MeSH
• Humans MeSH
• Lymph Node Excision adverse effects   methods   MeSH
• Lymph Nodes diagnostic imaging   surgery   pathology   MeSH
• Urinary Bladder Neoplasms * pathology   MeSH
• Ureteral Neoplasms * surgery   MeSH
• Nephroureterectomy methods   MeSH
• Retrospective Studies MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Review MeSH

BACKGROUND: There are currently no guideline recommendations regarding the treatment of cisplatin-ineligible, clinically lymph node-positive (cN+) bladder cancer (BCa). OBJECTIVE: To investigate the oncological efficacy of gemcitabine/carboplatin induction chemotherapy (IC) in comparison to cisplatin-based regimens in cN+ BCa. DESIGN SETTING AND PARTICIPANTS: This was an observational study of 369 patients with cT2-4 N1-3 M0 BCa. INTERVENTION: IC followed by consolidative radical cystectomy (RC). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoints were the pathological objective response (pOR; ypT0/Ta/Tis/T1 N0) rate and the pathological complete response (pCR; ypT0N0) rate. We applied 3:1 propensity score matching (PSM) to reduce selection bias. Overall survival (OS) and cancer-specific survival (CSS) were compared across groups using the Kaplan-Meier method. Associations between the treatment regimen and survival endpoints were tested in multivariable Cox regression analyses. RESULTS AND LIMITATIONS: After PSM, a cohort of 216 patients was available for analysis, of whom 162 received cisplatin-based IC and 54 gemcitabine/carboplatin IC. At RC, 54 patients (25%) had a pOR and 36 (17%) had a pCR. The 2-yr CSS was 59.8% (95% confidence interval [CI] 51.9-69%) for patients who received cisplatin-based IC versus 38.8% (95% CI 26-57.9%) for those who received gemcitabine/carboplatin. For the pOR (p = 0.8), ypN0 status at RC (p = 0.5), and cN1 BCa subgroups (p = 0.7), there was no difference in CSS between cisplatin-based IC and gemcitabine/carboplatin. In the cN1 subgroup, treatment with gemcitabine/carboplatin was not associated with shorter OS (p = 0.2) or CSS (p = 0.1) on multivariable Cox regression analysis. CONCLUSIONS: Cisplatin-based IC seems to be superior to gemcitabine/carboplatin and should be the standard for cisplatin-eligible patients with cN+ BCa. Gemcitabine/carboplatin may be an alternative treatment for selected cisplatin-ineligible patients with cN+ BCa. In particular, selected cisplatin-ineligible patients with cN1 disease may benefit from gemcitabine/carboplatin IC. PATIENT SUMMARY: In this multicenter study, we found that selected patients with bladder cancer and clinical evidence of lymph node metastasis who cannot receive standard cisplatin-based chemotherapy before surgery to remove their bladder may benefit from chemotherapy with gemcitabine/carboplatin. Patients with a single lymph node metastasis may benefit the most.

• Keywords
• Carboplatin, Induction chemotherapy, Oligometastatic, Survival, Urinary bladder neoplasms,
• Publication type
• Journal Article MeSH