Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, China.
BJU Int. 2013 Jul;112(2):E87-91. doi: 10.1111/j.1464-410X.2012.11650.x. Epub 2013 Jan 16.
WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Bladder cancer (BC) is a public health problem throughout the world, and now radical cystectomy (RC) has been introduced as a standard treatment for BC invading muscle and some BCs not invading muscle. Pelvic lymph node dissection (PLND) is considered an integral part of RC for its prognostic and therapeutic significance, but the extent of the PLND has not been precisely defined. Computed tomography is considered one of the most preferable methods to assess the BC stage preoperatively because of its high sensitivity and specificity. However, there are few articles referring to CT as an aid in deciding the extent of lymphadenectomy during RC. In the present study, we prospectively studied the clinical value of preoperative CT staging of primary tumours in deciding the extent of PLND during laparoscopic RC in the management of BC. The preliminary findings suggested that all patients with higher preoperative CT stage should be given super-extended PLND during RC. For those with lower CT stage, careful and thorough clearance of all lymphatic and adipose tissues within the true pelvis could be more helpful than super-extended PLND.
To study prospectively the clinical value of preoperative spiral computed tomography (CT) staging of primary tumours in deciding the extent of pelvic lymph node dissection (PLND) during laparoscopic radical cystectomy (RC) in the management of bladder cancer (BC).
Between January 2010 and December 2011, a total of 63 patients with urothelial BC received laparoscopic RC, super-extended PLND and ileac conduit. The super-extended PLND removed all lymphatic tissues in the boundaries at the level of the inferior mesenteric origin from the aorta (cephalad), the pelvic floor (distally), the genitofemoral nerve (laterally) and the sacral promontory (posteriorly). All of the operations were performed by one experienced surgeon, and all harvested lymph nodes were submitted separately. CT was used to evaluate the preoperative CT stage (CTx) of each primary bladder tumour.
All patients were divided into five categories according to their CTx stages: three at CT1, seven at CT2a, 38 at CT2b, seven at CT3b, and eight at CT4a. All 63 procedures were completed successfully without any conversion to open surgery. The mean estimated blood loss was 450 mL, and 14 patients (22.2%) had postoperative lymphatic leakage. Each case was pathologically confirmed as transitional cell carcinoma with negative margins at the urethral and ureteric stumps. None of the patients with a low CTx stage (CT1-CT2a) had positive lymph nodes above the level of the common iliac artery bifurcation. There was no jump lymph node metastasis, and no positive lymph node was detected above the level of aortic bifurcation in all cases.
Based on the preoperative CT staging, urological surgeons can determine the boundaries of PLND to reduce intraoperative injury and postoperative complications in patients with BC, especially those at the lower CTx stages (CT1 and CT2a).
前瞻性研究术前螺旋 CT 对膀胱癌患者原发肿瘤的分期在决定腹腔镜根治性膀胱切除术（RC）时盆腔淋巴结清扫（PLND）范围中的临床价值。
2010 年 1 月至 2011 年 12 月，63 例膀胱癌患者接受了腹腔镜 RC、超广泛 PLND 和回肠造口术。超广泛 PLND 切除了主动脉起源水平以下的肠系膜（头侧）、骨盆底部（尾侧）、生殖股神经（外侧）和骶骨岬（后侧）边界内的所有淋巴组织。所有手术均由一位经验丰富的外科医生完成，所有采集的淋巴结均单独提交。CT 用于评估每个原发性膀胱肿瘤的术前 CT 分期（CTx）。
所有患者根据 CTx 分期分为五类：CT1 期 3 例，CT2a 期 7 例，CT2b 期 38 例，CT3b 期 7 例，CT4a 期 8 例。所有 63 例手术均顺利完成，无中转开放手术。平均估计出血量为 450ml，14 例（22.2%）术后发生淋巴漏。每个病例均经病理证实为移行细胞癌，尿道和输尿管残端切缘阴性。无低 CTx 期（CT1-CT2a）患者在髂总动脉分叉上方有阳性淋巴结。无跳跃性淋巴结转移，所有病例均未在主动脉分叉上方检测到阳性淋巴结。
根据术前 CT 分期，泌尿外科医师可以确定 PLND 的边界，以减少膀胱癌患者术中损伤和术后并发症，特别是 CTx 分期较低（CT1 和 CT2a）的患者。
