Evaluation of regional lymph node dissection in patients with upper urinary tract urothelial cancer

OBJECTIVE: The role of the lymph node dissection (LND) in conjunction with nephroureterectomy (NU) in upper tract urothelial cell carcinoma (UT-UCC) remains undefined. We evaluated the manner in which the LND was applied at NU, the patterns of lymph node (LN) involvement and the preoperative variables that could identify patients at high risk for lymph node metastasis (LNM). METHODS: We examined clinical, radiological and pathological records of patients who underwent NU for UT-UCC between 1985 and 2004. The central pathology laboratory reviewed all specimens and graded tumors using the 2002 World Health Organization/International Society of Urologic Pathologists grading system. RESULTS: Of the NU performed in 252 patients for UT-UCC, 105 (42%) were N0, 28 (11%) N+ and 119 (47%) Nx. Some form of LN resection was performed with NU in 53% of patients, with a median of four LN sampled (interquartile range, 2-10). After adjustment for tumor and patient characteristics, surgeon remained a significant predictor of LN resection (P < 0.0005). Of the evaluated variables, suspicious LN on preoperative computed tomography, present in 60% of N+ patients, was the only preoperative variable associated with the pathological finding of LNM (P < 0.0005). CONCLUSIONS: LND in patients with UT-UCC is surgeon-dependent. Given the prognostic importance of LN status and the limited accuracy of preoperative staging of the regional LN, surgeons should perform a regional LND at the time of NU.