Pelvic Lymph Node Dissection Before Versus After Radical Cystectomy: A Systematic Review and Meta-Analysis.

Objective: Radical cystectomy (RC) is the standard of care for patients with bladder cancer, and pelvic lymph node dissection (PLND) is a pivotal step that can be carried out either before or after RC. Evidence on the optimal timing for PLND remains limited.

Methods: We searched PubMed, Embase, Cochrane Central, Scopus and Google Scholar for studies comparing PLND before versus after RC. Outcomes assessed were total operative time, PLND time, RC time, number of lymph nodes (LN) dissected, and estimated blood loss. Mean differences (MDs) and 95% confidence intervals (CIs) were computed using a random-effects model. Subgroup analysis was conducted for robot-assisted RC (RARC).

Results: A total of 801 patients from six studies were included, of whom 360 (44.94%) underwent PLND before RC. There were no significant differences in total operative time (MD -17.49; 95% CI -41.65,6.67; p = 0.16; I2 = 94%), PLND time (MD -14.91; 95% CI -44.91,15.09; p = 0.33; I2 = 96%), LN yielded (MD -1.13; 95% CI -4.81,2.55; p = 0.55; I2 = 83%), and estimated blood loss (MD 0.17; 95% CI -51.33,51.68; p = 0.99; I2 = 81%). However, RC time was significantly reduced (MD -28.89; 95% CI -42.84,-14.93; p < 0.0001; I2 = 75%) when PLND was performed prior to RC. In RARC studies, PLND before RC decreased total operative time, RC time, and estimated blood loss.

Conclusions: The timing of lymphadenectomy was not associated with a significant reduction in total operative time, PLND time, LN yield, and estimated blood loss.