Radical transurethral resection alone, robotic or partial cystectomy, or extended lymphadenectomy: can we select patients with muscle invasion for less or more surgery?

Improvements in the accuracy of clinical staging and refinements in patient selection may allow for improved outcomes of bladder-preservation strategies for muscle-invasive bladder cancer incorporating radical transurethral resection (TUR) and partial cystectomy (PC). Retrospective studies of patients treated with radical cystectomy and pelvic lymph node dissection have reported an association between greater extent of lymphadenectomy and improved clinical outcomes. However, there is no consensus regarding the optimal extent of lymphadenectomy, as there are currently no reports from prospective, randomized trials to address this issue in regards to cancer-specific and overall survival. Future advances in the understanding of the appropriate extent of lymphadenectomy requires well-designed prospective clinical trials that directly compare varying extents of surgery with their ability to provide local and distant disease control and disease-specific survival.