What to do if the lymph nodes are positive.

Lymph node metastases are common in patients with advanced bladder cancer. Survival rates have apparently improved from about 15% to 30% as management evolved from lymphadenectomy plus cystectomy to multimodal therapy, but investigators have not conclusively shown the benefit of adjuvant irradiation and/or chemotherapy. If clinical staging indicates nodal metastases, we recommend primary multiagent chemotherapy with subsequent exploratory laparotomy, lymphadenectomy, and possibly cystectomy for complete responders. Patients without clinical evidence of metastases undergo complete bilateral pelvic lymphadenectomy plus cystectomy if nodes are normal, or if grossly abnormal but resectable. Patients with nodal metastases may be candidates for adjuvant chemotherapy.