Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

The role of lymphadenectomy for upper tract urothelial carcinoma

Nature Reviews Urology volume 8, pages 394–401 (2011)Cite this article

Subjects

Abstract

Regional lymphadenectomy, with both its diagnostic and therapeutic roles, serves as an integral component of the management of many malignancies. Extended pelvic lymph node dissection (LND) is the standard of care for urothelial carcinoma of the bladder, with the extent of lymphadenectomy correlating positively with cancer-related outcomes. Given their histologic similarities with bladder cancer, it is reasonable to hypothesize that a similar relationship exists for upper tract urothelial carcinomas (UTUCs). However, the data published to date have failed to consistently demonstrate a therapeutic benefit of regional LND for UTUC. As a consequence, utilization of regional lymphadenectomy remains at the discretion of the surgeon, the extent of LND lacks standardization, and its clinical utility continues to be debated. In order to better clarify the existing data, we present a review of the role of regional lymphadenectomy in patients with UTUC.

Key Points

  • Patients with pathologic node-positive (pN+) upper tract urothelial carcinoma (UTUC) have a poor overall survival rate

  • The role of regional lymphadenectomy for UTUC is currently undefined, with conflicting data in the literature

  • The template for regional lymphadenectomy has not been standardized, which has in part contributed to lymph node dissections being performed in only 44–67% of patients undergoing surgery for UTUC

  • The therapeutic benefit of adjuvant chemotherapy for patients with pN+ UTUC remains unproven

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Proposed template for lymphadenectomy in patients with UTUC, based on the location of the primary tumor.

Similar content being viewed by others

References

  1. Jemal, A. et al. Cancer statistics, 2009. CA Cancer J. Clin. 59, 225–249 (2009).

    PubMed  Google Scholar 

  2. Margulis, V. et al. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer 115, 1224–1233 (2009).

    Article  PubMed  Google Scholar 

  3. Hall, M. C. et al. Prognostic factors, recurrence, and survival in transitional cell carcinoma of the upper urinary tract: a 30-year experience in 252 patients. Urology 52, 594–601 (1998).

    Article  CAS  PubMed  Google Scholar 

  4. Huben, R. P., Mounzer, A. M. & Murphy, G. P. Tumor grade and stage as prognostic variables in upper tract urothelial tumors. Cancer 62, 2016–2020 (1988).

    Article  CAS  PubMed  Google Scholar 

  5. Kondo, T. et al. Primary site and incidence of lymph node metastases in urothelial carcinoma of upper urinary tract. Urology 69, 265–269 (2007).

    Article  PubMed  Google Scholar 

  6. Raman, J. D., Messer, J., Sielatycki, J. A. & Hollenbeak, C. S. Incidence and survival of patients with carcinoma of the ureter and renal pelvis in the USA, 1973–2005. BJU Int. 107, 1059–1064 (2011).

    Article  PubMed  Google Scholar 

  7. Roscigno, M. et al. Prognostic value of lymph node dissection in patients with muscle-invasive transitional cell carcinoma of the upper urinary tract. Eur. Urol. 53, 794–802 (2008).

    Article  PubMed  Google Scholar 

  8. Brausi, M. A. et al. Retroperitoneal lymph node dissection (RPLD) in conjunction with nephroureterectomy in the treatment of infiltrative transitional cell carcinoma (TCC) of the upper urinary tract: impact on survival. Eur. Urol. 52, 1414–1418 (2007).

    Article  PubMed  Google Scholar 

  9. Stein, J. P. & Skinner, D. G. The role of lymphadenectomy in high-grade invasive bladder cancer. Urol. Clin. North Am. 32, 187–197 (2005).

    Article  PubMed  Google Scholar 

  10. Novara, G. et al. Independent predictors of cancer-specific survival in transitional cell carcinoma of the upper urinary tract: multi-institutional dataset from 3 European centers. Cancer 110, 1715–1722 (2007).

    Article  PubMed  Google Scholar 

  11. Melamed, M. R. & Reuter, V. E. Pathology and staging of urothelial tumors of the kidney and ureter. Urol. Clin. North Am. 20, 333–347 (1993).

    CAS  PubMed  Google Scholar 

  12. Leissner, J., Hohenfellner, R., Thuroff, J. W. & Wolf, H. K. Lymphadenectomy in patients with transitional cell carcinoma of the urinary bladder; significance for staging and prognosis. BJU Int. 85, 817–823 (2000).

    Article  CAS  PubMed  Google Scholar 

  13. Herr, H. W. et al. Impact of the number of lymph nodes retrieved on outcome in patients with muscle invasive bladder cancer. J. Urol. 167, 1295–1298 (2002).

    Article  PubMed  Google Scholar 

  14. Skinner, D. G. Management of invasive bladder cancer: a meticulous pelvic node dissection can make a difference. J. Urol. 128, 34–36 (1982).

    Article  CAS  PubMed  Google Scholar 

  15. Lerner, S. P. et al. The rationale for en bloc pelvic lymph node dissection for bladder cancer patients with nodal metastases: long-term results. J. Urol. 149, 758–764 (1993).

    Article  CAS  PubMed  Google Scholar 

  16. Stein, J. P., Cai, J., Groshen, S. & Skinner, D. G. Risk factors for patients with pelvic lymph node metastases following radical cystectomy with en bloc pelvic lymphadenectomy: concept of lymph node density. J. Urol. 170, 35–41 (2003).

    Article  PubMed  Google Scholar 

  17. Buckley, J. A., Urban, B. A., Soyer, P., Scherrer, A. & Fishman, E. K. Transitional cell carcinoma of the renal pelvis: a retrospective look at CT staging with pathologic correlation. Radiology 201, 194–198 (1996).

    Article  CAS  PubMed  Google Scholar 

  18. Scolieri, M. J., Paik, M. L., Brown, S. L. & Resnick, M. I. Limitations of computed tomography in the preoperative staging of upper tract urothelial carcinoma. Urology 56, 930–934 (2000).

    Article  CAS  PubMed  Google Scholar 

  19. Puigvert, A. Comments on the book “Medecine Operatoire des Voies Urinaires”, by J. Albarran [Spanish]. Arch. Esp. Urol. 14, 159–185 (1958).

    CAS  PubMed  Google Scholar 

  20. Arancibia, M. F., Bolenz, C., Michel, M. S., Keeley, F. X. Jr & Alken, P. The modern management of upper tract urothelial cancer: surgical treatment. BJU Int. 99, 978–981 (2007).

    Article  PubMed  Google Scholar 

  21. Olgac, S., Mazumdar, M., Dalbagni, G. & Reuter, V. E. Urothelial carcinoma of the renal pelvis: a clinicopathologic study of 130 cases. Am. J. Surg. Pathol. 28, 1545–1552 (2004).

    Article  PubMed  Google Scholar 

  22. Bariol, S. V., Stewart, G. D., McNeill, S. A. & Tolley, D. A. Oncological control following laparoscopic nephroureterectomy: 7-year outcome. J. Urol. 172, 1805–1808 (2004).

    Article  PubMed  Google Scholar 

  23. Skinner, D. G. Technique of nephroureterectomy with regional lymph node dissection. Urol. Clin. North Am. 5, 252–260 (1978).

    CAS  PubMed  Google Scholar 

  24. Capitanio, U. et al. Comparison of oncologic outcomes for open and laparoscopic nephroureterectomy: a multi-institutional analysis of 1,249 cases. Eur. Urol. 56, 1–9 (2009).

    Article  PubMed  Google Scholar 

  25. Waldert, M., Remzi, M., Klingler, H. C., Mueller, L. & Marberger, M. The oncological results of laparoscopic nephroureterectomy for upper urinary tract transitional cell cancer are equal to those of open nephroureterectomy. BJU Int. 103, 66–70 (2009).

    Article  PubMed  Google Scholar 

  26. Manabe, D. et al. Comparative study of oncologic outcome of laparoscopic nephroureterectomy and standard nephroureterectomy for upper urinary tract transitional cell carcinoma. Urology 69, 457–461 (2007).

    Article  PubMed  Google Scholar 

  27. Busby, J. E., Brown, G. A. & Matin, S. F. Comparing lymphadenectomy during radical nephroureterectomy: open versus laparoscopic. Urology 71, 413–416 (2008).

    Article  PubMed  Google Scholar 

  28. Soderdahl, D. W., Fabrizio, M. D., Rahman, N. U., Jarrett, T. W. & Bagley, D. H. Endoscopic treatment of upper tract transitional cell carcinoma. Urol. Oncol. 23, 114–122 (2005).

    Article  PubMed  Google Scholar 

  29. Palou, J. et al. Percutaneous nephroscopic management of upper urinary tract transitional cell carcinoma: recurrence and long-term followup. J. Urol. 172, 66–69 (2004).

    Article  PubMed  Google Scholar 

  30. Skinner, D. G. et al. The role of adjuvant chemotherapy following cystectomy for invasive bladder cancer: a prospective comparative trial. J. Urol. 145, 459–464 (1991).

    Article  CAS  PubMed  Google Scholar 

  31. Stockle, M. et al. Adjuvant polychemotherapy of nonorgan-confined bladder cancer after radical cystectomy revisited: long-term results of a controlled prospective study and further clinical experience. J. Urol. 153, 47–52 (1995).

    Article  CAS  PubMed  Google Scholar 

  32. Kurahashi, T. et al. Detection of micrometastases in pelvic lymph nodes in patients undergoing radical cystectomy for locally invasive bladder cancer by real-time reverse transcriptase-PCR for cytokeratin 19 and uroplakin II. Clin. Cancer Res. 11, 3773–3777 (2005).

    Article  CAS  PubMed  Google Scholar 

  33. Shariat, S. F. et al. Outcomes of radical cystectomy for transitional cell carcinoma of the bladder: a contemporary series from the Bladder Cancer Research Consortium. J. Urol. 176, 2414–2422 (2006).

    Article  PubMed  Google Scholar 

  34. Herr, H. W. Extent of surgery and pathology evaluation has an impact on bladder cancer outcomes after radical cystectomy. Urology 61, 105–108 (2003).

    Article  PubMed  Google Scholar 

  35. Keeley, F. X., Kulp, D. A., Bibbo, M., McCue, P. A. & Bagley, D. H. Diagnostic accuracy of ureteroscopic biopsy in upper tract transitional cell carcinoma. J. Urol. 157, 33–37 (1997).

    Article  CAS  PubMed  Google Scholar 

  36. Guarnizo, E. et al. Ureteroscopic biopsy of upper tract urothelial carcinoma: improved diagnostic accuracy and histopathological considerations using a multi-biopsy approach. J. Urol. 163, 52–55 (2000).

    Article  CAS  PubMed  Google Scholar 

  37. Messer, J. et al. Urinary cytology has a poor performance for predicting invasive or high-grade upper-tract urothelial carcinoma. BJU Int. doi:10.1111/j.1464-410X.2010.09899.x.

  38. Ng, C. K. et al. Does the presence of hydronephrosis on preoperative axial CT imaging predict worse outcomes for patients undergoing nephroureterectomy for upper-tract urothelial carcinoma? Urol. Oncol. 29, 27–32 (2011).

    Article  PubMed  Google Scholar 

  39. Brien, J. C. et al. Preoperative hydronephrosis, ureteroscopic biopsy grade and urinary cytology can improve prediction of advanced upper tract urothelial carcinoma. J. Urol. 184, 69–73 (2010).

    Article  PubMed  Google Scholar 

  40. Margulis, V. et al. Preoperative multivariable prognostic model for prediction of nonorgan confined urothelial carcinoma of the upper urinary tract. J. Urol. 184, 453–458 (2010).

    Article  PubMed  Google Scholar 

  41. Secin, F. P. et al. Evaluation of regional lymph node dissection in patients with upper urinary tract urothelial cancer. Int. J. Urol. 14, 26–32 (2007).

    Article  PubMed  Google Scholar 

  42. Kondo, T. et al. Template-based lymphadenectomy in urothelial carcinoma of the upper urinary tract: impact on patient survival. Int. J. Urol. 17, 848–854 (2010).

    Article  PubMed  Google Scholar 

  43. Komatsu, H., Tanabe, N., Kubodera, S., Maezawa, H. & Ueno, A. The role of lymphadenectomy in the treatment of transitional cell carcinoma of the upper urinary tract. J. Urol. 157, 1622–1624 (1997).

    Article  CAS  PubMed  Google Scholar 

  44. Miyake, H., Hara, I., Gohji, K., Arakawa, S. & Kamidono, S. The significance of lymphadenectomy in transitional cell carcinoma of the upper urinary tract. Br. J. Urol. 82, 494–498 (1998).

    Article  CAS  PubMed  Google Scholar 

  45. Lughezzani, G. et al. A critical appraisal of the value of lymph node dissection at nephroureterectomy for upper tract urothelial carcinoma. Urology 75, 118–124 (2010).

    Article  PubMed  Google Scholar 

  46. Roscigno, M. et al. Assessment of the minimum number of lymph nodes needed to detect lymph node invasion at radical nephroureterectomy in patients with upper tract urothelial cancer. Urology 74, 1070–1074 (2009).

    Article  PubMed  Google Scholar 

  47. Roscigno, M. et al. Impact of lymph node dissection on cancer specific survival in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy. J. Urol. 181, 2482–2489 (2009).

    Article  PubMed  Google Scholar 

  48. Abe, T. et al. The role of lymph-node dissection in the treatment of upper urinary tract cancer: a multi-institutional study. BJU Int. 102, 576–580 (2008).

    Article  PubMed  Google Scholar 

  49. Bolenz, C. et al. Risk stratification of patients with nodal involvement in upper tract urothelial carcinoma: value of lymph-node density. BJU Int. 103, 302–306 (2009).

    Article  PubMed  Google Scholar 

  50. Batata, M. A., Whitmore, W. F., Hilaris, B. S., Tokita, N. & Grabstald, H. Primary carcinoma of the ureter: a prognostic study. Cancer 35, 1626–1632 (1975).

    Article  CAS  PubMed  Google Scholar 

  51. McCarron, J. P., Mills, C. & Vaughn, E. D. Jr. Tumors of the renal pelvis and ureter: current concepts and management. Semin. Urol. 1, 75–81 (1983).

    CAS  PubMed  Google Scholar 

  52. Akaza, H., Koiso, K. & Niijima, T. Clinical evaluation of urothelial tumors of the renal pelvis and ureter based on a new classification system. Cancer 59, 1369–1375 (1987).

    Article  CAS  PubMed  Google Scholar 

  53. Abe, T. et al. Role of lymph node dissection in the treatment of urothelial carcinoma of the upper urinary tract: multi-institutional relapse analysis and immunohistochemical re-evaluation of negative lymph nodes. Eur. J. Surg. Oncol. 36, 1085–1091 (2010).

    Article  CAS  PubMed  Google Scholar 

  54. Audenet, F., Yates, D. R., Cussenot, O. & Rouprêt, M. The role of chemotherapy in the treatment of urothelial cell carcinoma of the upper urinary tract (UUT-UCC). Urol. Oncol. doi:10.1016/j.urolonc.2010.07.016.

    Article  CAS  PubMed  Google Scholar 

  55. Grossman, H. B. et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N. Engl. J. Med. 349, 859–866 (2003).

    Article  CAS  PubMed  Google Scholar 

  56. Hellenthal, N. J. et al. Adjuvant chemotherapy for high risk upper tract urothelial carcinoma: results from the Upper Tract Urothelial Carcinoma Collaboration. J. Urol. 182, 900–906 (2009).

    Article  PubMed  Google Scholar 

  57. Matin, S. F. et al. Incidence of downstaging and complete remission after neoadjuvant chemotherapy for high-risk upper tract transitional cell carcinoma. Cancer 116, 3127–3134 (2010).

    Article  PubMed  Google Scholar 

  58. Moussa, S. et al. Outcome of surgical treatment of patients with upper versus lower urinary tract urothelial carcinoma: stage-by-stage comparison. Urol. Int. 84, 50–55 (2010).

    Article  CAS  PubMed  Google Scholar 

  59. Okano, T. et al. Regional lymphadenectomy for renal pelvic and ureteral cancers [Japanese]. Nippon Hinyokika Gakkai Zasshi 82, 816–820 (1991).

    CAS  PubMed  Google Scholar 

  60. Lehmann, J. et al. Surgery for metastatic urothelial carcinoma with curative intent: the German experience (AUO AB 30/05). Eur. Urol. 55, 1293–1299 (2009).

    Article  PubMed  Google Scholar 

  61. Kondo, T. et al. Impact of the extent of regional lymphadenectomy on the survival of patients with urothelial carcinoma of the upper urinary tract. J. Urol. 178, 1212–1217 (2007).

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Urology, Penn State Milton S. Hershey Medical Center, 500 University Drive, H055, Hershey, 17033-0850, PA, USA

    Jamie Messer & Jay D. Raman

  2.  Penn State College of Medicine, 500 University Drive, Hershey, 17033-0850, PA, USA

    Yu Kuan Lin

Authors
  1. Jamie Messer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yu Kuan Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jay D. Raman
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors researched data and discussed the content of the manuscript. J. Messer and J. D. Raman wrote the article and performed review and editing of the manuscript before submission.

Corresponding author

Correspondence to Jay D. Raman.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Messer, J., Lin, Y. & Raman, J. The role of lymphadenectomy for upper tract urothelial carcinoma. Nat Rev Urol 8, 394–401 (2011). https://doi.org/10.1038/nrurol.2011.78

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrurol.2011.78

This article is cited by

Search

Advanced search

Quick links

Nature Briefing: Cancer

Sign up for the Nature Briefing: Cancer newsletter — what matters in cancer research, free to your inbox weekly.

Get what matters in cancer research, free to your inbox weekly. Sign up for Nature Briefing: Cancer