Discussion
obese, blood loss, cancer, MIBC, tumour
METASTASIS, OBESE, TUMOURS, CANCER, BLOOD LOSS, DISEASE, TUMOUR, SENTINEL NODE, METASTASES
Nodal involvement in BCa is associated with a worse oncological outcome. It is reported in 25% of patients. So, it is an important prognostic parameter with a major impact on the outcome and the overall survival. Therefore, careful PLND is critical to stage patients with BCa accurately. The value of PLND has been addressed in details in multiple studies [Multiple factors ensure safe and adequate PLND. This includes; the extent of PLND, a meticulous surgical technique, the number of LNs removed including the positive ones, the surgeon and the pathologist experience [The initial site of lymphatic drainage from a primary tumour is called the sentinel node. In BCa, the endopelvic LNs are the sentinel region, metastasis occurs in an orderly fashion and skip lesions are rare. Moreover, crossover lymphatic drainage is seen in 40% of patients. So, PLND should always be performed bilaterally [The ePLND provides a better local control. It removes about 90% of the primary lymphatic landing sites while the limited one removes only 50%. But, the rate of nodal involvement may be the same. The super-extended PLND increases the number of LNs and the positive nodes removed. However, it has no additional survival benefits, with an increased operative time and patient morbidity [The number of LNs removed and the concept of LNs density are useful prognostic indicators in both LN positive and LN negative patients [Nodal involvement is associated with a worse oncological outcome, and may benefit from adjuvant systemic therapies. Its incidence is ranging from 5% in NMIBC, 18–27% in MIBC, 45% in extra-vesical tumours. About 60% of patients with MIBC and LN metastases will die from cancer [Performing ePLND before RC may be advantageous as it clearly visualize the vascular pedicles and clarify the tissue planes especially in obese patients. So, RC can be performed more rapidly and without a significant blood loss [In a study evaluating the timing of PLND in 2 groups regarding the operative time, the mean ePLND time was similar in both groups (The surgeon experience in performing meticulous PLND can cure 30% of patients with only few LN metastases or with microscopic LN involvement. It was shown that, negative surgical margins and ≥ 10 LN removed were associated with better overall survival independent of patient age, pathological stage, nodal status and neo-adjuvant chemotherapy, all this is surgeon dependent [The Limitations of the current study are, the lack of stage to stage comparison regarding the oncological failure and absence of molecular markers to predict LN positivity. However, the current study is the first one to discuss the effect of timing of ePLND on the oncological outcome of RC in prospective nature over a good cohort of patients, which is a point of strength if compared to the previous LND studies which were retrospective in nature with their inherent biases.In conclusion, the results of the current study support that lymphadenectomy before and after RC will not compromise the radicality of surgery with similar oncological outcome. However, lymphadenectomy after RC is performed more easily and in a shorter time. The stage of the disease, the time since the first diagnosis of BCa till RC and the surgeon experience in performing meticulous PLND are more important. Moreover, the timing of ePLND should be judged according to the patient’s related factors to facilitate safe RC with minimal morbidity.