More Extensive Lymph Node Dissection Improves Survival Benefit of Radical Cystectomy in Metastatic Urothelial Carcinoma of the Bladder

Background: Radical cystectomy (RC) may occasionally be performed in individuals with metastatic urothelial carcinoma of the bladder (mUCB). However, the role of lymph node dissection (LND) for such cases is unknown. Thus, we tested the effect of RC on cancer-specific mortality (CSM) and overall mortality in mUCB patients and the effect of LND and its extent on CSM. Patients and Methods: Within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2013), we identified patients with mUCB who underwent RC with or without LND or non-RC management. Kaplan-Meier analyses and multivariable Cox regression models (CRMs) were used, after propensity score matching. The number of removed nodes best predicting CSM was identified using cubic splines and then was tested in multivariable CRMs. Results: Of 2314 patients, 319 (13.8%) underwent RC. After 2:1 propensity score matching, CSM-free survival was 14 versus 8 months (P <.001), and overall mortality–free survival was 12 versus 7 months (P <.001) for, respectively, RC and non-RC patients. In multivariable CRMs, lower CSM (hazard ratio = 0.48; P <.001) and lower overall mortality (hazard ratio = 0.49; P <.001) rates were recorded in RC patients. LND status did not affect CSM-free survival (13 vs. 10 months; P =.1). Cubic splines-derived cutoff of ≥ 13 number of removed nodes showed better CSM-free survival (20 vs. 11 months; P =.02) and reduced CSM in CRMs (hazard ratio = 0.67; P =.02). Conclusion: Our study validates the survival benefit of RC in mUCB and highlights the importance of more extensive LND. These findings may corroborate the hypothesis of potential cytoreductive effect of surgery in the context of metastatic disease. We studied the effect of radical cystectomy (RC) on cancer-specific mortality and overall mortality in contemporary metastatic urothelial carcinoma of the bladder (mUCB) patients. Additionally, we analyzed the role of lymph node dissection (LND) in the same context. We found that RC plus extended LND is associated with better survival outcomes relative to no local treatment in mUCB patients.