Clinical nodal staging scores for bladder cancer: A proposal for preoperative risk assessment

Shahrokh F. Shariat, Behfar Ehdaie, Michael Rink, Eugene K. Cha, Robert S. Svatek, Thomas F. Chromecki, Harun Fajkovic, Giacomo Novara, Scott G. David, Siamak Daneshmand, Yves Fradet, Yair Lotan, Arthur I. Sagalowsky, Thomas Clozel, Patrick J. Bastian, Wassim Kassouf, Hans Martin Fritsche, Maximilian Burger, Jonathan I. Izawa, Derya TilkiFiras Abdollah, Felix K. Chun, Guru Sonpavde, Pierre I. Karakiewicz, Douglas S. Scherr, Mithat Gonen

Research output: Contribution to journalArticlepeer-review

63 Scopus citations


Background: Radical cystectomy (RC) with pelvic lymph node dissection (LND) is the standard of care for refractory non-muscle-invasive and muscle-invasive bladder cancer. Although consensus exists on the need for LND, its extent is still debated. Objective: To develop a model that allows preoperative determination of the minimum number of lymph nodes (LNs) needed to be removed at RC to ensure true nodal status. Design, setting, and participants: We analyzed data from 4335 patients treated with RC and pelvic LND without neoadjuvant chemotherapy at 12 academic centers located in the United States, Canada, and Europe. Measurements: We estimated the sensitivity of pathologic nodal staging using a beta-binomial model and developed clinical (preoperative) nodal staging scores (cNSS), which represent the probability that a patient has LN metastasis as a function of the number of examined nodes. Results and limitations: The probability of missing a positive LN decreased with an increasing number of nodes examined (52% if 3 nodes were examined, 40% if 5 were examined, and 26% if 10 were examined). A cNSS of 90% was achieved by examining 6 nodes for clinical Ta-Tis tumors, 9 nodes for cT1 tumors, and 25 nodes for cT2 tumors. In contrast, examination of 25 nodes provided only 77% cNSS for cT3-T4 tumors. The study is limited due to its retrospective design, its multicenter nature, and a lack of preoperative staging parameters. Conclusions: Every patient treated with RC for bladder cancer needs an LND to ensure accurate nodal staging. The minimum number of examined LNs for adequate staging depends preoperatively on the clinical T stage. Predictive tools can give a preoperative estimation of the likelihood of nodal metastasis and thereby allow tailored decision-making regarding the extent of LND at RC.

Original languageEnglish (US)
Pages (from-to)237-242
Number of pages6
JournalEuropean Urology
Issue number2
StatePublished - Feb 2012


  • Bladder cancer
  • Lymph node
  • Prognosis
  • Radical cystectomy
  • Survival
  • Urothelial carcinoma

ASJC Scopus subject areas

  • Urology


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