Platinum Priority – Bladder Cancer
Editorial by Alexandre R. Zlotta on pp. 243–244 of this issue

Clinical Nodal Staging Scores for Bladder Cancer: A Proposal for Preoperative Risk Assessment

By: Shahrokh F. Shariata 1 lowast , Behfar Ehdaiea 1, Michael Rinka b, Eugene K. Chaa, Robert S. Svatekc, Thomas F. Chromeckia d, Harun Fajkovica e, Giacomo Novaraf, Scott G. Davida, Siamak Daneshmandg, Yves Fradeth, Yair Lotani, Arthur I. Sagalowskyi, Thomas Clozela, Patrick J. Bastianj, Wassim Kassoufk, Hans-Martin Fritschel, Maximilian Burgerl, Jonathan I. Izawam, Derya Tilkij, Firas Abdollahn, Felix K. Chunb, Guru Sonpavdeo, Pierre I. Karakiewiczn, Douglas S. Scherra and Mithat Gonenp

European Urology, Volume 61 Issue 2, February 2012, Pages 237-242

Published online: 01 February 2012

Keywords: Lymph node, Radical cystectomy, Prognosis, Bladder cancer, Urothelial carcinoma, Survival

Abstract Full Text Full Text PDF (255 KB)



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.


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.


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.


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.

Take Home Message

Every patient treated with radical cystectomy for bladder cancer needs a lymph node (LN) dissection to ensure accurate nodal staging. Clinical tumor stage is a powerful predictor of the number of LNs needed to be removed to ascertain LN status. We developed a clinical nodal staging score that estimates the number of LNs needed to be removed to ensure accurate LN status.

Keywords: Lymph node, Radical cystectomy, Prognosis, Bladder cancer, Urothelial carcinoma, Survival.


a Weill Cornell Medical College, New York, NY, USA

b University Medical Center Hamburg-Eppendorf, Hamburg, Germany

c University of Texas San Antonio, San Antonio, TX, USA

d Medical University of Graz, Graz, Austria

e St. Poelten General Hospital, St. Poelten, Austria

f University of Padua, Padua, Italy

g University of Southern California, Los Angeles, CA, USA

h Laval University, Québec City, Québec, Canada

i University of Texas Southwestern Medical Center, Dallas, TX, USA

j Ludwig-Maximilians-Universität München, Klinikum Grosshadern, Munich, Germany

k McGill University Health Centre, Montréal, Québec, Canada

l Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany

m University of Western Ontario, London, Ontario, Canada

n University of Montréal, Montréal, Québec, Canada

o Baylor College of Medicine, Houston, TX, USA

p Memorial Sloan-Kettering Cancer Center, New York, NY, USA

lowast Corresponding author. Brady Urologic Health Center, Weill Cornell Medical College, 525 East 68th St., Box 94, Starr 900, New York, NY 10065, USA.

1 Both authors contributed equally to the manuscript.

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