Clinical and Pathological Predictors for Occult Lymph Node Involvement in Patients With Clinical Node-Negative Bladder Cancer Undergoing Radical Cystectomy.

Background: Occult pathological lymph node involvement in patients with clinical node-negative (cN0) bladder cancer (BC) remains a diagnostic challenge. We evaluate predictors of lymph node positivity (pN+) in patients with cT1-4N0M0 BC undergoing radical cystectomy and pelvic lymph node dissection (RC-PLND).

Methods: We included patients with cT1-4N0M0 BC undergoing RC-PLND from February 2004 through October 2020. Patients were classified as pN+ vs. pN0. Baseline characteristics were summarized using descriptive statistics. Logistic regression models and multivariable analysis estimated odds ratios (OR) for pN+ status. Kaplan Meier analysis and multivariable Cox proportional hazards models analyzed recurrence-free survival (RFS) and overall survival (OS).

Results: 440 patients were evaluated, of which 81% (n = 359) had pN0 and 17% (n = 74) had pN+ disease. Most were male (80%), white (88%), and had a median age of 71 years. Most had clinical T2 (55%) and T1 (25%) disease. Lymphovascular invasion (LVI) on TURBT (OR 2.62, P = .04), positive surgical margins (OR 16.77, P < .001), and ≥ cT2 disease (OR 1.89, P = .04) had higher odds of pN+ status. pN+ patients were more likely to suffer recurrence (HR 7.67, P < .001) or death (HR 3.26, P < .001) compared to pN0 patients. Preoperative hydronephrosis predicted worse RFS (HR 1.76, P = .011) and OS (HR 1.55, P = .007). Positive surgical margins (HR 2.34, P = .008) and preoperative renal function (HR 1.50, P = .004) predicted worse OS.

Conclusion: Positive surgical margins, LVI, and ≥ cT2 disease strongly predict pN+ findings in patients with cT1-4N0M0 BC. Preoperative variables can inform treatment for patients with a higher risk for positive lymph node findings at surgery.