Pelvic lymph node dissection (PLND) is performed during radical cystectomy for invasive bladder cancer, but the optimal extent of dissection has long been controversial. This updated Cochrane review synthesizes evidence from the two landmark randomized trials in this area (LEA and SWOG S1011), and finds that extended PLND likely improves bladder cancer-specific survival but also likely increases the risk of serious (Clavien-Dindo grade ≥ 3) complications, without clear benefit for overall survival or recurrence-free survival.

Extended versus standard lymph node dissection for urothelial carcinoma of the bladder in people undergoing radical cystectomy

Authors: Lee CH, Shepherd A, Sathianathen N, Hwang JE, Hwang EC, Kim MH, Narayan V, Jung JH, Dahm P
Published online: 23 April 2026
DOI: 10.1002/14651858.CD013336.pub2

Background

Pelvic lymph node dissection is an essential procedure during radical cystectomy for bladder cancer, but the benefits and harms of standard PLND compared to extended PLND have remained uncertain. This review updates the original 2019 Cochrane review to incorporate long-term follow-up data and the recent publication of two landmark randomized controlled trials providing the first Level I evidence on this question.

Objectives

To assess the effects of extended versus standard PLND in people undergoing cystectomy to treat muscle-invasive (cT2 and cT4a) and treatment-refractory, non-muscle-invasive (cT1 with or without carcinoma in situ) urothelial carcinoma of the bladder.

Search methods

We conducted a comprehensive literature search using multiple databases (CENTRAL, PubMed, Embase, Web of Science, and LILACS), trial registries, and conference proceedings published up to 24 September 2025, with no restrictions on language or publication status.

Selection criteria

We included randomized controlled trials in which participants underwent radical cystectomy for muscle-invasive or therapy-refractory non-muscle-invasive urothelial carcinoma of the bladder, with either extended PLND (upper extent reaching as far as the inferior mesenteric artery) or standard PLND (up to the bifurcation of the internal and external iliac artery), with otherwise the same anatomical boundaries.

Data collection and analysis

We followed standard Cochrane methodology. Two review authors independently screened studies, extracted data, and assessed risk of bias using the Cochrane RoB 2 tool. We combined results using random-effects meta-analyses and rated the certainty of evidence using GRADE.

Results

We included two RCTs with 993 randomized participants (extended PLND 490, standard PLND 503). Median age ranged from 67 to 69 years across groups, and all participants had locally completely resectable, invasive urothelial bladder cancer. The certainty of evidence for most outcomes was moderate to low, primarily downgraded due to imprecision.

Critical outcomes

Time to death from any cause: Extended PLND may result in little to no difference compared to standard PLND (HR 0.99, 95% CI 0.75 to 1.30; 2 studies, 993 participants; low-certainty evidence). This corresponds to 3 fewer deaths per 1000 participants at five years (95% CI 86 fewer to 88 more).

Time to death from bladder cancer: Extended PLND likely extends the time to death from bladder cancer compared to standard PLND (HR 0.65, 95% CI 0.44 to 0.97; 1 study, 401 participants; moderate-certainty evidence). This corresponds to 106 fewer cancer deaths per 1000 participants at five years (95% CI 177 fewer to 8 fewer).

Clavien-Dindo grade ≥ 3 complications (up to 90 days): Extended PLND likely increases serious complications compared to standard PLND (RR 1.22, 95% CI 1.06 to 1.41; 2 studies, 993 participants; moderate-certainty evidence). This corresponds to 86 more complications per 1000 participants (95% CI 23 more to 160 more).

Important outcomes

Time to recurrence: Extended PLND may result in little to no difference compared to standard PLND (HR 0.96, 95% CI 0.71 to 1.31; 2 studies, 993 participants; low-certainty evidence). This corresponds to 12 fewer recurrences per 1000 participants at five years (95% CI 96 fewer to 88 more).

Clavien-Dindo grade ≤ 2 complications (up to 90 days): Extended PLND likely results in similar minor complication rates compared to standard PLND (RR 0.85, 95% CI 0.73 to 1.00; 2 studies, 993 participants; moderate-certainty evidence).

Disease-specific quality of life: No included studies reported this outcome.

Authors' conclusions

This updated systematic review synthesizes the evidence from the two available RCTs in this field. We found that extended PLND likely improves bladder cancer-specific survival; however, it may result in little to no difference in overall survival or recurrence-free survival. Extended PLND likely increases severe complications (Clavien-Dindo grade ≥ 3), while likely showing similar rates of minor complications (grade ≤ 2) at 90-day follow-up compared to standard PLND. These findings underscore the trade-offs of potential oncologic benefits of extended PLND versus the increased risk of serious complications in patients undergoing radical cystectomy. The absence of any health-related quality of life data is a notable evidence gap and a priority for future research.