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. 2022 Nov 25:12:986150.
doi: 10.3389/fonc.2022.986150. eCollection 2022.

Which lymph node dissection template is optimal for radical cystectomy? A systematic review and Bayesian network meta-analysis

Wenqiang Qi  1 , Minglei Zhong  1 , Ning Jiang  2 , Yongheng Zhou  1 , Guangda Lv  1 , Rongyang Li  3 , Benkang Shi  1 , Shouzhen Chen  1
Affiliations

Which lymph node dissection template is optimal for radical cystectomy? A systematic review and Bayesian network meta-analysis

Wenqiang Qi et al. Front Oncol. .

Abstract

Objective: This study aims to determine the optimal pelvic lymph node dissection (PLND) template for radical cystectomy (RC).

Methods: A systematic search was conducted using the PubMed, Embase and Cochrane Library database in December 2021. Articles comparing recurrence-free survival (RFS), disease-specific survival (DSS), overall survival (OS), and postoperative complications among patients undergoing limited PLND (lPLND), standard PLND (sPLND), extended PLND (ePLND), or super-extended PLND (sePLND) were included. A Bayesian approach was used for network meta-analysis.

Results: We included 18 studies in this systematic review, and 17 studies met our criteria for network meta-analysis. We performed meta-analyses and network meta-analyses to investigate the associations between four PLND templates and the RFS, DSS, OS, or postoperative complications. We found that the ePLND group and the sePLND group were associated with better RFS than the sPLND group (Hazard Ratio [HR]: 0.65, 95% Credible Interval [CrI]: 0.56 to 0.78) (HR: 0.67, 95% CrI: 0.56 to 0.83) and the lPLND group (HR: 0.67, 95% CrI: 0.50 to 0.91) (HR: 0.70, 95% CrI: 0.49 to 0.99). For RFS, Analysis of the treatment ranking revealed that ePLND had the highest probabilities to be the best template. There was no significant difference between the four templates in DSS, however, analysis of the treatment ranking indicated that sePLND had the highest probabilities to be the best template. And We found that the sePLND group and the ePLND group were associated with better OS than lPLND (HR: 0.58, 95% CrI: 0.36 to 0.95) (HR: 0.63, 95% CrI: 0.41 to 0.94). For OS, analysis of the treatment ranking revealed that sePLND had the highest probabilities to be the best template. The results of meta-analyses and network meta-analyses showed that postoperative complications rates did not differ significantly between any two templates.

Conclusion: Patients undergoing sePLND and ePLND had better RFS but not better DSS or OS than those undergoing lPLND or sPLND templates, however, RFS did not differ between patients undergoing sePLND or ePLND. Considering that sePLND involves longer operation time, higher risk, and greater degree of difficulty than ePLND, and performing sePLND may not result in better prognosis, so it seems that there is no need for seLPND. We think that ePLND might be the optimal PLND template for RC.

Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022318475.

Keywords: Bayesian analysis; bladder cancer; complications; pelvic lymph node dissection; prognosis.

PubMed Disclaimer

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
PRISMA flow diagram of literature retrieval. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Figure 2
Figure 2
(A) Forest plot for direct comparisons of RFS in patients with different PLND templates. (B) Forest plot for direct comparisons of DSS in patients with different PLND templates. (C) Forest plot for direct comparisons of OS in patients with different PLND templates. RFS, Recurrence free survival. PLND, Pelvic lymph node dissection. DSS, Disease specific survival. OS, Overall survival. CI, confidence interval. lPLND, limited pelvic lymph node dissection. sPLND, standard pelvic lymph node dissection. ePLND, extended pelvic lymph node dissection. sePLND, super-extended pelvic lymph node dissection.
Figure 3
Figure 3
(A) Forest plot for direct comparisons of early Clavien-Dindo grade 5 complications rates in patients with different PLND templates. (B) Forest plot for direct comparisons of late Clavien-Dindo grade 5 complications rates in patients with different PLND templates. (C) Forest plot for direct comparisons of early Clavien-Dindo grade 3-4 complications rates in patients with different PLND templates. (D) Forest plot for direct comparisons of late Clavien-Dindo grade 3-4 complications rates in patients with different PLND templates. PLND, Pelvic lymph node dissection. CI, confidence interval. lPLND, limited pelvic lymph node dissection. sPLND, standard pelvic lymph node dissection. ePLND, extended pelvic lymph node dissection. sePLND, super-extended pelvic lymph node dissection.
Figure 4
Figure 4
(A) Network plot showing the association of different PLND templates with the RFS in patients undergoing radical cystectomy. (B) Network plot showing the association of different PLND templates with the DSS in patients undergoing radical cystectomy. (C) Network plot showing the association of different PLND templates with the OS in patients undergoing radical cystectomy. PLND, Pelvic lymph node dissection. RFS, Recurrence free survival. PLND, Pelvic lymph node dissection. DSS, Disease specific survival. OS, Overall survival. lPLND, limited pelvic lymph node dissection. sPLND, standard pelvic lymph node dissection. ePLND, extended pelvic lymph node dissection. sePLND, super-extended pelvic lymph node dissection. Note: Lymph node dissection templates are represented by nodes and direct comparison trials between different templates are linked with a line. The area of the dot represents the sample size of each template and the width of the line corresponds the number of direct comparison trials.
Figure 5
Figure 5
(A) Network plot showing the association of different PLND templates with the early Clavien-Dindo grade 5 complications rates in patients undergoing radical cystectomy. (B) Network plot showing the association of different PLND templates with the late Clavien-Dindo grade 5 complications rates in patients undergoing radical cystectomy. (C) Network plot showing the association of different PLND templates with the early Clavien-Dindo grade 3-4 complications rates in patients undergoing radical cystectomy. (D) Network plot showing the association of different PLND templates with the late Clavien-Dindo grade 3-4 complications rates in patients undergoing radical cystectomy. PLND, Pelvic lymph node dissection. lPLND, limited pelvic lymph node dissection. sPLND, standard pelvic lymph node dissection. ePLND, extended pelvic lymph node dissection. sePLND, super-extended pelvic lymph node dissection. Note: Lymph node dissection templates are represented by nodes and direct comparison trials between different templates are linked with a line. The area of the dot represents the sample size of each template and the width of the line corresponds the number of direct comparison trials.
Figure 6
Figure 6
Bayesian network analysis results for RFS and rank probabilities of each PLND template based on the random effects model. (A) Other three PLND templates vs. lPLND template. (B) Other three PLND templates vs. sPLND template. (C) Other three PLND templates vs. ePLND template. (D) Other three PLND templates vs. sePLND template. (E) Probabilities of ranking the lPLND template in the first, second, third and fourth place among four PLND templates. (F) Probabilities of ranking the sPLND template in the first, second, third and fourth place among four PLND templates. (G) Probabilities of ranking the ePLND template in the first, second, third and fourth place among four PLND templates. (H) Probabilities of ranking the sePLND template in the first, second, third and fourth place among four PLND templates. RFS, Recurrence free survival. PLND, Pelvic lymph node dissection. HR, Hazard ratio. CrI, credible interval. lPLND, limited pelvic lymph node dissection. sPLND, standard pelvic lymph node dissection. ePLND, extended pelvic lymph node dissection. sePLND, super-extended pelvic lymph node dissection.
Figure 7
Figure 7
Bayesian network analysis results for DSS and rank probabilities of each PLND template based on the random effects model. (A) Other three PLND templates vs. lPLND template. (B) Other three PLND templates vs. sPLND template. (C) Other three PLND templates vs. ePLND template. (D) Other three PLND templates vs. sePLND template. (E) Probabilities of ranking the lPLND template in the first, second, third and fourth place among four PLND templates. (F) Probabilities of ranking the sPLND template in the first, second, third and fourth place among four PLND templates. (G) Probabilities of ranking the ePLND template in the first, second, third and fourth place among four PLND templates. (H) Probabilities of ranking the sePLND template in the first, second, third and fourth place among four PLND templates. DSS, Disease specific survival. PLND, Pelvic lymph node dissection. HR, Hazard ratio. CrI, credible interval. lPLND, limited pelvic lymph node dissection. sPLND, standard pelvic lymph node dissection. ePLND, extended pelvic lymph node dissection. sePLND, super-extended pelvic lymph node dissection.
Figure 8
Figure 8
Bayesian network analysis results for OS and rank probabilities of each PLND template based on the random-effects model. (A) Other three PLND templates vs. lPLND template. (B) Other three PLND templates vs. sPLND template. (C) Other three PLND templates vs. ePLND template. (D) Other three PLND templates vs. sePLND template. (E) Probabilities of ranking the lPLND template in the first, second, third and fourth place among four PLND templates. (F) Probabilities of ranking the sPLND template in the first, second, third and fourth place among four PLND templates. (G) Probabilities of ranking the ePLND template in the first, second, third and fourth place among four PLND templates. (H) Probabilities of ranking the sePLND template in the first, second, third and fourth place among four PLND templates. OS, Overall survival. PLND, Pelvic lymph node dissection. HR, Hazard ratio. CrI, credible interval. lPLND, limited pelvic lymph node dissection. sPLND, standard pelvic lymph node dissection. ePLND, extended pelvic lymph node dissection. sePLND, super-extended pelvic lymph node dissection.
Figure 9
Figure 9
(A) Bayesian network analysis results for early Clavien-Dindo grade 5 complications rates of each PLND template based on the random effects model. (B) Bayesian network analysis results for late Clavien-Dindo grade 5 complications rates of each PLND template based on the random effects model. (C) Bayesian network analysis results for early Clavien-Dindo grade 3-4 complications rates of each PLND template based on the random effects model. (D) Bayesian network analysis results for late Clavien-Dindo grade 3-4 complications rates of each PLND template based on the random effects model. lPLND, limited pelvic lymph node dissection. sPLND, standard pelvic lymph node dissection. ePLND, extended pelvic lymph node dissection. sePLND, super-extended pelvic lymph node dissection.
Figure 10
Figure 10
(A) Rank probabilities of each PLND template in the first, second, third and fourth place among three PLND templates for early Clavien-Dindo grade 5 complications rates. (B) Rank probabilities of each PLND template in the first, second, third and fourth place among three PLND templates for late Clavien-Dindo grade 5 complications rates. (C) Rank probabilities of each PLND template in the first, second, third and fourth place among four PLND templates for early Clavien-Dindo grade 3-4 complications rates. (D) Rank probabilities of each PLND template in the first, second, third and fourth place among four PLND templates for late Clavien-Dindo grade 3-4 complications rates. lPLND, limited pelvic lymph node dissection. sPLND, standard pelvic lymph node dissection. ePLND, extended pelvic lymph node dissection. sePLND, super-extended pelvic lymph node dissection.
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