Vol. 181, No. 4, Supplement, Sunday, April 26, 2009 THE JOURNAL OF UROLOGY® 125

mean number of lymph nodes removed increased by 2.6 nodes (from 10-13 in the 1 group, from 13-16 in the 5 group, and from 17-20 in the 10 group), and the percentage of patients undergoing any form of lymph

node dissection increased by an average of 19%. Year of diagnosis was most strongly predictive of the likelihood of undergoing lymphadenectomy and most correlative with the mean number of nodes sampled.

CONCLUSIONS: Over time, urologists have continued to improve both in terms of the performance of lymphadenectomy and node counts obtained at the time of radical cystectomy. This becomes relevant in terms of surgical quality control as we move to an era of minimally invasive cystectomy.

Source of Funding: None

344PROGNOSTIC VALUE OF LYMPH NODE DENSITY IN A MULTI-CENTER, INTERNATIONAL COHORT OF PATIENTS WITH NODE POSITIVE UROTHELIAL CARCINOMA OF THE BLADDER

Robert S Svatek*, Houston, TX; Shahrokh F Shariat, Dallas, TX; Wassim Kassouf, Montreal, QCCanada; Giacomo Novara, Padua, Italy; Yves Fradet, Quebec City, QCCanada; Patrick J Bastian, Munich, Germany; Pierre I Karakiewicz, Montreal, QCCanada; Hans-Martin Fritsche, Regensburg, Germany; Stefan C. Muller, Bonn, Germany; Jonathan I. Izawa, London, ONCanada; Colin P. Dinney, Houston, TX; Christian G. Stief, Munich, Germany; Vincenzo Ficarra, Padua, Italy; Ashish Kamat, Houston, TX; Bjoern G Volkmer, Ulm, Germany; Francesco Montorsi, Milano, Italy; Hendrik Isbarn, Montreal, QCCanada; Seth P Lerner, Houston, TX; Arthur I. Sagalowsky, Dallas, TX; Mark P Schoenberg, Baltimore, MD; Yair Lotan, Dallas, TX; Eila Skinner, Los Angeles, CA

INTRODUCTION AND OBJECTIVE: Lymph node density (LND) has been identified as a prognostic variable in single-institution cystectomy series. The optimal cut-point for relevant LND varies across studies. We sought to validate the prognostic value of LND and to identify its optimal cut-point.

METHODS: We collected and analyzed data from fourteen centers contributing retrospective cohorts of 3,357 patients with UCB treated with radical cystectomy without neo-adjuvant chemotherapy.

RESULTS: A total of 850 (25.3%) patients were found to have node positive disease at cystectomy. Mean number of lymph nodes removed was 26.86 (Range 1-214). Median 10-year cancer-specific survival estimates for node negative and node positive patients were 71.5% (95%CI 69-74%) and 31.6% (95%CI 28-36%), respectively (P<0.001). Median LND was 12.5% (IQR 6.25-32.2%). In multivariable models that adjusted for effects of standard clinical and pathologic features, LND evaluated as a continuous variable was an independent predictor of both UCB recurrence and cancer-specific death (HR 1.44, 95%CI 1.18-1.77, P<0.001 and HR 1.64, 95%CI 1.32-2.04, P<0.001, respectively). Prognostic value of LND is improved after exclusion of patients with less than 10 lymph nodes removed (P<0.001). The maximum predictive accuracy was observed using a LND cut-point of 30% (Harrell’s c-index 64.9%, P<0.001). However, the HRs for cancer-specific death increased incrementally with increasing LND cut-points (adjusted HRs range 1.36-2.27, figure1). Also, categorization of LND into equal-numbered quintiles revealed a strong tertiary distribution of risk based on LNDs 5%, 5-40%, and 40% (figure2).

CONCLUSIONS: This large collaborative study confirms the concept of LND as a poor risk feature in patients with node positive disease. The prognostic value of LND is best represented as a continuum of risk and a LND of 5% represents the best possible outcome for patients with node positive disease.

Source of Funding: None

345FEASIBILITY AND EXTENSION OF LYMPHADENECTOMY AT LAPAROSCOPIC RADICAL CYSTECTOMY FOR BLADDER CANCER

Carlos Nunez, Jose M Garcia Mediero*, Pedro M Cabrera, Ana Garcia-Tellio, Emilio Hernandez, Javier Gonzalez, Javier Angulo, Madrid, Spain

INTRODUCTION AND OBJECTIVE: The number of lymph nodes obtained at the time of radical cystectomy has both prognostic and therapeutic value. We analyze the feasibility to perform extensive lymphadenectomy in a consecutive series of laparoscopic radical cystectomy for bladder cancer.

METHODS: Between September 2004 and October 2008, 60 consecutive laparoscopic radical cystectomies with pelvic lymphadenectomy have been performed for bladder cancer by a single surgeon (CN). Male-female ratio was 5:1. Mean age was 64.1 years (47-85) and mean Body Mass Index was 26.3 (20.8-40.1). Indication for cystectomy was muscle invasive carcinoma (54 cases) and recurrent T1G3/CIS despite intravesical BCG therapy (6 cases). Eight cases received pre-emptive chemotherapy and two cases induction radiotherapy. Extended lymphadenectomy to the aortic bifurcation was intended in every case with templates as follows: common iliac, external iliac, internal iliac and obturator groups from both sides. We analyzed the total number of lymph nodes obtained, and its relationship with age, gender, BMI, indication for cystectomy and neoadjuvant therapy.

RESULTS: Lymphadenectomy was always performed after the bladder was excised and the specimen pocketed. Mean surgical time was 28 minutes (17-46). No mayor vascular lesion or any other complication was produced. Mean number of nodes was 20.8 (range 7-41, median 19). More than 12 lymph nodes were obtained in 54 out of 60 patients (90 %). Lymph node metastasis were present in 24 cases (40.7%), with a single positive node in 7 cases, 2 to 5 lymph nodes in 13 and more than 5 in 4. Number of nodes obtained was not age (p=NS, X2) or sex (20.4 in males [7-41] and 23.1 in females [8-40]; t Student, p=NS) dependent. A correlation was not found either between number of nodes and BMI (Pearson=0,23, p=NS) or induction treatment (t Student, p=NS). Finally mean number of lymph nodes