Maria Fernanda Dias Azevedo, Pedro Henrique Souza Brito, Lucas Kallas-Silva, Bruno Liebl, Beatriz Taveira Constantinou, Bianca Caroline Benedicto, Lucas Paschoalino de Oliveira, Mauricio Dener Cordeiro, William Carlos Nahas, Walid Shabana, Walid Shahrour, Leopoldo Alves Ribeiro-Filho, Caio Vinicius Suartz
Pelvic lymph node dissection is an essential component of radical cystectomy (RC) for bladder cancer (BC), but the optimal extent of lymphadenectomy remains uncertain. We conducted a systematic review and meta-analysis to compare oncologic and perioperative outcomes between extended and non-extended lymphadenectomy during RC for BC. PubMed/MEDLINE, Embase, and ClinicalTrials. gov were searched up to October 2025 following PRISMA guidelines and PROSPERO registration. Randomized controlled trials (RCTs) and observational studies comparing extended versus non-extended lymphadenectomy in adults undergoing RC were included. Outcomes included surgery duration, intraoperative blood loss, overall survival (OS), disease-free survival (DFS), recurrence-free survival (RFS), and cancer-specific survival (CSS). Random-effects meta-analyses were performed, reporting hazard ratios (HRs) or mean differences (MDs) with 95% confidence intervals (CIs). Risk of bias was assessed using RoB 2.0 and ROBINS-I, and certainty of evidence using GRADE. Fifteen studies including 5671 patients were analyzed, of which two were RCTs. Extended lymphadenectomy was associated with longer operative time (MD + 26.2 min) and improved DFS (HR: 1.47), but no significant benefit in OS or CSS. Non-extended lymphadenectomy was associated with higher RFS (HR: 0.79). Heterogeneity was moderate to high, and certainty of evidence was very low for most outcomes and low for OS considering only RCTs. Extended lymphadenectomy during RC increases operative time and may improve DFS; however, the available evidence does not clearly support a consistent oncologic benefit.