S1011 Intra-Op Surgical Assessment Form Standard Versus Extended LND (#10689) Standard or Extended Pelvic Lymphadenectomy in Treating Patients Undergoing Surgery for Invasive Bladder Cancer Source Form: NCI FormBuilder:



  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
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January 9, 2015


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Bladder Cancer NCT01224665 Treatment - S1011 Intra-Op Surgical Assessment Form Standard Versus Extended LND (#10689) - 3153877v1.0

Instructions: To be completed by attending surgeon. Please complete post surgery, on the day of surgery. Surgeons should be provided with this form prior to the surgical event. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form

Intra-operative Extent-of-disease Assessment
Clinical T4b (fixed or involvement of pelvic side wall, abdominal wall, or adjacent viscera e.g. colon, small bowel)
Specify location of tumor (select all that apply)
Gross Lymphadenopathy (Note: if in the extended template, must be frozen)
Location of gross lymphadenopathy (Please complete if the answer was "Yes" to Gross Lymphadenopathy. Select all that apply)
Pathologic Lymph Node Assessment (if selected please specify)
Description Of How Nodal Packets Were Submitted To Your Pathologist
Did the participant have surgery per protocol treatment?
Extent of pelvic lymph node dissection
Cranial extent of dissection (If "Extended,")
Surgical Assessment Of Nodal Dissection
Which lymph node areas were dissected (Please check all that apply Boundaries for "pelvic" are defined by the Standard node dissection)
Surgical Reconstruction
Anastomosis Performed Type
Operative Information
Intraoperative vascular injury
Perioperative DVT prophylaxis (other than sequential compression device)
Epidural anesthesia employed
Nerve sparing
Laterality (Please complete if the answer was "yes" to nerve sparing. Select all that apply)
Nerve-sparing status (if selected please specify)
Photographic documentation (required per protocol)

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