The prognosis for patients with bladder cancer metastatic to regional lymph nodes is dismal and only minimally altered by current treatment modalities. The 5-year survival rate after radical cystectomy for 134 bladder cancer patients with positive regional lymph nodes was only 7 per cent and 82 per cent of the patients died of bladder cancer. Stratification of patients into groups with varying extent of nodal disease showed a correlation between the level of nodal involvement and the interval to recurrence. While 38 per cent of the patients died of distant disease alone 25 per cent had only pelvic recurrence, indicating a possible therapeutic effect of a systmatic bilateral pelvic lymphadenectomy and implicating extrapelvic disease as a major determinant of patient survival.