Defining Good Candidates for Extraperitoneal Cystectomy: Results From Random Peritoneum Biopsies of 136 Cases

Extraperitoneal Versus Intraperitoneal Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

This study aimed to compare perioperative and oncologic outcomes of extraperitoneal radical cystectomy (EPRC) and transperitoneal radical cystectomy (TPRC).

METHODS

A systematical search of multiple scientific databases was performed in September 2022. The systematic review and cumulative meta-analysis of the primary outcomes of interest were performed according to the PRISMA and AMSTAR guidelines and registered in the PROSPERO database (PROSPERO [CRD42022359322]).

RESULTS

The review and analysis included eight studies with 989 participants. No significant differences were found between EPRC and TPRC in terms of operation time, estimated blood loss (EBL), hospital length of stay (LOS), or transfusion. A shorter exhaust time (standardized mean difference [SMD] - 0.59; 95 % confidence interval [CI] - 0.97 to 0.21; p = 0.002) and time to liquid intake (SMD, - 0.56; 95 % CI - 1.07 to 0.04; p = 0.03) were associated with EPRC. No clinically meaningful difference was observed in terms of postoperative infection, wound complications, postoperative genitourinary complications, late postoperative complications, early major complications, or late major complications. However, EPRC was related to lower incidences of early postoperative complications (odds ratio [OR], 0.66; 95 % CI 0.51-0.86; p = 0.002), gastrointestinal complications (OR 0.28; 95 % CI 0 0.17-0.46; p < 0.00001), and postoperative ileus (OR 0.38; 95 % CI 0.25-0.59; p < 0.0001). A higher incidence of postoperative lymphocele was associated with EPRC (OR 3.05; 95 % CI 1.13-8.25; p = 0.03). No clinically meaningful difference was found in terms of positive surgical margin (PSM), local recurrence, distant metastasis, or OS.

CONCLUSIONS

Although EPRC had a higher incidence of lymphoceles than TPRC, it was found to have similar oncologic outcomes and fewer early complications, particularly in terms of postoperative gastrointestinal complications and ileus. These results suggest that EPRC is a safe option both functionally and oncologically.

Initial experience with 161 extraperitoneal laparoscopic radical cystectomy procedures: Comparison with transabdominal laparoscopic radical cystectomy

OBJECTIVES

There is substantial concern about traditional transperitoneal laparoscopic radical cystectomy (TLRC) due to multiple postoperative complications. In contrast, extraperitoneal laparoscopic radical cystectomy (ELRC) appears to cause a lower rate of morbidity. The present study aimed to compare the efficacy of ELRC and TLRC for bladder cancer (BCa).

METHODS

The clinical data of patients undergoing laparoscopic radical cystectomy for BCa from April 2018 to October 2021 were retrospectively analyzed, as ELRC and TLRC groups. The postoperative follow-up data of 275 patients were collected and the incidence of postoperative complications and other perioperative outcomes were compared between the two groups.

RESULTS

Surgery was successfully completed in all patients without conversion to open surgery. There was no significant difference in the duration of cystectomy surgery (67.32 ± 23.53 vs 72.17 ± 25.72 min, p = 0.106), intraoperative blood loss (178.06 ± 110.4 vs. 174.56 ± 127.40 ml, p = 0.413), or the number of lymph node dissection (15.1 ± 5.7 vs. 14.5 ± 5.1, p = 0.380) between the two groups. The length of stay (11.6 ± 3.8 vs 14.7 ± 5.6 d, p < 0.001), time to resume food intake after surgery (2.3 ± 0.9 vs 3.0 ± 1.3 d, p < 0.001), and the incidence of ileus (p < 0.001) in the ELRC group were significantly lower than in the TLRC group.

CONCLUSIONS

ELRC is a safe procedure that can reduce the incidence of postoperative complications, shorten postoperative hospital stay, reduce the duration of recovery of patients, and, therefore, should be promoted.

Extraperitoneal laparoscopic radical cystectomy with intracorporeal neobladder: a comparison with transperitoneal approach

Background

Bladder cancer is one of the most common genitourinary cancers. Traditional transperitoneal radical cystectomy is the gold standard treatment for muscle-invasive bladder cancer. Our study was to compare the perioperative and oncological outcomes of extraperitoneal laparoscopic radical cystectomy (ELRC) with intracorporeal neobladder versus transperitoneal urinary diversion for bladder cancer.

Method

A total of 113 patients who underwent laparoscopic radical cystectomy performed at our center were included in this retrospective study. The perioperative data of the extraperitoneal laparoscopic radical cystectomy (ELRC) with intracorporeal urinary diversion (ICUD) and transperitoneal laparoscopic radical cystectomy (TLRC) with ICUD groups were compared. The demographic, perioperative, oncological, and complication data were collected and analyzed.

Results

In total, 113 patients were enrolled for the final analysis. The median follow-up period was 22 months. The ELRC group had shorter interval to flatus (p < 0.001), solid food (p < 0.001), shorter length of hospital stay (p < 0.01), and fewer early gastrointestinal complications (p < 0.05). Furthermore, urinary continence, recurrence-free, cancer-specific, and overall survival rates and recurrence patterns did not significantly differ.

Conclusions

Surgical technique of ELRC with ICUD can achieve the established oncologic criteria of TLRC, and such technique can improve perioperative and early postoperative outcomes.

Extraperitoneal Laparoscopic Radical Cystectomy With Preservation of Fertility for the Treatment of Ewing Sarcoma: The First Report of a Reliable Surgical Method

OBJECTIVE

To improve the complications of traditional laparoscopic radical cystectomy (LRC), a novel technique of extraperitoneal laparoscopic radical cystectomy (ELRC) with preservation of fertility was described.

MATERIALS AND METHODS

Selected patients with bladder cancer were treated with the ELRC technique. The seminal vesicles and the vas deferens were preserved. Patient's perioperative conditions, tumor prognosis, and follow-up data were analyzed retrospectively.

RESULTS

We successfully completed ELRC surgery in dozens of patients. The orthotopic ileal neobladder was placed in the extraperitoneal area, completely preserving the peritoneum. The postoperative complications caused by postoperative peritoneal loss were reduced. Moreover, the perioperative period was strictly managed with the concept of enhanced recovery after surgery (ERAS). We described the operation process in detail through a typical case of a child. All patients were free of complication at short-term follow-up, and reported satisfied sexual function with normal erections.

CONCLUSION

The ELRC technique has benefits in terms of decreased ileus, reoperation rates, hospital stay, ease of management of urinary leaks, and improves the patient quality of life. ELRC is also an oncologically safe approach with excellent significant functional outcomes in carefully selected transitional cell carcinoma (TCC) or non-TCC patients who expect to maintain sexual function and fertility, especially for young patients. In addition, more patient groups and longer follow-ups are needed to further understand the safety and practicality of the ELRC technology.

Perioperative Outcomes of Open Retrograde Extraperitoneal Versus Intracorporeal Robot-assisted Radical Cystoprostatectomy in Men: A Dual-center Comparative Study

INTRODUCTION

We compared retrograde extraperitoneal open radical cystoprostatectomy (REORC) and robot-assisted radical cystoprostatectomy with intracorporeal diversion (iRARC) and have reported the early perioperative outcomes.

PATIENTS AND METHODS

REORC and iRARC were each performed at a different tertiary high-volume center in 2 countries. Men aged ≥ 18 years with precystectomy clinical stage T1-T3 disease were included. Patients with previous major pelvic and/or intra-abdominal surgery, those who had undergone previous pelvic and/or abdominal irradiation, women, and patients with clinical stage T4 disease were excluded. All cases were managed according to a standardized enhanced recovery after surgery protocol, and all the patients had undergone ileal conduit urinary diversion. Bowel recovery was one of the main endpoints; thus, the intervals to passing flatus, tolerating oral feeding, and bowel opening were determined. The operative time, estimated blood loss, intraoperative complications, length of hospital stay, postcystectomy tumor type, stage, margin status, lymph node yield, and 30- and 90-day complications were analyzed.

RESULTS

We performed a retrospective analysis of prospectively collected data from October 2016 to December 2018 of 99 patients, 50 of whom had undergone REORC and 49 iRARC. The demographic data and preoperative parameters were comparable between the 2 groups. REORC resulted in a significantly shorter mean operative time (P < .001), significantly greater mean estimated blood loss (P < .001), and greater percentage of patients requiring blood transfusion (98% vs. 12.24%). No significant differences in the length of stay were observed (P = .412). The rate of prolonged postoperative ileus was 16% and 18.4% in the REORC and iRARC groups, respectively (P = .3). Differences in the interval to passing flatus, tolerating solid oral intake, and bowel opening were not statistically significant between the 2 groups (P = .423, P = .770, and P = .700, respectively). No statistically significant difference was observed in the postcystectomy pathologic outcomes and overall and major complications rates at 30 and 90 days.

CONCLUSION

REORC resulted in quicker bowel recovery and a shorter length of stay compared with conventional open procedures, with advantages comparable to those realized with iRARC. Thus, REORC can be adopted as the preferred open approach at institutions without surgical robots available.

Extraperitoneal versus transperitoneal laparoscopic radical cystectomy for selected elderly bladder cancer patients: a single center experience

OBJECTIVE

This study reports the initial experience of extraperitoneal laparoscopic radical cystectomy (ELRC) and compared with transperitoneal laparoscopic radical cystectomy (TLRC) in the treatment of selected elderly bladder cancer patients.

PATIENTS AND METHODS

A total of forty male bladder cancer patients who underwent ELRC (n=19) or TLRC (n=21) with ureterocutaneostomy were investigated. Demographic parameters, perioperative variables, oncological outcomes and follow-up data were retrospectively analyzed.

RESULTS

A significantly shorter time to exsufflation (1.5±0.7 vs 2.1±1.1 d; p=0.026) and liquid intake (1.8±0.9 vs 2.8±1.9 d; p=0.035) were observed in the ELRC group compared with the TLRC group. The incidence of postoperative ileus in the ELRC group was lower than the TLRC group (0 vs 9.5%). However, the difference had no statistical significance (p>0.05). The removed lymph node number in the ELRC group was significantly lower than the TLRC group (p<0.001). No significant differences were observed between the two groups in the overall and cancer-free survival rates (p>0.05).

CONCLUSIONS

ELRC seems to be a safe and feasible surgical strategy for the selected elderly bladder cancer patients with ≤T2 disease. The surgical and oncological efficacy of the ELRC is similar to that of the TLRC, but with faster intestinal function recovery. Further studies with a large series including different urinary diversions are needed to confirm our results and to better evaluate the benefit of ELRC in bladder cancer patients.

Retrograde radical cystectomy and consequent peritoneal cavity reconstruction benefits localized male bladder cancer: results from a cohort study

Background

Bladder cancer is the second most common genitourinary malignancy. Our study was to introduce a standardized surgical procedure of retrograde radical cystectomy and consequent peritoneal cavity reconstruction in localized male bladder cancer.

Methods

Eighty-four consecutive male patients with localized bladder cancer (clinical stage T2 or lower) underwent surgery in our institute with the proposed procedure between May 2012 and April 2013. Median age was 65 years (range, 35 to 83 years); patient characteristics, surgical parameters, perioperative complications, pathology, and short-term prognosis were analyzed. Median follow-up was 24 months (range, 18 to 30 months).

Results

The complete procedure including urinary diversion took 4.0 h (2.2 to 5.0 h), with a median exposed peritoneal cavity of 45 min (0 to 75 min); the median blood loss was 140 ml (50 to 600 ml), and 2 patients needed transfusion; neurovascular bundles were reserved in 76 cases; the median abdominal and pelvic drainage was 9.0 days (6 to 15 days), the median gastrointestinal recovery was 2.5 days (1 to 12 days), and the median postoperative hospital stay was 13.0 days (10 to 21 days). Four patients had severe surgical complications, and two had mild to moderate ileus, with recovery in 1 and 2 weeks with supportive treatment. No perioperative deaths or postoperative recurrence were reported.

Conclusions

The surgical procedure in male localized bladder cancer described in the present study provided surgical facilities, with limited abdominal organ disturbance and satisfactory tumor control. The procedure was associated with good gastrointestinal recovery, few postoperative complications, and a short hospital stay.