Can laparoscopic cystectomy become the method of choice in the treatment of invasive urothelial urinary bladder cancer?

Comparison of Laparoscopic and Open Radical Cystectomy for Muscle-Invasive Bladder Cancer

The goal of the study was to compare laparoscopic and open radical cystectomy in treatment of muscle-invasive bladder cancer in the Department of Urology and Oncological Urology PUM in Szczecin. A total of 78 patients in the study group underwent laparoscopic cystectomy between 2016−2018, and 81 patients from the control group had open cystectomy between 2014−2016. Both groups were comparable in terms of age, stage, and concomitant diseases. The 3 year overall survival was comparable in both groups (37.7% for laparoscopy and 44.4% for open, p = 0.64). There was no difference in positive surgical margin rate. Lymph node yield during cystectomy was higher in open cystectomy (14 vs. 11.5, p = 0.001). Post-operative blood loss and transfusion rates were lower in laparoscopic cystectomy. Decrease in hemoglobin level was lower in laparoscopy (0.9 mmol/L, p < 0.001). Intraoperative transfusion rate was 11.8% in laparoscopy vs. 34.8% in open cystectomy (p = 0.002). Operation time, duration of hospitalisation, and time to full oral alimentation were comparable in both groups. Patients with BMI > 30 kg/m2 and those with pT3-T4 cancer in the laparoscopy group had less septic complications post-operatively. Patients with ASA score ≥ 3 from the laparoscopy group had fewer reoperations due to ileus. Laparoscopic cystectomy is less invasive and offers similar oncological outcomes to the open method. Patients benefit from less tissue trauma, less blood loss, and faster recovery. The presented results, as well as other publications, should encourage a wider use of this procedure in everyday urological practice.

Effect of Radical Laparoscopic Surgery and Conventional Open Surgery on Surgical Outcomes, Complications, and Prognosis in Elderly Patients with Bladder Cancer

Background

Bladder cancer is a common malignant tumor of the urinary system in the clinic. It has multiple lesions, easy recurrence, easy metastasis, poor prognosis, and high mortality.

Objective

The aim of this study is to investigate the impact of laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC) on the surgical outcome, complications, and prognosis of elderly patients with bladder cancer.

Materials and Methods

One hundred elderly bladder cancer patients who underwent surgery in our hospital from June 2019 to June 2021 were selected for the retrospective study and were divided into 50 cases each in the ORC group and the LRC group according to the different surgical methods. The ORC group was treated with ORC, and the LRC group implemented LRC treatment. The differences in surgery, immune function, recent clinical outcomes, and complications between the two groups were observed and compared.

Results

The mean operative time, mean intraoperative bleeding, intraoperative and postoperative transfusion rate, and transfusion volume of patients in the LRC group were statistically significant when compared to the ORC group. The differences in the meantime to resume eating, time to get out of bed, mean number of days in hospital after surgery, and the amount of postoperative numbing analgesics used by patients in the LRC group after surgery were statistically significant compared to the ORC group (P < 0.05). There was no statistically significant difference in the comparison of immune function between the two groups before surgery (P > 0.05), while the comparison of CD8⁺ and B cells 1 week after surgery of the LRC group was significantly better than that of the ORC group (P < 0.05), and the operation time of the LRC group was longer than that of the ORC group (P < 0.05). Statistical analysis of postoperative complications showed that the overall incidence of postoperative complications in the LRC group was significantly lower than that in the ORC group (16.67% vs. 46.67%) (P < 0.05).

Conclusion

LRC has less surgical trauma and intraoperative bleeding, faster postoperative recovery, and fewer postoperative complications, providing some reference for clinical surgery for elderly bladder cancer patients.

The Influence of Lymph Node Count on Oncological Outcome of Radical Cystectomy in Chemotherapy Pre-Treated and Chemotherapy-Naïve Patients with Muscle Invasive Bladder Cancer

Radical cystectomy (RC) with pelvic lymph node dissection (PLND) remains the mainstay of treatment for muscle-invasive bladder cancer (MIBC). The extent of PLND and number of removed lymph nodes (LNs) have been associated with improved staging and survival outcomes in several series of RC patients. Neoadjuvant chemotherapy (NAC) has become standard of care for cisplatin-eligible patients qualified to RC, yet few studies on PLND stratified cases according to the receipt of NAC. We aimed to address this issue and reevaluate the prognostic value of PLND nodal yields in series of patients who underwent RC on the verge of the NAC era. This single-center, retrospective, clinical follow-up study enrolled 439 consecutive patients, out of whom 83 received NAC. We analyzed survival outcome of RC according to the number of removed nodes between NAC and non-NAC subgroups. We found PLND thresholds of 10 and 15 LNs prognostically meaningful in our study cohort, and this association was particularly pronounced in the non-NAC subgroup. Higher numbers of LNs provided a 25% reduction in risk of all-cause mortality and correspondingly correlated with up to a 14% increase in 3-year overall survival. The receipt of NAC diminished the benefit of adequate PLND, as the number of retrieved LNs was not associated with survival in the NAC-RC cohort. Given the limitations of our study, additional research is needed to verify these findings.

Complication Rate after Radical Cystectomy Depends on the Surgical Technique and Patient's Clinical Status

PURPOSE

This study aimed to explore the complication rates of radical cystectomy in patients with muscle-invasive bladder cancer and identify potential risk factors.

METHODS

A total of 553 patients were included: 131 were operated on via an open approach (ORC), 242 patients via a laparoscopic method (LRC), and 180 by a robot-assisted procedure (RARC). Patient age, gender, American Society of Anesthesiologists (ASA) score, urinary diversion type, preoperative albumin level, body mass index (BMI), pathological (TNM) stage, and surgical times were collected. The severity of complications was classified according to the Clavien-Dindo scale (Grades 1-5).

RESULTS

The surgical technique was significantly related to the number of complications (p < 0.00005). Grade 1 complications were observed most frequently following LRC (52.5%) and RARC (51.1%), whereas mostly Grade 2 complications were detected after ORC (78.6%). Those with less severe complications had significantly higher albumin levels than those with more severe complications (p < 0.05). Patients with an elevated BMI had fewer complications if a minimally invasive approach was used rather than ORC. The patient's general condition (ASA score) did not impact the number of complications, and urinary diversion type did not affect the severity of the complications. Mean surgical time differed according to the urinary diversion type in patients with a similar TNM stage (p < 0.005); however, no difference was found in those with more locally advanced disease. Longer operation time and lower protein concentration were associated with higher probability of complication rate, that is, Clavien-Dindo score 3-5.

CONCLUSIONS

The risk of complications after RC is not related to the type of urinary diversion, and can be reduced by using a minimally invasive surgical technique, especially in patients with high BMI.

Role of the Laparoscopic Approach for Complex Urologic Surgery in the Era of Robotics

(1) Introduction: The advent of robotic surgery led to the assumption that laparoscopic surgery would be replaced entirely. However, the high costs of robotic surgery limit its availability. The aim of the current study was to assess the feasibility of the 3D laparoscopic approach for the most complex urological procedures. (2) Materials and methods: We included in the current study all patients who had undergone complex 3D laparoscopic procedures in our department since January 2017, including radical nephrectomy (LRN) using a dual combined approach (19 patients), radical nephroureterectomy (LRNU) with bladder cuff excision (13 patients), and radical cystectomy (LRC) with intracorporeal urinary diversion (ICUD) (21 patients). (3) Results: The mean operative time was 345/230/478 min, the complications rate was 26%/30.76%/23.8% and positive surgical margins were encountered in 3/1/1 patients for the combined approach of LRN/LRNU/LRC with ICUD, respectively. A single patient was converted to open surgery during LRN due to extension of the vena cava thrombus above the hepatic veins. After LRC, sepsis was the most common complication and 8 patients were readmitted at a mean of 15.5 days after discharge. (4) Conclusions: In the era of robotic surgery, laparoscopy remains a plausible alternative for most complex oncological cases.

Orthotopic MAINZ pouch bladder substitution - long-term follow-up

INTRODUCTION

After radical cystectomy, orthotopic neobladder is one surgical strategy for urinary diversion. To assess the usefulness of an operation, long-term data are essential. We examined long-term complications and continence rates of orthotopic ileocecal (MAINZ pouch) bladder substitution.

MATERIAL AND METHODS

Between 1986 and 2011, 193 patients underwent orthotopic MAINZ pouch bladder substitution. Until July 2000, ureter implantation was performed into the ascending colon through a submucosal tunnel technique (Goodwin-Hohenfellner). After July 2000, ureters were implanted into the terminal Ileum using the ileocecal valve to prevent reflux: the left spatulated ureter by an end-to-end (Wallace) and the right ureter by an end-to side technique (Nesbit). Surgical and medical follow-up reports were evaluated and a recent follow-up was obtained by a questionnaire.

RESULTS

Median follow-up in 183 patients was 72 months (1-336). A total of 74 patients (38%) died during the follow-up. A surgical intervention was required in 26 out of 193 patients with early complications while 45 out of 183 patients had late and 17 patients had both, early and late complications. Ureteral stenosis was found in 13% of submucosal implanted ureters, 13% with the Wallace technique, and 3.6% with the Nesbit technique. In total, 66 patients responded to the questions concerning long-term continence (minimal follow-up >2 years). Overall, 84.8% were completely continent, 1.6%, reported grade I and 9.8% grade II stress incontinence.

CONCLUSIONS

The long-term continence and complication rates are comparable to those of other types of orthotopic bladder substitution. Orthotopic MAINZ pouch procedure can be considered as one of the options for orthoptic diversion, which stands the test of time.