With the continuous improvement of laparoscopic techniques, laparoscopic radical cystectomy and urinary diversion is increasingly accepted by patients and urologists, and this procedure has been actively explored by urologists around the world. Initial clinical outcomes have shown its feasibility and attractive application. However, since laparoscopic radical cystectomy and urinary diversion is still in the exploratory stage, the number of reported cases is small, with the largest group of cases being only a few dozen, and the number of reported cases worldwide is not more than a few hundred, and there are great differences in the surgical methods reported by each group. Therefore, comparing the advantages and disadvantages of various surgical methods and discussing more reasonable surgical procedures, techniques and methods are of great clinical significance to promote the development of this technique and improve the surgical efficacy and reduce complications. This article focuses on some hot issues related to this procedure.
I. Improvement of cystectomy method
In 1992, Parra et al. first reported laparoscopic simple cystectomy, and in 1993 and 1995, Sanchez et al. first reported laparoscopic radical cystectomy for invasive bladder cancer with ileal access through a small incision in the right abdominal wall in Spanish and English, respectively, and in 2000, Gill et al. reported 2 cases of pure laparoscopic radical cystectomy with ileal access. In 2002, the first pure laparoscopic radical cystectomy with in situ ileal cystectomy was reported. Laparoscopic radical cystectomy has problems such as long operation time and complicated operation not easy to popularize, but with the improvement of its surgical method, these problems have been gradually weakened.
1. Optimization of surgical sequence: By optimizing the surgical sequence, the surgical procedure is more reasonable and smooth, and the operation time is greatly shortened. By summarizing the experience of more than 100 cases of radical laparoscopic cystectomy completed by his main surgeon, the optimized surgical sequence used is.
(i) first perform pelvic lymph node dissection and free the distal ureter.
(ii) Exposure of Denonvillier’s hiatus with the posterior prostatic hiatus.
(iii) Separation of the anterior bladder from the posterior pubic space.
(iv) Separation of the vascular tissues on both sides of the bladder prostate.
⑤ separating the apical part of the prostate.
(vi) constructing the urinary storage sac in vitro.
(vii) extracorporeal ureteral reimplantation.
⑧ laparoscopic neocystourethral anastomosis. This surgical sequence of bilateral pelvic lymph node dissection first, followed by cystectomy, is conducive to revealing important structures such as iliac vessels and closed nerves, and reducing surgical malpractice.
2. Treatment of dorsal deep penile vein complex: Since the location and course of the dorsal deep penile vein complex can be clearly identified under the magnified view of laparoscopy, the exact and firm suture can be made, while the pneumoperitoneal pressure helps to reduce venous bleeding. Therefore, laparoscopic management of the deep dorsal penile vein complex has greater advantages. There are several main methods to treat the deep dorsal penile vein complex as follows.
(i) Use of bipolar electrocoagulation (Ligasure or PK knife).
(ii) Application of hemostatic clips, such as titanium clips or plastic clips with locking clips (Hem-Lock).
③Suture ligation of the deep dorsal penile vein complex. According to the author’s experience and the reports of most scholars at home and abroad, although the operation with bipolar electrocoagulation is simpler, the hemostatic effect is not satisfactory in some patients, and it is easy to cause thermal damage to the erectile nerve and external sphincter. Hemostasis with titanium clips is not effective enough, and Hem-Lock hemostasis must be performed by freeing the dorsal deep vein complex before snap-lock. Therefore, we recommend using 2-0 absorbable sutures followed by scissors to cut the dorsal deep venous complex of the penis, which has the most effective hemostasis and reduces the impact on the erectile nerve and sphincter, but the operation is difficult and requires skilled suturing skills.
3. Treatment of the vascular tip on the prostatic side of the bladder: Some reports use Endo-GIA or Endo-CUT to treat the vascular tip can also obtain good hemostatic effect, but this method is more expensive and cannot preserve the penile vascular nerve bundle, so it is not an ideal method. Treatment of the vascular tract on the prostatic side of the bladder with LigaSure (intelligent bipolar electrocoagulation) is indeed effective and can greatly reduce the operative time. Intraoperative care is taken to preserve the vascular nerve bundle, and postoperative erectile function can be preserved in some patients. In the author’s experience, the possibility of damaging the nerve bundle can be further reduced if titanium clips and cold knife are applied intraoperatively to treat the vascular tissues.
4.Use LigaSure “ligation speed” to clear the lymph nodes: When clearing the pelvic lymph nodes, a combination of electrocoagulation hook and LigaSure is used to open the lateral peritoneum first and peel off the lymph tissue and blood vessels along the course of the vessels, and then the lymph tissue is pushed away and removed with LigaSure. This improves the efficiency of lymph node dissection while reducing the chance of postoperative lymphatic fistula.
5.Female total cystectomy: When female bladder cancer patients undergo laparoscopic radical cystectomy, three different surgical procedures, radical cystectomy plus uterine and ovarian resection, radical cystectomy plus uterine resection and simple radical cystectomy, can be used according to the patient’s age, sexual function and tumor location and scope. On the basis of ensuring the effect of radical tumor treatment, sexual function and fertility are preserved for some female patients, which greatly improves the quality of life after surgery.
Determination of the scope of pelvic lymph node dissection and the effect of laparoscopic lymph node dissection
The extent of the impact of pelvic lymph node dissection on the prognosis of patients with bladder cancer is currently a hot topic of debate. The scope of pelvic lymph node dissection can be divided into 3 types: limited dissection, standard dissection, and extended dissection. The scope of standard lymph node dissection is below the bifurcation of the common iliac vessels, the external iliac artery, the internal iliac artery, and the lymphatic tissue around the closed nerve.
In a long-term follow-up study of 1054 patients undergoing total open cystectomy, Stein JP found that the 10-year tumor-free survival rate was 36% when more than 15 lymph nodes were removed for pelvic lymph node dissection. In contrast, the 10-year tumor-free survival rate was only 25% when fewer than 15 lymph nodes were removed, which was a significant difference. However, as the understanding of tumor metastasis and recurrence has improved, it has been found that expanding lymph node dissection in breast and gastric cancer patients does not improve tumor-free survival. Therefore, is the prognosis for bladder cancer better the more lymph nodes are removed? Honma I et al. concluded that the extent of lymphatic node dissection in patients without lymph node metastases was not associated with long-term outcome, whereas in patients with lymphatic metastases, dissection of more than 13 lymph nodes may improve tumor-free survival. In contrast, David Y et al. summarized data from multiple centers and suggested that expanding the extent of pelvic lymphatic dissection for bladder cancer did not improve tumor-free survival, and that the rate of tumor recurrence was associated with the density of pelvic tumor lymph nodes.
In light of these observations and clinical experience, we believe that, as of yet, it is appropriate to perform standard pelvic lymph node dissection in patients with bladder cancer who do not have lymph node metastases on preoperative imaging. This is because it is the most studied and has been shown to be effective in a large sample of cases, and it undoubtedly increases the likelihood of metastasis and recurrence if limited or no debulking is performed. Expanded clearance, on the other hand, is not necessary for this group of patients because of the long operative time, high cost, injury, and complications. Expanded debulking can be used in patients with lymph node metastases already confirmed on preoperative imaging, which minimizes the chance of recurrence.
In a group of cases reported by Simonato, an average of 18.5 pelvic lymph nodes were removed, and Finelli A of Cleveland Medical Center reported a laparoscopic pelvic lymph node dissection with expansion to the abdominal aortic bifurcation, which took approximately 90 minutes longer than a standard dissection. The procedure took approximately 90 minutes longer than standard lymph node dissection and allowed the removal of an average of 21 pelvic lymph nodes. Porpiglia F of the University of Turin, Italy, prospectively compared the results of open versus laparoscopic lymphatic dissection in 22 versus 20 patients, respectively, with no significant difference in the number of lymph nodes dissected. This shows that laparoscopic lymph node dissection of the pelvis is technically feasible, clearly revealing important structures such as the common iliac vessels, internal and external iliac vessels, closed nerves and ureters, and avoiding intraoperative injuries.
III. Choice of urinary diversion method
From the literature reports, there are many methods used for laparoscopic urinary tract reconstruction, including uretero-sigmoid reimplantation, ileal access, controlled cystoplasty via abdominal wall stoma and in situ neocystoplasty, etc. There are reports of laparoscopic reconstructive surgery performed inside the abdominal cavity as well as reconstruction with the bowel raised outside the abdominal wall, which are briefly described as follows.
Ileal conduit: In 1993 Sanchez-de-Badajoz reported the first laparoscopic total cystectomy-ileal conduit. After laparoscopic removal of the bladder, the right abdominal trocar channel was enlarged to 4 cm, the bladder specimen was removed, and the ileum was lifted out of the body using this incision. Interception of the bowel section, ileal anastomosis, ureteral implantation and abdominal wall stoma were completed outside the body. In 2000, Gill reported 2 cases of complete laparoscopic total cystectomy-ileal access with operative times of 11.5 and 10 hours and bleeding volumes of 1200 ml and 1000 ml, respectively, with rapid postoperative recovery and no postoperative complications. The largest number of completed cases reported to date was 33 laparoscopic total cystectomy-ileal access cases done in 2005 at Cathelineau X. The average operative time also decreased to 4.7 hours, with 150-2000 ml of bleeding and an 18% rate of major complications.
Controlled cystectomy via abdominal wall stoma: In 2000, Gill performed a successful laparoscopic controlled Indiana ileocecal cystectomy in a 55-year-old male patient with bladder cancer. After laparoscopic complete radical cystoprostatectomy and pelvic lymph node dissection, the trocar channel in the right abdominal wall was enlarged to 2-3 cm, and a segment of ileocecal bowel was pulled out through the incision. The Indiana urinary bladder is constructed outside the body and a controlled ileal output tract is formed through the umbilicus. The ureter is then retracted into the abdominal cavity, re-pneumoperitoneum, and laparoscopic implantation of the ureter is completed. The operation took 7 hours, with approximately 300 ml of bleeding, and the patient was discharged 6 days postoperatively. At postoperative follow-up, the patient’s renal function was normal and there were no significant complications.
Controlled cystectomy with transanal voiding: Turk I reported 11 cases of complete laparoscopic total cystectomy-Mainz II sigmoid cystectomy. After total cystectomy, surgically resected tissue was packed into specimen bags and retrieved vaginally in women and through the dissected rectum in men. From the rectosigmoid junction, the opposite mesenteric margin of the intestinal canal was incised for 20 cm, the posterior wall of the urinary bladder was sutured continuously, the ureter was anastomosed with the urinary bladder by submucosal tunneling, bilateral ureteral stent tubes were led out of the body by the rectum, a 26F urinary catheter was placed in the urinary bladder for drainage, and the anterior wall of the urinary bladder was closed. The operative time was 6.7 hours, and 10 days after surgery, excretory urography showed no obstruction in the upper urinary tract and good function of the urinary bladder.
In situ neocystectomy: Gill et al reported 2 cases of laparoscopic total cystectomy-in situ ileal neocystectomy in 2002 based on animal studies. After resection of the bladder using 6 trocars, a 65-cm-long segment of ileum was sectioned 15 cm from the ileocecal junction, with the proximal 10 cm preserved tubular and the distal 55-cm intestine dissected and folded along the opposite mesenteric margin for reconstruction to form a Studer neobladder. The bilateral ureters were anastomosed at the proximal end of the 10-cm ileal segment. The excised tissue is removed from the enlarged umbilical manipulation channel to 2-3 cm. The endo-GIA suture was used to dissociate the vascular tip of the prostatic side of the bladder and the bowel resection anastomosis. Abdel et al. reported laparoscopic total cystectomy with in situ Camey II neobladder in 9 patients (1 female and 8 male) with bladder cancer. In the first 3 cases, an Endo-GIA suture was used to control the lateral bladder vascular tissues, and a Y-shaped Camey II neobladder was constructed through a small 3-5 cm incision in the right iliac fossa, with ureteral implantation and a neobladder-urethral anastomosis. In 2004, the author first reported 15 cases of total cystoprostatectomy with in situ ileal neobladder in China, in which a 4-5 cm incision was made in the lower abdominal midline after laparoscopic removal of the bladder, the specimen was removed, the ileum was pulled out of the incision, and the 50 cm ileum was dissected and folded in an M-shape. In 2008, 108 cases were reported with an average operative time of 330 min, average bleeding volume of 320 ml, daytime urinary control rate of 90.7%, nighttime urinary control rate of 82.6%, and maximum urinary flow rate of (18.4±6.1) ml/s. Professor Liu Chunxiao from Guangzhou Zhujiang Hospital reported five cases of laparoscopic total cystectomy with sigmoid neo-cystectomy in 2004. After laparoscopic resection of the bladder, an 8-cm incision was made in the mid-lower abdomen, and an open detrusor with sigmoid cyst, ureter and urethral anastomosis was performed. The duration of laparoscopic surgery was 210-270 min, and the duration of open in situ neocystectomy was 210-300 min. The postoperative urinary control was good during the daytime, with occasional incontinence at night in two cases, and there were no surgical complications.
The principles of laparoscopic urinary tract reconstruction are basically the same as those of open surgery, mainly based on the growth site of the tumor, the patient’s general condition, the patient’s wishes and the surgeon’s technical level. In situ neocystectomy is the most commonly used method of lower urinary tract reconstruction in clinical practice due to its high postoperative quality of life. It can be the first choice under the conditions of no tumor in the urethral section, no stricture in the anterior urethra, and no abnormalities in the abdominal wall muscles, pelvic floor muscles and diaphragm. In choosing which segment of intestine to construct the urinary reservoir, the main considerations are the convenience of the procedure and whether a tension-free anastomosis between the reservoir and the urethral stump can be achieved. The ileum, because of its long mesentery, is easy to pull out for incisional surgery and can be anastomosed to the urethra without tension in the vast majority of patients, making it more suitable for laparoscopic surgery with a small incision. The sigmoid colon is located in the pelvic cavity and has a larger diameter and longer mesentery, which can be pulled out of the abdominal wall and also form a new bladder in the abdominal cavity, which is more convenient for completely laparoscopic surgery. For patients whose bladder tumor has invaded the posterior urethra and in situ neobladder is not appropriate, if the general condition is poor or adjuvant radiotherapy is required, ureteral skin stoma or ileal access can be considered as an option. Controlled cystectomy with transabdominal wall stoma or sigmoid rectal cystectomy with transanal voiding may also be considered when the patient’s general condition permits.
There are two approaches to urinary diversion after laparoscopic removal of the bladder: laparoscopic intraperitoneal surgery and extraperitoneal surgery via a small incision. Most of the cases reported so far have been performed by laparoscopic plus small incision surgery, which may be explained by the following reasons.
(1) to reduce the difficulty of surgery and shorten the operative time. The construction of the urinary bladder necessarily involves complex steps such as dissection and anastomosis of the intestine, dissection and shaping of the intestine, anastomosis of the ureter, etc., and laparoscopic suturing and tying of the knot are difficult and time-consuming operations; therefore, changing these steps to operate under direct vision not only facilitates early operation, but also greatly reduces the operation time for skilled laparoscopic surgeons.
②Small incisions do not increase surgical trauma: In order to avoid tumor implantation and dissemination and to facilitate postoperative pathological grading and staging of tumors, it is generally not advocated to use a tissue grinder to grind the resected specimen in vivo and remove it, but to place the specimen in a tough sealed bag for complete removal. Therefore, a 4- to 5-cm incision must be opened to remove the specimen, and this incision is utilized to form a urinary storage bag outside the body without additional trauma.
③Reducing intra-abdominal contamination: incision of the intestinal canal in the abdominal cavity to form a storage urinary bladder inevitably increases the chance of contamination.
④Reducing operation cost: In order to reduce intra-abdominal contamination and shorten operation time, special laparoscopic anastomosis and formation of intestinal canal are mostly used, which will greatly increase the operation cost.
⑤ Avoiding prolonged pneumoperitoneum: lower urinary tract reconstruction through a small incision can reduce the pneumoperitoneum time by 2 to 3 hours, which can significantly reduce the impact of prolonged pneumoperitoneum on respiratory circulation and internal environment.
Although laparoscopic plus small incision surgery has the above-mentioned advantages, it cannot be applied to all patients. In overly obese patients, it is often difficult to mention the bowel outside the incision because of the hypertrophy of the abdominal wall and the short thickness of the mesentery, and the formation of a urinary storage sac in the abdominal cavity can solve this problem. Therefore, it is necessary to use laparoscopic urinary tract reconstruction. The author has performed complete laparoscopic total cystectomy-sigmoid neobladder for 4 patients. After removal of the bladder, the 15-cm sigmoid colon was isolated, the ureter was inserted and implanted at both ends of the intestinal tube, the openings at both ends were closed with consecutive sutures, the midpoint opening of the intestinal tube was anastomosed to the urethra, and the colonic band against the mesenteric margin was incised to form a decorticated colon bladder. The average operative time was approximately 7 hours, with good postoperative urinary control.
According to the current level of development of laparoscopic technology, laparoscopic plus small incision surgery should be preferred for such a complex procedure as total cystectomy-lower urinary tract reconstruction, or complete laparoscopic sigmoid colon neobladder or sigmoid colon rectal cystectomy can be used for overly obese patients.
IV. The value of laparoscopic robotic applications
In 2003 Menon completed 14 cases of Da Vinci robot-assisted laparoscopic total cystectomy, including 11 cases in men, and the article highlights the experience of applying the robot to protect the erectile nerve. The average time used for radical total cystectomy was 168 min, 120 min for constructing the ileal channel, and 168 min for forming the ileal neobladder. a small suprapubic incision was used to construct the urinary reservoir outside the abdominal cavity, and the in situ ileal neobladder was retracted back into the abdominal cavity by those who formed the reservoir outside the body, re-pneumoperitoneum and completed the neobladder-urethral anastomosis using robot-assisted laparoscopy. In the same year, Beecken reported a case of robotic total laparoscopic cystectomy with ileal neobladder, which took 8.5 h and resulted in good postoperative voiding and urinary control. in 2004, Menon reported 2 cases of robotic total laparoscopic cystectomy with preservation of vagina and uterus and lower urinary tract reconstruction. The Da Vinci robotic surgical system, with its three-dimensional view and flexible endoscopic wrist, allows the operator to operate in a comfortable position, making laparoscopic operations more delicate and accurate. Therefore, it is very helpful for total cystectomy-lower urinary tract reconstruction surgery, which is complicated, with many suture ligation steps and long operating time. Many medical centers in developed countries already have this type of equipment, and it is expected that more reports of laparoscopic robotic applications for total cystectomy will be available in the near future. However, because the robot is very expensive and costly to use, it is difficult to promote its application in China in the short term.
It is indeed an effort to improve the sexual function and urinary control of patients after surgery. In addition to the above-mentioned proposal of Menon et al. to improve the accuracy of surgery by using robot, Guazzoni proposed to perform total cystectomy with preservation of seminal vesicles, prostatic envelope and erectile nerve one week after TURP, and the sexual function and urinary control ability of patients were well preserved after surgery.
V. Evaluation of surgical efficacy
With the increase in the number of laparoscopic total cystectomy and lower urinary tract reconstruction cases, there have been recent reports of complication rates in some of the larger comprehensive cases, which provide a basis for comparing the complication rates of laparoscopic surgery with those of open surgery. Chang SS reported a group of 304 cases of total open cystectomy with 35.8% early postoperative complications. Steven K reported 166 total open cystectomies with 23.5% early postoperative complications. 2007 Bikram Raychaudhuri, Guy’s Hospital, London, UK, conducted a comprehensive review of 210 reported laparoscopic radical cystectomy-urinary diversions for bladder cancer to date, of which 34 cases had complications, 3 cases were converted to open surgery The overall incidence was 18.1%, which is a decrease compared to current open surgery. In 2008, the author compared the surgical outcomes and complications of 63 open surgeries with 108 laparoscopic surgeries and found that the incidence rate in the open surgery group was 30.0% (19/63), including 4 cases of new vesicourethral anastomotic leak, 2 cases of uretero-vesical anastomotic stricture, 5 cases of incisional infection, 2 cases of pulmonary infection, 2 cases of pelvic infection, 2 cases of intestinal obstruction, and 2 cases of new vesicourethral anastomotic stricture. From the current clinical reports, the perioperative complications of laparoscopic total cystectomy-lower urinary tract reconstruction were lower than those of open surgery.
For the study of postoperative long-term complications, because laparoscopic surgery has not been performed for a long time, it remains to be accumulated and counted in a large sample of cases. gill recently summarized the long-term outcome of a group of laparoscopic radical cystectomy for bladder cancer and found that its oncologic outcome was comparable to that of open surgery, and our recent follow-up results of a group of 63 patients with open surgery and 108 patients with laparoscopic surgery also showed that performing The 2-year survival rates of patients in the open and laparoscopic groups who underwent radical resection of in situ neobladder for bladder cancer were 71.2% and 81%, respectively, and the tumor-free survival rates were 80.4% and 80.9%, respectively, with no statistically significant differences between the two groups. Therefore, the radical treatment of bladder cancer under laparoscopy is comparable to open surgery in terms of radical tumor treatment.
VI. Summary and outlook.
In conclusion, the surgical method of laparoscopic radical resection of bladder cancer is being improved continuously, and the use of the improved surgical method can shorten the operation time and reduce bleeding and complications. The extent of lymphatic clearance is still debated and it is recommended to perform standard pelvic lymph node dissection for patients without preoperative imaging and expanded lymphatic clearance for those with existing lymphatic metastases. There are many different ways to reroute the urinary stream, with ileal access and in situ neocystectomy being the main surgical approaches currently used, with in situ neocystectomy being the main one. Ileal neocystectomy patients have a high quality of life after surgery and is the main surgical approach used in the future. Robotic laparoscopic technology is constantly improving and has some advantages in radical resection of bladder cancer, which has been developing faster in recent years. For patients undergoing laparoscopic radical resection of bladder cancer, the recent complications are lower than those of open surgery, and the long-term tumor removal results are comparable to those of open surgery.
Although it faces some problems and difficulties, these difficulties will be solved gradually with the improvement of surgical methods and the application of various more convenient professional instruments. It can be expected that in the near future, laparoscopic radical resection of bladder cancer – in situ neocystectomy will become the main surgical procedure for invasive bladder cancer.