Objective To improve the surgical technique of radical cystectomy for male bladder cancer and reduce complications. Methods To improve radical cystectomy, including cystoprostatectomy with cis-reversible union, distal ureteral cryobiopsy, suture of deep dorsal vein, protection of neurovascular bundle, and extensive pelvic lymph node dissection. The clinical data of 62 patients were retrospectively analyzed. Results The average age of the patients was 67 years, and the operative time of radical cystectomy ranged from 2.2 to 3.5 h, with an average of 2.5 h. The intraoperative bleeding volume ranged from 150 to 1200 ml, with an average of 400 ml. 7 of 62 cases (11.3%) had intraoperative frozen sections confirming tumor cell infiltration or epithelial atypical hyperplasia in the ureteral stump. Lymph nodes were removed from 8 to 16 patients per case, with a positive rate of 16.1% (10/62). Six cases in this group had mild intestinal obstruction after surgery, which improved with symptomatic treatment; one case had partial fat liquefaction of the incision, no lung or pelvic infection, no rectal injury and other complications, and no one case died during the perioperative period. At 3-52 months follow-up, one case died of bone metastasis at 5 months, and no distant metastasis to the pelvis, anastomosis and other organs was found in one case. There were 10 cases with intentional preservation of the neurovascular bundle, of which 4 had erectile function; 3 cases with no intentional preservation of the neurovascular bundle and postoperative erectile function (30 cases at follow-up). Conclusion Improved radical cystectomy can effectively remove the tumor radically, which can reduce intraoperative postoperative bleeding, decrease complications, and preserve sexual function.
Radical cystectomy is currently recognized as the gold standard for the treatment of muscle-invasive bladder cancer and high-grade recurrent bladder cancer. However, there are still many controversial issues regarding the indications for radical total cystectomy (e.g., T1G3) and the extent of lymphatic dissection. In addition, post-radical cystectomy complications (e.g., incisional infection, gastrointestinal complications, erectile dysfunction) are nevertheless as high as 25% ~35%. From May 2002 to September 2006, we treated 62 patients with male bladder cancer using a modified radical cystectomy technique with satisfactory results, which are reported below.
Materials and methods I. Clinical data There were 62 cases in this group. The median age was 67 years (32-78 years), all patients obtained pathological diagnosis before surgery, 58 cases of metastatic cell carcinoma, 3 cases of adenocarcinoma, 1 case of squamous carcinoma, 45 cases of primary tumor, 17 cases of recurrent tumor, all patients did not receive pelvic radiotherapy and systemic chemotherapy before surgery, after total cystectomy, 54 cases had ileal cystectomy (Bricher procedure) and 8 cases had in situ ileal neobladder ( Studer procedure).
All patients were performed under a uniform surgical approach, with an incision around the umbilicus on the left side of the lower midsection to enter the abdominal cavity and resect the atretic umbilicus to the epigastric bladder. The main features of radical cystectomy in this group were: ① cystoprostatectomy first, followed by pelvic lymph node dissection; ② frozen biopsy of the ureteral stump until the pathological examination was reported as negative for tumor cells; ③ combined cystoprostatectomy in a cis-reversible manner; ④ after cutting the peritoneum of the cysto-rectal fossa, the posterior part of the bladder and the rectal space were sharply or bluntly freed against the rectal surface; ⑤ 2-0 absorbable suture was used to deal with the deep dorsal vein, and sharp
III. Postoperative observation and follow-up contents Statistical analysis was performed on the data of patients’ general condition, operation time, intraoperative and postoperative bleeding, and postoperative complications, etc. Regular postoperative follow-up was performed every 3 months, which included chest X-ray, pelvic CT, abdominal ultrasound, liver and kidney function, and sexual function.
Intraoperative bleeding volume ranged from 150 to 1200 ml, with an average of 400 ml. 7 of 62 cases (11.3%) had abnormalities in one ureteral stump confirmed by frozen section, including malignant tumor cell infiltration in 6 cases and atypical metastatic epithelial hyperplasia in 1 case. In all seven patients, the ureteral stump was immediately resected and sent for frozen biopsy again until the diagnosis was confirmed, and then urinary diversion was performed. The postoperative pathological WHO stage was T2 in 35 cases, T3 in 25 cases, and T4 in 2 cases; 8 cases (12.9%) were graded as grade I, 34 cases (54.8%) as grade II, and 20 cases (32.3%) as grade III tumors. Each patient had 8-16 lymph nodes removed, with a positive rate of 16.1% (10/62); 6 cases in this group had mild intestinal obstruction after surgery, which improved with symptomatic treatment; 1 case had partial fat liquefaction of the incision, no lung or pelvic infection, no rectal injury and other complications, and no 1 case died during the perioperative period. At 3-52 months follow-up, only 1 patient died of bone metastasis at 5 months, and the rest were reviewed without distant metastases to the pelvis, anastomosis, or other organs. There were 10 cases with intention to preserve the neurovascular bundle, of which 4 had erectile function; 3 cases with no intention to preserve the neurovascular bundle and had erectile function after surgery (30 cases at follow-up).
Discussion The standard male radical cystectomy resection includes the complete bladder and its surrounding fat, the peritoneum covering the bladder, the umbilical ureter, the prostate, the seminal vesicles, and the clearance of the pelvic lymph nodes. Early (1930s) radical cystectomy had a mortality rate of 34.5% and was once considered a pointless treatment modality [1]. Modern advances and refinements in anesthesia, surgical techniques and preoperative preparation have now reduced the radical cystectomy mortality rate to 1%-3% [2]. The radical cystectomy approach in our group is mainly based on Campbell’s urology [1], which involves freeing the bladder, ureter and other organs and tissues through a transabdominal approach, complete removal of the bladder, prostate and seminal vesicles, and clearing the pelvic lymph nodes. This procedure has some of our own characteristics and experiences in the operation of specific sessions.
Cervical prostate resection in a paracervical fashion: Walsh et al. proposed modern anatomical radical prostatectomy in 1998 [1]. Exhaustive knowledge of the applied anatomy of the prostate and techniques ensure that the surgical field can be operated in a clear state. With a caval prostatectomy, due to the narrow pelvic cavity, it is not easy to operate under direct vision laterally at the seminal vesicles of the bladder, and blind operation may lead to hemorrhage as well as injury to the vascular nerve bundles; whereas, the application of the radical prostatectomy approach in cystectomy at this time allows safe treatment of the dorsal plexus venous complex, and after freeing the prostate, the bladder prostate can be made to pass up and down behind Dili’s fascia. This approach reduces bleeding, preserves erectile nerve function, and allows for fine treatment of the prostate tip, allowing for a more definitive anastomosis of the urethra to the “new bladder (Studer)”. The average operative time for radical total cystectomy in this group was 2.5 h, as well as the bleeding volume was around 400 ml, which indicates the rationality and superiority of the cis-transgressive union.
Ureteral stump problem: Radical cystectomy for bladder cancer routinely requires intraoperative ureteral biopsy. It is known from the biological behavior of uroepithelial tumors that if intraoperative frozen biopsy is not performed, resulting in a missed diagnosis, it may be a source of later tumor recurrence. the first findings of this problem were reported by Culp [3] et al. who examined specimens after total bladder surgery for bladder cancer and found that abnormal ureteral cut margins (cancer, atypical hyperplasia) were found in 38 of 231 patients (17%), and in our group of 68 cases In 7 cases (10.3%), intraoperative frozen section confirmed abnormalities in the ureteral stump on one side, among which malignant tumor cell infiltration was seen in 6 cases and metastatic epithelial atypical hyperplasia in 1 case. In all 7 cases, the ureteral stump was immediately resected and sent for frozen biopsy again until no abnormality was diagnosed, and then urinary flow was rerouted.
Pelvic lymph node dissection and extent: 14.5% to 28% of patients with bladder cancer develop lymph node metastasis, and the rate of lymph node metastasis is mainly positively correlated with tumor stage [4, 5]. The extent of lymphatic clearance in radical cystectomy, from early regional lymph node clearance and traditional pelvic lymph node clearance, to expanded lymph node clearance and the recent increase in the level of clearance to the level of the inferior mesenteric artery, has not been standardly defined so far. The greater the extent of lymph node dissection, the greater the number of lymph nodes removed, and the greater the chance of complications (such as lymphatic fistula, hemorrhage, and lower extremity lymphedema). The scope of lymphatic clearance in our group includes extensive lymph node dissection starting 2 cm above the bifurcation of the iliac artery, the skeletalized common iliac, internal and external iliac vessels, and the closed nerve travel range, which is approximately the same as the traditional clearance range proposed by Leadbetter and Cooper, and most of the literature [4, 5, 6] suggests that lymph nodes cleared to this range can cover more than 80% of the area. In our group, 8-16 lymph nodes were removed per patient, with a positive rate of 16.1% (10/62), and there was no one case of intrapelvic lymphatic recurrence, nor was there one case of abdominal lymphatic cyst or lower limb edema at the postoperative follow-up of 3 to 52 months. We believe that the traditional scope of pelvic lymphatic dissection still has validity and utility. In addition, we found that resection of the bladder followed by lymph node dissection could reduce the compression of the bladder and tumor, and lymphadenectomy was simpler and more complete.
Preservation of the neurovascular bundle: The recovery of sexual function after radical cystectomy is related to the age of the patient, the stage of the tumor, and whether the neurovascular bundle is preserved during surgery. 42.5%. In this group, 30 patients with a mean age of 60 years were followed up. 10 cases with intentional preservation of the neurovascular bundle, of which 4 had erectile function; 3 cases with unintentional preservation of the neurovascular bundle and postoperative erectile function (30 cases were followed up).
Complications: Complications after radical cystectomy in men range from approximately 25% to 35%. Common complications are pulmonary atelectasis, incisional infection, rectal injury, intestinal obstruction, lymphatic fistula (or cyst) and erectile dysfunction [1]. In our group, all important organ functions were routinely evaluated before surgery, infection was controlled and functional imbalance was corrected in a timely manner, and bowel preparation was improved. At the end of surgery, one drain was placed on each side of the pelvis to fully avoid the possibility of pelvic effusion and infection. Six cases in this group had mild intestinal obstruction after surgery, which improved with symptomatic treatment; one case of partial fat liquefaction of the incision, no lung or pelvic infection, no rectal injury and other complications, and no one case of perioperative death. At the follow-up of 3~52 months, only one case died of bone metastasis at 5 months, and the rest of the review did not find distant metastasis of pelvis, anastomosis and other organs.