Laparoscopic radical cystectomy with pelvic lymph node dissection and ileal orthotopic neobladder by a total extraperitoneal approach: Our initial technique and short-term outcomes

Abstract

Purpose: With the increasing application of laparoscopic or robot-assisted radical cystectomy, a reliable and promising method is needed for reducing postoperative complications. We describe the short-term outcomes of totally extraperitoneal laparoscopic radical cystectomy (TELRC) with extraperitoneal pelvic lymph node dissection (EPLND) and extraperitoneal ileal orthotopic neobladder (EION) techniques.

Materials and methods: From January 2020 to December 2021, we performed TELRC and EPLND with EION in 72 patients in our center. The accompanying video highlights our novel techniques. The patients' demographic data, intraoperative data, and perioperative complications were collected, and short-term oncological and functional results are reported.

Results: All procedures were technically successful without conversion to open surgery. The patients' mean body mass index was 26.22±5.71. Median age was 57.51±12.34 years. Average hospital stay was 13.78±4.62 days. Median intraoperative blood loss was 112.92±88.56 mL. No blood transfusion was needed during the operations and only one blood transfusion was performed during the perioperative period. Mean operating time was 259.44±49.84 minutes. Average cost was US$9,875.71±1,873.08. Postoperative short-term complications included short-term ileus (n=3), infection (n=13), leakage of urine (n=11), and lymph fistula (n=7). One late complication of unilateral vesicoureteral anastomotic stenosis occurred. The mean follow-up was 13.42±8.77 months, and no patient developed local or systemic recurrence. The short-term follow-up and small cohort of patients limited our evaluation of outcomes.

Conclusions: TELRC with PLND and EION was technically feasible and clinically promising, with a reduced potential harm of postoperative complications. Long-term follow-up and a larger cohort of patients are needed for further study.

Keywords: Cystectomy; Laparoscopes; Urinary bladder neoplasms; Urinary diversions.

Conflict of interest statement

The authors have nothing to disclose.

© The Korean Urological Association.

Figures

Fig. 1. Operative position.

Fig. 2. Port placement. Median incision of the lower abdomen was closed by 7-0 Mersilk sutures followed by 10-cm trocar placement. In our experience, a rectangular distribution of ports was more beneficial to subsequent operations.

Fig. 3. Step-by-step totally extraperitoneal laparoscopic radical cystectomy. (A) Transection of spermiduct. Spermiduct and spermatic cord were transected separately. (B) Transection of umbilical artery. (C) Identification and dissection of ureter. Ureter was close to the peritoneum and the dissection range was from the common iliac artery to the ureterovesical junction. (D) Identification of vesico-umbilical ligament. Vesico-umbilical ligament was transected and the peritoneum was separated from the bladder posteriorly. (E) Dissection along with spermiduct. (F) Bilateral seminal vesicle was dissected followed by incision of prostatic pedicles and remaining attachments. (G) Pelvic structure after extraperitoneal pelvic lymph node dissection. (H) Extracorporal manufacture of ileal neobladder. A liner cutter was put into ileum at the bottom of the pouch. Usually, two clips were enough for neobladder.

Fig. 4. Extraperitonealization of orthotopic neobladder. Peritoneum was sutured for extraperitonealization of orthotopic neobladder with proper tightness. Bilateral single-J stents were pulled out through the suprapubic incision.