Laparoscopic extraperitoneal radical cystectomy

Introduction: Laparoscopic radical cystectomy (LRC) has gradually established as a reliable minimally invasive method for the treatment of muscle-invasive bladder cancer (MIBC), which can significantly reduce the number of complications. However, in the elderly and patients with serious comorbidities, LRC is still associated with a high risk of complications. There are only a few reports on the use of extraperitoneal access for LRC in the literature. At the same time, extensive experience in laparoscopic extraperitoneal radical prostatectomy and retroperitoneoscopic kidney procedures showed significant advantages of extraperitoneal access.

Materials and methods: During 2017–2021, four extraperitoneal laparoscopic radical cystectomy (ELRC) in male patients with MIBC of stage T2-T4. All patients had serious comorbidities. All but one patient had MIBC of G2-G3. Two of them had an invasion in the posterior urethra. In one patient, prostate adenocarcinoma (Gleason score 5+3=8) with invasion of the bladder wall was also diagnosed. He had chronic kidney disease of 3-4 stage due to hydronephrosis.

Results. All procedures were done laparoscopically by extraperitoneal approach. In one case, urine diversion was performed by transperitoneal route into a colon conduit. Simultaneous retroperitoneoscopic ureterocutaneostomy were performed to two cases: on one side (in a patient with a single functioning kidney) and on both sides, respectively. Simultaneous bilateral retroperitoneoscopic nephrectomy was done in a patient with CKD 5, who was on chronic dialysis. In two patients, salvage cystectomy was done for recurrent bleeding. The maximum intraoperative blood loss did not exceed 500 ml. No transfusion was required in any of the patients. Bowel function in all patients was recovered within 24-36 hours after the intervention.

Conclusion. ELRC is a reproducible minimally invasive surgical procedure for patients with bladder cancer, which has advantages in terms of postoperative recovery in patients with severe comorbidities. The use of an extraperitoneal approach may be a rational alternative for salvage cystectomy. More cases are needed to determine the role of the method in the surgical treatment of MIBC.