Anterior versus posterior approach laparoscopic radical cystectomy: a retrospective analysis

This study was approved by the ethics board of Xiangya Hospital, Central South University, in Changsha, China. All the participants were informed that their clinical information may be applied in later clinical study when they entered hospital. Also, their written informed consents were given. Between May 2011 and January 2018, there were 157 male patients in our hospital, with high-grade bladder urothelial carcinoma, of which 72 and 85 patients are in the PLRC and ALRC group respectively; we failed to follow up 4/72 patients in PLRC group and 6/85 patients in ALRC group. Thus, these patients were excluded, and the medical records of the 147 patients retrospectively were collected and analyzed from our bladder cancer database. We made the technique rotation from month to month. All patients have high-grade bladder urothelial carcinoma (cT_2-3N_XM₀) in line with TMN classification of the Union for International Cancer Control [9]. All patients had primary tumors, and none of the patients had received bladder surgeries, radiotherapy, or chemotherapy before.

Patients were evaluated in accordance with the American Society of Anesthesiologists (ASA) physical status classification system. Each patient underwent preoperative examination including routine laboratory test, echocardiography, chest radiography, lung function test, computerized tomography, or magnetic resonance imaging of urinary system. Common comorbidities were recorded, including diabetes mellitus, coronary artery disease, hypertension, chronic obstructive pulmonary disease, and other chronic diseases. Patients began semi-liquid diet 48 h before surgery, liquid diet 24 h before surgery, and underwent bowel preparation with enema and oral sodium phosphates solution 12 h before surgery. All patients got broad-spectrum systemic antibiotic intravenously during the induction of anesthesia. Same laparoscopic instruments and devices from KARL STORZ were used in both groups. All the operations and perioperative management were performed by the same experienced surgical team. Three surgeons (MC, LQ, and XZ) performed the operations. MC performed 30 and 35, LQ performed 22 and 24, and XZ performed 16 and 20 in PLRC and ALRC respectively. All the surgeons are very experienced and perform more than 25 cases of laparoscopic radical cystectomy annually. Follow-up studies were conducted with ultrasonography and CT scan at 3 and 9 months postoperatively.

The baseline patient characteristics included age, BMI, hemoglobin (Hb), total tumor and blot clot volume, comorbid conditions, and ASA score. Total tumor and blot clot volume were measured with CT scan. Operative characteristics included operation time, cystectomy time, estimated blood loss (EBL), and transfusion needed, while postoperative characteristics included Hb, time to liquid intake, time to exsufflation, and hospital stay after surgery. Operation time was defined as anesthesia from the beginning to the end, and cystectomy time was defined as procedure from starting mobilization to bladder removed completely. Intraoperative complication includes rectal injury and external iliac vein injury. Complications that occurred within 90 days after surgery were considered early complications, which included ileus, deep vein thrombosis, pyelonephritis, infection, obturator nerve paresis, and wound dehiscence [10]. The complication occurring within 90 days or later after surgery were defined as late complications, including ileus, ureteral stricture, and incisional hernia [10].

Chi-square test and Student’s t test were performed to compare categorical and parametric data respectively between the two groups. Parametric data is denoted as mean ± SD, and categorical data is presented as frequency (%). Linear regression analysis was conducted to assess the relationship between cystectomy time and total tumor and blood clot volume. Significant differences were considered when p < 0.05. Statistical analysis was conducted with the Statistical Package for Social Scientists, version 22.0 (IBM Inc).

The basic laparoscopic radical cystectomy procedures were performed according to Campbell-Walsh Urology [11], A five-port fan-shaped trans-peritoneal approach was employed for LRC. The camera port was placed just below the umbilicus. The residual four ports were placed under endoscopic control after the establishment of the pneumoperitoneum. A dorsal supine position with a 20–25° Trendelenburg position was used to keep the bowel from the pelvis during surgery. Surgery was performed by visualizing the pelvis and releasing adhesions of the sigmoid colon to find the anatomical landmarks in the pelvis, such as obliterated umbilical arteries, obliterated urachus, spermatic cord, and vas deferens. The standard lymphadenectomy was performed in all cases [12]. After laparoscopic cystectomy, urinary diversion, bricker operation, or orthotopic neobladder, was conducted according to patients’ preferences.

The posterior approach laparoscopic radical cystectomy is a conventional LRC, the posterior plane was developed first, and the whole operation procedure was performed according to Campbell-Walsh Urology [11]. The anterior approach laparoscopic radical cystectomy was performed as follows. The anterior plane was first developed distally towards the prostate. Both puboprostatic ligaments were mobilized and dissected, and the Santorini venous plexus was ligated. Subsequently, the bladder was suspended towards the abdominal wall with a 2-0 synthetic non-absorbable suture (Fig. 1a). The laparoscopy observation showed that nearly half of the needle was punctured into the abdominal, 3 cm above the pubic symphysis, and about 2 cm right to the midline (Fig. 1b). The needle was punctured through the right side of bladder wall, then intermittently through the posterior and left side, puncturing out to the symmetrical position of the abdominal wall (Fig. 1c–f). The needle should be avoided from penetrating the bladder wall, and the suture should be limited in the superficial peritoneum. After puncturing out the abdominal wall (Fig. 1g), the end of this suture was knotted with tension. The vesicorectal fossa could extend to the fullest after bladder suspension was completed (Fig. 1h). After bladder suspension, the posterior plane was developed. Next, the procedures of handling the posterior and lateral planes were the same as those of PLRC. After the posterior and lateral bladder attachments were released, the bladder was released from the anterior abdominal wall. The attachments of the prostatic apex to the pelvic floor were released, and the urethral catheter was removed. After the dissection of Santorini venous plexus, the urethra was dissected.

In general, 147 patients were recruited here, including 68 patients who underwent PLRC and 79 patients proceeded with ALRC. Patients in the PLRC group and ALRC group had comparable baseline characteristics, including age, BMI, Hb, total tumor and blood clot volume, comorbid conditions, and ASA score (Table 1).

One patient in the PLRC group was transferred to open surgery, and no patients in the ALRC groups were transferred to open surgery. Operative and postoperative characteristics of the two groups are shown in Table 2. Estimated blood loss (EBL) of the ALRC group was significantly lower than that of the PLRC group (477.8 ± 97.4 vs 550.4 ± 99.9). Also, less patients in ALRC group needed transfusion (Table 2). The Hb after surgery in ALRC group was a little higher than the PLRC group (102.1 ± 11.6 vs 98.1 ± 12.5). There were no significant differences between the two groups in operation time, cystectomy time, time to liquid intake, time to exsufflation, and hospital stay after surgery.

When patients were sub-grouped based on BMI, cystectomy time was different between sub-groups though the operation time (317.3 ± 40.9 vs 321.9 ± 37.5) and cystectomy time (64.8 ± 8.7 vs 65.6 ± 14.0) were similar between the two groups. When BMI was less than 18.5, the PLRC group took less cystectomy time compared with the ALRC (52.5 ± 6.5 vs 60.3 ± 6.2). When BMI was ranged from 18.5 to 24, cystectomy time was similar between the two groups. It took longer cystectomy time for the PLRC group when BMI was greater than 24 (77.4 ± 14.9 vs 67.8 ± 10.1) (Table 3). Liner regression analysis was conducted to access the relationship between cystectomy time and total tumor and blood clot volume. In both PLRC (y = 0.1787x + 34.66, r² = 0.8225, p < 0.0001) and ALRC (y = 0.0851x + 49.29, r² = 0.4459, p < 0.0001), cystectomy time were correlated significantly positively with total tumor and blood clot volume. Both PLRC and ALRC required similar cystectomy time when total tumor and blood clot volume was about 160 cm³. Compared with ALRC, PLRC required less cystectomy time and operation time when total tumor and blood clot volume was less than 160 cm³, and PLRC required more cystectomy time and operation time when total tumor and blood clot volume was larger than 160 cm³ (Table 2, Fig. 2).

There were no deaths in the two groups during the perioperative period. Intraoperative and postoperative complications of the two groups are listed in Table 4. Two patients underwent rectal injury and another patient got external iliac vein injury in the PLRC group during surgery, and one patient underwent external iliac vein injury in the ALRC group. Ileus was considered the most common early postoperative complication, and there existed no significant difference between the PLRC and ALRC group. Also, there were no significant differences between the two groups in the incidence of other early complications, including deep vein thrombosis, pyelonephritis, infection, obturator nerve paresis, and wound dehiscence. Likewise, the incidence of late complications including ileus, ureteral stricture, and incisional hernia was comparable.