Comparison of Laparoendoscopic Single-Site and Laparoscopic Radical Cystectomy for Male Patients with Bladder Cancer: Perioperative and Oncologic Outcomes

Abstract

Objective:

To compare the surgical and early oncological outcomes in patients with bladder cancer who had laparoendoscopic single-site radical cystectomy (RC) or laparoscopic RC.

Materials and Methods:

From July 2012 to May 2019, 28 consecutive men suffering from bladder cancer underwent laparoendoscopic single-site RC or laparoscopic RC with extracorporeally ileal conduit diversion. Data regarding the patient characteristics, surgical outcomes, and short-term oncological outcomes were analyzed retrospectively.

Results:

Compared with laparoscopic RC, laparoendoscopic single-site RC was associated with less postoperative pain (mean, 4.67 versus 6.08 scores; P = .004), and shorter convalescence (time to ambulation, mean, 1.13 days versus 2.15 days; P = .000; hospital stay after surgery, mean, 13 days versus 19 days; P = .001). In addition, differences in patient characteristics, mean total operation time, and mean estimated blood loss were not statistically significant between laparoendoscopic single-site RC and laparoscopic RC groups. There was no difference in the early or late complication rate between the two groups as well. It is also revealed that there was no significant difference in the overall survival rate at 24 months between laparoendoscopic single-site RC and laparoscopic RC groups.

Conclusions:

Based on our initial experience with laparoendoscopic single-site RC, it is a safe procedure with acceptable complications and oncological outcomes. Notably, laparoendoscopic single-site RC is associated with less postoperative pain and rapider convalescence compared with the historical series of laparoscopic RC. However, further comparative studies with longer follow-up period are warranted to validate this procedure.

Introduction

Bladder cancer is the most common urinary tract malignancy, which also accounts for the fourth most common cancer in men in the United States.¹ According to the European Association of Urology guidelines, radical cystectomy (RC) and urinary diversion with pelvic lymph node dissection is considered to be the standard treatment for muscle-invasive bladder cancer.² Typically, ileal conduit (IC) and orthotopic neobladder are the two most frequently used urinary diversion approaches. Although orthotopic bladder is increasingly reported in large centers worldwide, IC remains the standard diversion approach following cystectomy, which is ascribed to its cost-effectiveness, satisfactory postoperative quality of life, and acceptable complication rate.^3,4 With the improvements in minimally invasive techniques, laparoscopic RC (LRC) has emerged as an alternative to the open procedure. Moreover, the laparoendoscopic single-site surgery (LESS) is representative of the state-of-the-art development in the field of minimally invasive surgery, which is potentially associated with less postoperative pain, lower estimated blood loss, rapider convalescence, and superior cosmetic effect.^5–7 At present, the urologic application of LESS includes a wide range of ablative and reconstructive procedures.⁸ In this study, our initial experience with LESS-RC, together with the long-term follow-up results, was presented.

Materials and Methods

Patients

From July 2012 to May 2019, 28 patients underwent LESS or LRC RC and pelvic lymph node dissection (PLND) combined with IC diversion by a single surgeon in our department. All patients underwent transurethral resection of the bladder tumor before RC. This study was approved by the Research Ethics Committee of Affiliated Hospital of Nanjing University of Chinese Medicine. Table 1 shows the demographic data of all enrolled patients.

Table 1.

Patient Characteristics

Variables	LESS-RC	LRC	P
Patients, n	15	13
Age (mean ± SD), year	62.13 ± 7.41	64.00 ± 8.06	.529
ASA classification, n			.877
≤2	13	11
>2	2	2
Body mass index (mean ± SD) (kg/m²)	24.78 ± 2.97	23.74 ± 2.27	.315
Previous abdominal or pelvic surgery, n	5	4	1.000

ASA, American Society of Anesthesiologists; LESS, laparoendoscopic single-site surgery; LRC, laparoscopic radical cystectomy; SD, standard deviation.

Patient preparation

On the day before surgery, the patient's bowel was prepared by oral self-administration of polyethylene glycol. Antibiotic prophylaxis combined with a clear liquid diet was performed for 3 days. For the LESS-RC, the patients were secured to the table and placed in a steep Trendelenburg position, with their legs being abducted in the modified lithotomy position (Fig. 1A). General anesthesia with endotracheal intubation was performed for all patients.

FIG. 1.

Procedures for extracorporeal ileal conduit urinary diversion. (A) The patient and operator's positions. (B) The QuadPort and an additional 10 mm port in the right iliac fossa. (C) Extracorporeal reconstruction of the urinary diversion. (D) Extracorporeal creation of ureteroileal anastomosis through the wound protector. (E) External picture of the bladder specimen and reconstruction of the umbilical incision.

Surgical technique

At first, a 2.5 cm umbilical skin incision was made circumferentially in the infraumbilical crescent. Then, an additional 12 mm trocar was placed at 2 cm below the umbilicus on the right side of the midclavicular line. A multichannel port QuadPort (Senscure, Zhejiang, China) (Fig. 1B), which consisted of two 5 mm and two 12 mm trocars, was placed through the umbilical incision. The LESS-RC and PLND are similar to our experience in LESS-RC combined with cutaneous ureterostomy.⁹ Specifically, IC was created extracorporeally through the wound protector. Thereafter, the ileum was extracted through the incision, and a 15 cm ileal segment was harvested at ∼20 cm proximal to the ileocecal valve (Fig. 1C). Subsequently, the isolated ileal segment was placed caudad, and the intestinal continuity was reestablished through side-to-side anastomosis using the Endo-GIA staplers. Besides, the mesenteric detect was closed using the interrupted sutures. The ureters were spatulated, and ureteroenteric anastomoses were performed separately in a Bricker manner to the IC using two 4-0 Polysorb interrupted sutures (Fig. 1D). Moreover, two 8F feeding tubes were intubated in ureters before accomplishing ureteroileal anastomoses. In the proximal end of the conduit, two small enterotomies were made for ureteral anastomoses, while the distal end of the ileal segment was anchored to the rectus fascia through the additional port and then to the skin (Fig. 1E). Further, an 18-Ch Foley catheter was placed in the IC for postoperative flushing.

With regard to LRC, the five-port transperitoneal technique was used. In brief, the first 10 mm trocar was placed at 1 cm above the umbilicus. Later, four secondary ports were placed, including a 12 mm port above the left anterior superior iliac spine, as well as three 10 mm ports in the right and left lower quadrants. Then, the specimen was placed in a bag, and a 5–6 cm midline incision was made below the umbilicus, which incorporated the camera incision. Later, the ileum was extracted through the same incision, and an ileal segment was selected.

Statistical analysis

Differences between groups were evaluated using Student's t-test for continuous variables, chi-square test for unordered categorical variables, and Mann–Whitney U-test for ordinal categorical variables. All P < .05 were considered statistically significant. All statistical analyses were calculated with SPSS v.21 software (IBM Corp., Armonk, NY, USA).

Results

Patient characteristics are shown in Table 1. There was no significant difference in mean age, body mass index (BMI), and American Society of Anesthesiologists score between the LESS-RC and LRC groups.

Differences in mean operation time, mean estimated blood loss, and transfusion rate between two groups were not statistically significant (Table 2). For LESS-RC, the mean operative time was 230.33 minutes, while that for LRC was 267.69 minutes. The median EBL for LESS-RC was 236.67 mL, while that for LRC was 265.38 mL. Two patients in LRC and LESS groups, respectively, required intraoperative blood transfusion. Patients in LESS-RC group had lower visual analog pain score (VAPS) on the day immediately after surgery (P = .004). Besides, the time to ambulation (mean: 1.13 days versus 2.15 days; P = .000) was significantly shorter in LESS-RC group than in LRC group.

Table 2.

Surgical, Pathological, and Follow-Up Data

Variables	LESS-RC	LRC	P
Operative time, minutes (mean ± SD)	230.33 ± 53.27	267.69 ± 66.60	.111
Estimated blood loss (mean ± SD), mL	236.67 ± 92.37	265.38 ± 253.76	.697
Transfusion rate, n	2	2	.877
Time to ambulation (mean ± SD), days	1.13 ± .35	2.15 ± 0.55	.000
Time to oral intake (mean ± SD), days	4.47 ± 1.68	4.77 ± 1.30	.604
Length of hospital stay after surgery (mean ± SD), days	13.20 ± 3.73	19.46 ± 5.36	.001
VAPS median the day immediately after surgery (mean ± SD)	4.67 ± 1.23	6.08 ± 1.12	.004
Lymph node yield (mean ± SD), n	14.93 ± 6.41	13.08 ± 6.64	.459
Early complication rate, n			.873
None	6	5
Minor (I–II)	8	6
Major (III–V)	1	2
Late complication rates, n			.686
None	10	9
Minor (I–II)	5	3
Major (III–V)	0	1
Pathologic stage, n			.213
T1	9	9
T2	5	1
T3	1	2
T4	0	1
pN stage, n			.226
N−	12	13
N+	3	0
Margin positivity, n	1	0	1.000
Incidental prostate cancer, n	2	1	1.000
Associated carcinoma in situ, n	5	1	.173
Urethrectomy, n	3	1	.600
Oncologic follow-up
Follow-up time (mean ± SD), months	23 ± 11	48 ± 25	.001
Recurrence, n
Local recurrence	1	0	1.000
Distant metastasis	2	3	.639
The 2-year rate of overall survival, %	87	92	1.000

LESS, laparoendoscopic single-site surgery; LRC, laparoscopic radical cystectomy; SD, standard deviation; VAPS, visual analog pain score.

The mean hospital stay after surgery was 13 days for LESS-RC and 19 days for LRC (P = .001).

Table 2 displays the overall early and late complication rates according to Clavien-Dindo classification. There were no significant differences for early and late complications within the first 90 days after surgery between the two groups. Three patients in LESS-RC group were diagnosed with positive lymph nodes, while one in LESS-RC group showed a positive surgical margin. The mean numbers of lymph nodes harvested were 14.93 for LESS-RC and 13.08 for LRC (P = .459). As for cancer staging, 6.7% patients in LESS group and 23% in LRC group had the pathological stage of T3 or T4.

In addition, the mean follow-up periods were 23 and 48 months for the LESS-RC and LRC groups, respectively. At the last follow-up, 2 patients in LESS-RC group and 3 patients in LRC group suffered cancer metastasis, whereas 1 patient in LESS-RC group experienced local recurrence. There is no significant difference in the 24-month overall survival (OS) rate (87% versus 92%, P = 1) between the LESS-RC and LRC groups.

Discussion

We confirmed the feasibility of IC among patients undergoing LESS-RC at our single center, which achieved similar perioperative outcomes and complications to those of LRC. However, LESS was associated with the superiorities of faster recovery to ambulation and lower VAPS on the day immediately after surgery.

According to the European Association of Urology guidelines, it is feasible to perform LESS in selective patients with bladder cancer. Nevertheless, LESS is not the frequently performed procedure at many institutions so far, which is possibly because of the two major controversies.

Notably, the first controversy regarding LESS is its oncological outcome. Although the long-term operative and oncological data are lacking currently, in a matched-pair comparative study by Xu et al., LESS-RC had lower estimated blood loss and less postoperative pain. In addition, there were no significant differences in the OS (86.7% versus 88.1%), cancer-specific survival (88.3% versus 90.9%), and recurrence-free survival (80.2% versus 87.5%) between LESS and LRC groups.¹⁰ Abdallah et al. reported that LESS-RC with orthotopic urinary diversion was technically feasible, which was linked with a favorable course of treatment and convalescence, along with an acceptable oncological outcome.¹¹ However, data regarding the long-term oncological outcomes of LESS-RC are lacking so far; as a result, the true oncological effectiveness of LESS-RC has not been established yet.

The second controversy about LESS is its steep learning curve, which increases the operation time and requires significant laparoscopic skills. Typically, the major challenges of our technique included the clashing of instruments and the lack of triangulation. Continuous innovations in the curved laparoscopic or articulating instruments may reduce the leading technical problems associated with instrument triangulation. In addition, an additional port was placed at 2 cm below the umbilicus on the right side of the midclavicular line, and the assistant port was utilized for instrument insertion, aspiration, and ureteral stenting through this port. Finally, the port was removed and the distal end of IC was brought through the stoma site. Based on our experience, the use of accessory ports was an ideal complement to LESS, which facilitated angulation and suturing with minimum cosmetic impact. Notably, the QuadPort multichannel port containing a dual-ring wound protector has been shown in several studies to reduce the incidence of surgical site infection during laparotomy for gastrointestinal surgery.^12,13 The wound protector has been developed as the physical barrier between the abdominal wound edges and the surgical practice, including viscera, gloves, and visceral contents.¹⁴ This also allows the ureteral anastomosis to be performed through a small incision. Nonetheless, more experience and practice are required to overcome these difficulties.

Some limitations should be noted in this study. First, this work was a retrospective study, which was linked with an inevitable selection bias, and all patients were treated by one surgeon at a single center. Therefore, further studies, including randomized control trials, are warranted to obtain the higher levels of evidence. Second, the long-term follow-up was not assessed, so future studies with a longer follow-up period should be performed.

Conclusions

Based on our early experience with LESS-RC, it is a safe procedure with acceptable morbidity and oncological outcomes. Besides, LESS is associated with less postoperative pain and rapider convalescence compared with the historical series of LRC.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by the National Natural Science Foundation of China (Grant Nos. 81902570 and 81772732).

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