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WJOLS

Comparison of Open and Laparoscopic Radical Cystectomy for Bladder Cancer: Safety and Early Oncological Results
suspected ileus in 38 and 4.7% of patients in the I and II number of cases and institution volume were not found to
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groups respectively. Suspicion of mechanical obstruc- be predictive. For every increase in pathological T stage
tion was an indication for repeated surgery – revision above pT2, there was a five times higher chance for posi-
of the abdominal cavity. This was performed in seven tive STSM (p < 0.001). In a series of 121 patients, Snow-Lisy
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(13.7%) cases. In the study conducted by Chang et al, et al reported a positive STSM rate of 6.6%. In patients
postoperative ileus was the most common cause for pro- with large tumors and/or suspected extravesical disease,
longed hospital stay after cystectomy. Our data support wide dissection of the perivesical tissue is recommended
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this position, making aware of the modern trends and to reduce STSM rates. We found positive surgical margin
standards for management of patients, which include, in two cases in both groups – 9.5% (p > 0.05).
for example, minimizing the traumatic mechanical in- The same absence of difference was noted regarding
traoperative effects on the intestine, which distinguishes the lymph nodes – the average number of totally removed
the technique of laparoscopic cystectomy using the open (15 and 16 in the LRC and ORC groups respectively) and
method. The study made some changes in the technique the amount of positive nodes (5 and 6 in the LRC and
of the operation and, predominantly, LRC. So, in the first ORC groups respectively). The 2004 consensus study
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10 patients, ureterolieal anastomosis (UIA) formation was by Herr et al targeted at standardizing outcomes
performed with interrupted sutures and holding the left of surgical treatment for invasive bladder cancer and
ureter through the mesentery of the sigmoid colon, and identified 15 lymph nodes as the minimal acceptable yield
in the next 4 to 5 cystectomies nodal sutures were made, for this surgery. Generally, this rule matches all studies
and the left ureter was thrown over the sigmoid colon. mentioned in this analysis.
This led to a significant decrease in the intestinal phase Unfortunately, due to a short period of follow-up,
time from 250 to 200 minutes. Furthermore, there was a we cannot provide survival analysis for our cohorts.
trend to reduce frequency in the formation of anastomotic However, several recent studies showed similar
strictures and, as a consequence, hydronephrosis (4% recurrence-free, cancer-specific, and overall survival after
for the first 10 operations and 1% subsequently) with the minimally invasive and open cystectomy. MD Anderson’s
absence of anastomosis defect (gap) developed (1 case in low-risk cohort of MIBC showed a 5-year DSS of 81%;
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both groups). the same statistic published by Hautmann et al for all-
Lymphocele and chyloperitoneum were more comers cT2-cT4a Nx was 71%.
common than LRC (6.4%), whereas no differences were The major limitations of our study are retrospective
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observed between ORC and RARC – about 2%. In our analysis, low number of patients in groups, single-
results, the frequency of such complications did not differ center experience, lack of long-term oncological results,
among the groups. and possible biases. However, there are few studies
Urinary fistula developed in about 1% after ORC, comparing LRC and ORC, particularly with totally
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LRC, and RARC. The incidence of UIA was higher intracorporeal urinary diversion.
after LRC in several studies – up to 15%, while after ORC
and RARC the rate was 1.5 to 10%. 5,23,29 According to CONCLUSION
some assumptions, the risk factor for this complication Laparoscopic cystectomy is a safe radical treatment of
is excessive dissection of the urether formation by bladder cancer associated with reduced blood loss, lower
extracorporeal anastomosis. However, in a recent incidence of early postoperative complications (including
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study represented by Anderson et al, the difference dynamic ileus), leading to a reduction in duration of hos-
in frequency of UIA stricture formation between ORC pitalization and good early functional results. However,
and LRC was not significant, despite some differences to be recognized as a standard treatment, it requires more
(8.5 and 12.6% respectively, p = 0.21), and decreases with prospective data on safety of laparoscopic cystectomy,
improvement of surgical technique. functional, oncological results, and cost-effectiveness.
In terms of oncological results, in recent meta-analysis Moreover, for complete evaluation of LRC effectiveness
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Fonseka et al showed that LRC provides better outcomes and its adequate comparison with the open procedure,
than ORC and similar to RARC. Totally, talking about early it is necessary to obtain long-term oncological results.
oncological results, we must reflect several factors: Surgi-
cal margins, the number of removed and positive lymph REFERENCES
nodes. Data from the International Laparoscopic Cystec-
tomy Registry (ILCR) demonstrate a soft-tissue surgical 1. Hollenbeck BK, Miller DC, Taub D, Dunn RL, Khuri SF,
Henderson WG, Montie JE, Underwood W 3rd, Wei JT. Iden-
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margins (STSMs) rate of 2%. Advancing T stage, positive tifying risk factors for potentially avoidable complications
lymph nodes, and increasing age were independently following radical cystectomy. J Urol 2005 Oct;174(4 Pt 1):
associated with a higher likelihood of STSMs, while the 1231-1237.
World Journal of Laparoscopic Surgery, May-August 2016;9(2):51-57 55