Clinical study of radical cystectomy under totally laparoscopy and ρ shape orthotopic ileal neobladder

Objective To explore the feasibility and advantages of totally laparoscopic radical cystectomy plus ρshape orthotopic ileal neobladder, and to summarize the experiences. Methods The clinical data of 11 patients with bladder cancer admitted to the second hospital of Hebei medical university from October 2018 to May 2019 were retrospectively analyzed. All patients were male, aged 33 to 77 years, with an average of 64.4 years. Body mass index ranged from 18.0 to 31.8 kg/m2, with an average of 23.2 kg/m2. One case underwent partial cystectomy and 10 cases underwent transurethral resection of bladder tumor, with 10 cases of invasive urothelial carcinoma and 1 case of adenocarcinoma. No case underwent neoadjuvant therapy, and all cases were clinically staged as cT2a-3bN0-2M0. Totally laparoscopic radical cystectomy and ρ shape orthotopic ileal neobladder intraperitonealy were performed. The specific procedures were described as follows. After bladder resection, the ileal segment of 55 cm in length was intercepted at 25 cm from ileocecal valve, with the proximal part retaining 15 cm lumen as the input loop, and the distal part of 40 cm ileum being folded in 1∶1 ratio. The folded intestinal segment was made into a allantoic sac by using a linear incision closure device, forming a "ρ" shape with the input loop, bilateral ureters and the input loop. Anastomosis of wall, distal end of allantoic and urethra was performed.Record the perioperative data such as operation time, estimated bleeding, postoperative recovery, complications, and follow-up results. Result All of the 11 cases underwent successfully operation, and no cases were transferred to open surgery. The operation time ranged from 320 to 440 minutes, with an average of 357.1 minutes. The estimated amount of bleeding ranged from 100 to 300 ml, with an average of 207.1 ml. The total time of intestinal tract procedure was 80-100 minutes, with an average of 89.3 minutes, and the time of allantoic preparation was 14-19 minutes, with an average of 16.1 minutes. The pain score was 2-5 points at 4 hours after operation, with an average of 3.8 points, and 1-4 points at 24 hours after operation, with an average of 2.3 points. Postoperative exhaust time ranged from 2.5 to 3.5 days, with an average of 3.0 days.Catheter removed 21 days after operation, with 9 cases of urinary incontinence, including mild in 6 cases, moderate in 2 cases and severe in 1 case, with daytime pad of 0-3 and nighttime pad of 1-3.which improved gradually following pelvic exercise for 4-18 weeks. Postoperative hospital stay ranged from 7 to 13 days, with an average of 10.4 days. The drainage removal time was 4-11 days, with an average of 6.7 days. Postoperative pathology revealed 7 cases of high-grade invasive urothelial carcinoma, 3 case of low-grade invasive urothelial carcinoma and 1 case of adenocarcinoma. The tumors invade the prostate in adenocarcinoma patient, with left (3/13) and right (1/9) positive lymph nodes. One case of high-grade invasive urothelial carcinoma had both left (2/11) and right (1/9) positive lymph nodes, and the other cases were negative. The margin were negative in all patients. Pathological staging was pT2a-4aN0-2M0. Postoperative adjuvant chemotherapy with gemcitabine+ cisplatin regimen were performed in 9 patients.The follow-up period ranged from 3 to 29 weeks, with an average of 17.4 weeks, the patients with adenocarcinoma died of multiple organ failure at the 13th week after operation, and the other cases have no recurrence or metastasis. Dual J-tube was removed in 9 cases in the last follow-up, and the new bladder volume was estimated 300-350 ml, with residual urine of 0-43 ml and 19 ml of average. There is no stone formation in the new bladder.No hydronephrosis or ureteral dilatation aggravated. Conclusions Totally laparoscopic radical cystectomy plus ρ shape orthotopic ileal neobladder simplify the procedure of making allantoic storage and shorten the procedure time. The patients suffered less pain and recovered quickly after operation.It is a safe and feasible surgical procedure based on this study. Key words: Cystectomy; Radical; Totally laparoscopic; ρ shape orthotopic ileal neobladder; Urinary diversion