The feasibility and efficacy of total laparoscopic radical cystectomy with intracorporeal Xing's orthotopic neobladder

Objective To explore the feasibility and clinical effect of laparoscopic radical cystectomy with intracorporeal Xing's orthotopic neobladder. Methods Forty-one patients who underwent laparoscopic radical cystectomy with intracorporeal Xing's orthotopic neobladder from July 2013 to August 2019. There were 31 cases performed in Beijing Chaoyang hospital and 10 cases in National Cancer Center. Mean age was 59(range 44-78) years, mean BMI was 25.3(range 20.1-34.7)kg/m2 , and mean CCI was 3 (range 2-6). No urethral stricture or urinary incontinence was found by preoperative examination. No distant metastasis was identified by bone scans, chest X-ray and sonography. Cystoscopy or TURBT was performed on all patients and biopsy was taken to confirm the diagnosis. Preoperative pathology showed 30 cases (73.2%) of MIBC, 9 cases of NMIBC (22.0%) and 2 cases (4.9%) of in-situ cancer. Laparoscopic radical cystectomy and lymphadenectomy were performed under general anesthesia. Urinary diversion was completed in the peritoneal cavity, by intercepting the terminal ileum about 60 cm, and taking the proximal ileum 10 cm as input loop on the right side with proximal to distal way, and the middle 40 cm ileum was detubated. After u-shaped suture, the ileum was folded back and stitched into a sphere building a novel orthotopic neobladder with bilateral isoperistaltic afferent limbs. The prognosis of perioperative data and postoperative satisfaction regarding continence were analyzed, continence was defined as 0-1 pad/day. The 41 patients were divided into two groups to compare the difference in term of operation time and blood loss between the first 21 patients and the last 20 patients. Results Mean total operative time was 324.9 mins (range 210-480) mins, and mean estimated blood loss was 177.6(range 50-700) ml. There were significant statistical differences in term of total operation time, construction time and blood loss between the first 21 patients and the next 20 patients (P<0.05). Postoperative pathological results were urothelial carcinoma in 40 cases (2 in situ carcinoma) and small cell carcinoma in 1 case. Mean number of dissected lymph nodes was 19 (range 11-58), with 7 cases(17.1%)of positive lymph nodes, and 3 cases(7.3%)had positive surgical margin. At a mean follow up of 17.6(range 2-64) months, 36 patients (87.8%) survived, including 2 patients (4.9%) with metastasis and 1 patient (2.4%) with recurrence, and 5 cases (12.2%)died. All patients were able to urinate without catheterization. Thirty-seven patients (90.2%) were satisfied with voiding control during the daytime (0-1 urinal pad), and 29 patients (70.7%) were satisfied with voiding control at nighttime (0-1 urinal pad) by the follow-up 12 months after the operation. Conclusions Total laparoscopic radical cystectomy combined with Xing's orthotopic ileum neobladder is a simple method with fewer postoperative complications and a satisfactory continence rate. Key words: Urinary bladder neoplasms; Totally Laparoscopes; Xing′s orthotopic neobladder; Urinary diversion