Three-port approach vs conventional laparoscopic radical cystectomy with orthotopic neobladder: a single-center retrospective study

Bladder cancer is a common malignant tumor of the urinary system, and RC remains the standard treatment [5]. With recent developments in science and technology, RC has gradually become minimally invasive, and most approaches have changed from traditional open surgery to the present LRC and RARC [5, 17]. Considering economic and other factors, LRC is still the preferred choice in most developing countries and in patients who are unwilling to bear high costs [9, 10]. In line with the concept of minimally invasive and concise surgery, Professor Bi of our research group improved and optimized LRC based on the traditional five-port method and adopted the three-port method [14]. Therefore, the clinical data of 100 patients undergoing LRC were collected in this study. The clinical effects of three-port LRC and traditional five-port LRC were compared by statistical analysis. Our study preliminarily showed that the three-port method was safe and feasible for patients who underwent traditional five-port LRC + ONB. We did not observe significant changes in perioperative data and postoperative complications, quality of life, or tumor outcomes; however, the cost of treatment was significantly reduced in patients who underwent the three-port procedure.

With continuous improvements in medical levels, minimally invasive and concise operations have received increasing attention. In this study, under the premise that the perioperative and postoperative clinical effect of three-port LRC is almost no worse than that of the five-port procedure, the number of cannulas and surgical cost can be reduced, which is quite valuable. In our research group's previous study on the learning curve, it was found that the sample size of the three-port procedure performed in our hospital steadily increased over time. As the number of cases increased and physicians became more skilled, the operative time decreased significantly [15]. This is consistent with the increase in the proportion of the three-port approach over the years in this study. The retrospective study of renal cancer conducted by Cheung et al. [18] also demonstrated the importance of minimally invasive trends in urology. They found that the proportion of minimally invasive procedures increased significantly over the years. In addition, as time has gone on and the volume of operations has increased, the techniques of doctors using minimally invasive procedures have also matured. We have been trying to accomplish the same goal with minimally invasive surgery in cases of bladder cancer. In the final analysis, these innovative minimally invasive attempts all follow the law of innovation diffusion, which is a principle describing the process and speed of new technologies and new attempts at their spread into society that has been verified in many disciplines [19,20,21]. According to this law, both the volume of surgery and the year of surgery are significant variables in the innovation and early trial phases, which are characterized by key discipline leaders proposing and leading the development of new technologies.

Because some patients were reluctant to undergo the innovative three-port procedure and others were reluctant to undergo more abdominal incisions, our team operated with different numbers of cannulas in different patients. The three-port method we used only required a primary surgeon and a laparoscopic assistant, while traditional LRC mostly employed the five-port method, which was jointly performed by three doctors. Although the traditional surgical method is quite classic, it still has some shortcomings, such as poor cooperation between different doctors, complicated operations, and high cost [5, 6, 22]. Three-port LRC is more in line with the concept of minimally invasive surgery and aesthetic needs. Fewer surgeon demands would allow for better allocation of fewer available physician resources. A lower number of cannulas can also directly reduce patient health care costs, which was preliminarily demonstrated in this study. In principle, a smaller number of incisions may also lead to fewer incision-related complications and a shorter recovery time; however, these were not significantly different between the two methods, which may be related to many factors such as insufficient sample size. Nevertheless, many perioperative and postoperative clinical data of patients undergoing LRC using the three-port method in this study are equal or even slightly better than those of patients with the traditional five-port method, which is a positive and optimistic signal. We believe that expanding the research scale and improving the surgical techniques will further reveal the advantages of the three-port method, being in line with the trend of simplified surgery and minimally invasive concepts. In summary, our study preliminarily suggests that the three-hole method may have the following advantages: (1) The perioperative and postoperative clinical data of the three-hole method are not significantly different from those of the traditional method, but the medical cost of the three-hole method is significantly reduced. (2) The three-hole method reduces the number of cannulas and is more concise and minimally invasive. It is thus in line with the aesthetic needs of patients and the trend of minimally invasive surgery. (3) The three-hole method reduces the need for surgeons and makes insufficient medical resources more reasonably distributed. (4) In addition, it is believed that with the increase in sample size and the progress of surgical technology, the advantages of the three-hold method, such as fewer trocars and less trauma, will become more statistically significant.

Of course, the three-port LRC also has many shortcomings. First, this surgical method has not been widely used worldwide, and there is no set of standardized procedures; therefore, it is quite a test of the skill and operation for the surgeon. Moreover, it is more difficult and time-consuming to learn. Our previous study on the learning curve also shows that LRC with the three-port method requires familiarity with a large sample size to be completed well [15]. Second, due to the lack of assistance from another assistant, it is difficult to carry out three-port LRC for obese patients and other situations that are difficult to fully expose. For primary surgeons with limited surgical experience and understanding, three-port LRC may even be less safe and reliable than the traditional method. Therefore, we recommend this innovative surgical approach for surgeons with extensive surgical experience.

Innovations such as three-port LRC to reduce the number of cannulas have been used in other urological procedures. Xu et al. [23,24,25] performed several cases of three-port laparoscopic radical prostatectomy (LRP). Their study successfully demonstrated that three-port LRP has significant advantages in terms of perioperative data such as operation time and intraoperative blood loss compared with traditional surgery, which is worthy of popularization and application. Because of the sufficient sample size and longer investigation time, their study is more convincing; however, the advantages of the three-port method are consistent with ours. We also reviewed and referred to other published literature on LRC, as shown in Table 6. Together with other LRC literature, we found that the three-port procedure may have certain advantages in shortening the operation time and reducing the amount of intraoperative blood loss. With a reduction in the number of cannulas, the surgical trauma of patients will be reduced in theory. However, considering the technical limitations of surgeons, when the number of cannulas is lower than a certain number, it may increase the operation time, EBL, postoperative complications, and other factors. From a single port to five ports, we adopted the three-port procedure as a compromise.

Table 6 Overview of the world literature on LRC

The main methods of urinary diversion after RC include orthotopic neobladder (ONB), ileal conduit (IC), and cutaneous ureterostomy (CU). Choosing a permanent urinary diversion method to reconstruct the lower urinary tract that can not only protect the function of the upper urinary tract but also improve the quality of life after surgery is the primary challenge associated with RC [32]. These three surgical methods are related to each other and each has their own advantages and disadvantages. The choice between these has been the focus of debate among doctors, patients, and even the entire urology department [33]. Houtmann et al. pointed out that these three procedures are most commonly used for ONB, followed by IC [34]. In ONB, we use the intestinal tract to create a new bladder and implant it into the body, which not only improves the quality of life of patients after surgery but also meets their psychological and aesthetic needs [35]. In view of this, for patients with better physical fitness or higher postoperative quality of life requirements, ONB is likely to be a more acceptable way to divert urine flow. Therefore, all patients selected in this study underwent ONB. All of them underwent standardized pelvic lymph node dissection and extracorporeal construction of Studer ONB. Moreover, our group will also conduct further research on more operative methods of three-port LRC in the near future.

A significant reduction in treatment costs (P = 0.035) was the only statistically significant measure in this study. The lower number of cannulas and lack of statistically significant differences in other metrics contributed to this result, which was not surprising. Bladder cancer has been reported to have the highest lifetime treatment cost among all malignancies [36]. Additionally, we often see that patients have doubts and concerns about the cost of treatment in clinical practice. Sometimes, they change the treatment method or even give up surgery. Therefore, the cost of treatment is not a negligible factor in treating bladder cancer and other malignant tumors. Many studies have shown that RARC is costly but superior to ORC in terms of complications and postoperative recovery [6,7,8,9,10]. In this case, for hospitals that do not have universal access to RARC and those that cannot afford the high cost, LRC is likely to be the most effective treatment, which is relatively a compromise as well. In LRC, the change from the five-port to the single-port approach means a reduction in the number of cannulas; however, the lack of surgical space and the limitations of the surgeon's skills may lead to poor outcomes. In this respect, the three-port LRC adopted by our research group is still in the middle position. Whether the effect brought by this "compromise" is at the middle point or the highest point of the statistical curve of all treatment methods is believed to be further reflected with the development and popularization of this surgical method.

With the development of biopsychosocial medical models, health-related quality of life (HRQOL) of patients with cancer has become a hot research topic in the field of medicine. Previous studies on RC have mainly focused on surgical methods and complications, but the postoperative quality of life has rarely been discussed. In recent studies, HRQOL has become an indispensable indicator for research on RC [37, 38]. Our research group counted the related indicators of HRQOL within one year after surgery. Here, the quality of life of patients decreased to the lowest level around one month after the operation and rose steadily in the following six months. Moreover, we observed that compared with the conventional five-port method, patients with three-port LRC showed a flat or even slightly higher quality of life. Although this difference was not significant, this result is substantial considering that our study was limited by the sample size and survey time. This suggests that the three-port approach is a reasonable alternative to the conventional five-port LRC.

This study has some shortcomings and deficiencies. First, the three-port LRC method is not widely used at present, which requires the surgeon to have rich experience in surgery and a high understanding of the relevant anatomy and operation. In some cases where it is difficult to fully expose the pelvic space, the three-port method may be inferior to the traditional five-port method, where an assistant can be arranged to assist in exposure and separation. Second, the three-port LRC procedure with other urinary diversion methods should be studied further. In addition, our sample size was inadequate and selection bias was possible. Surgical techniques, medical instruments, and perioperative management must be continuously improved. Finally, we did not have enough time to investigate the feasibility and reproducibility of this type of laparoscopic surgery before it was widely accepted. We still need a longer time and larger sample size data, as well as experience reports from other surgeons, to further confirm its feasibility and reproducibility.

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