Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India.
Stanley Medical College, Chennai, India.
Urol Oncol. 2025 Jan;43(1):61.e19-61.e28. doi: 10.1016/j.urolonc.2024.10.008. Epub 2024 Oct 24.
Radical cystectomy with urinary diversion is the gold standard treatment for bladder cancer (high-risk/muscle invasive). The transperitoneal approach is associated with significant gastrointestinal complications like ileus. In the elderly and frail with a single functional kidney, we describe an extraperitoneal technique of radical cystectomy, with a ureterostomy, to be performed without general anesthesia.
The elderly, frail, and high-risk candidates for general anesthesia, with a prior history of nephroureterectomy with a second primary muscle-invasive bladder cancer, were chosen. All patients underwent the described procedure under combined spinal and epidural anesthesia. The posterior dissection was retrograde, caudal to cranial, with the peritoneum being opened only for resection of the dome. A cutaneous ureterostomy was fashioned on the side of the functional kidney. Peri-operative parameters were assessed for early recovery in this high-risk group.
The mean age was 82 years (range: 73-91), with Charleson Comorbidity Index 5, and were all deemed unfit for neoadjuvant chemotherapy. With a median duration of 127.5 minutes, an average blood loss of 225ml, and no patient requiring general anesthesia; early ambulation, early return of bowel function, and a lesser hospital stay (7 days) with minimal morbidity were achieved. Negative surgical margins were achieved in all cases, with a mean harvest of 29 lymph nodes. Only 1 patient developed stomal stenosis. The cause-specific survival (CSS) is 100% at 2 years.
The highlighting features are the early return of bowel function (flatus passage on day 1) and the avoidance of the cardio-pulmonary complications of general anesthesia. The extraperitoneal cystectomy offers a promising alternative in this select group and warrants further studies to extrapolate this technique for bilateral urinary drainage.
根治性膀胱切除术伴尿流改道是膀胱癌（高危/肌层浸润性）的金标准治疗方法。经腹腔途径与肠麻痹等显著的胃肠道并发症相关。对于只有一个功能性肾脏的老年体弱患者，我们描述了一种经腹膜外根治性膀胱切除术和输尿管造口术的技术，可在不使用全身麻醉的情况下进行。
选择高龄、体弱、不能耐受全身麻醉且有既往肾输尿管切除术和第二原发肌层浸润性膀胱癌病史的高危候选者。所有患者均在脊髓和硬膜外联合麻醉下接受描述的手术。后向解剖为逆行，从尾到头，仅切开腹膜切除穹窿。在功能性肾脏一侧形成皮输尿管造口术。评估该高危组的围手术期参数以实现早期恢复。
平均年龄为 82 岁（范围：73-91 岁），Charlson 合并症指数为 5，均被认为不适合新辅助化疗。中位手术时间为 127.5 分钟，平均失血量为 225ml，无患者需要全身麻醉；实现了早期下床活动、早期恢复肠道功能以及较短的住院时间（7 天）和最小的发病率。所有病例均获得阴性切缘，平均淋巴结采集 29 个。仅 1 例发生吻合口狭窄。2 年时的癌症特异性生存率（CSS）为 100%。
突出的特点是肠道功能恢复早（第 1 天排气），避免了全身麻醉的心肺并发症。经腹膜外膀胱切除术为这一选择人群提供了一种有前途的替代方法，需要进一步研究来推断该技术用于双侧尿路引流。
