==inizio objective==
Urothelial cancer is the fourth most common malignancy in developed countries, affecting more frequently the urinary bladder and in only 5–10% of cases the upper urinary tract [1]. Furthermore, an association between these two cancers was found in the 17% of cases [2]. Open radical cystectomy is still considered the gold standard treatment for muscle-invasive or high risk and recurrent non-muscle-invasive bladder tumors, Bacillus Calmette-Guerin (BCG) refractory, relapsing and unresponsive T1G3 tumors [3, 4]. Open radical nephroureterectomy with bladder cuff excision is the standard treatment for high risk upper urinary tract cancer [5]. Simultaneous nephroureterectomy and radical cystectomy can be performed in patients affected by recurrent high grade or muscle-invasive bladder cancer and concomitant upper urinary tract cancer or non-functional kidney [6]. Several studies have shown the advantages of laparoscopic approach (compared with open techniques), especially when performed by experienced surgeons. These advantages include: fewer intraoperative and postoperative complications, decreased intraoperative blood loss, less need of analgesics, shorter hospital stay and earlier recovery [7–9], having at the same time functional and oncological results similar to those of open surgery [10, 11]. We report our experience with simultaneous laparoscopic radical cystectomy and nephroureterectomy in three patients.
==fine objective==
==inizio methodsresults==
Three male patient (aged between 65 and 75 years) affected by recurrent polyfocal high grade or muscle-invasive bladder cancer and an associated renal pathology (in one case right renal pelvis carcinoma of 16 mm in diameter on CT scan while in other cases while in the other two cases neoplastic involvement of the left distal ureter extending up to the middle tract, with concomitant hydronephrosis) underwent simultaneous radical cystectomy and nephroureterectomy performed by laparoscopic approach. According to the pre-operative imaging study, the two tumors were organ-confined. The Clavien–Dindo classification was used to evaluate post-operative complications. We performed laparoscopic transperitoneal approach, using the trocars arrangement shown in the figure. After positioning a catheter into the bladder, the patient was first placed in lateral (right or left) decubitus for the nephroureterectomy. After inducing pneumoperitoneum using a Verres needle, a 12-mm trocar (used as the camera port and indicated in the figure as ‘X’) was placed 2 cm laterally to the right or the left of the umbilicus (based on the kidney to be removed). The other two 12-mm trocars were placed in line, in the right or left pararectal area. During this surgical procedure the renal artery and the renal vein were identified, clamped with Hem-o-lock clips and sectioned between. A perifascial dissection of the kidney was performed, preserving the adrenal gland. For the next step of the surgery, radical cystectomy and bilateral pelvic lymph node dissection, the patient was positioned in dorsal decubitus, in a Trendelenburg position. The camera trocar was the same as for the right or left nephroureterectomy. Three other trocars (two 5- mm and one 12-m trocars) were placed in addition. The 12-mm trocar was placed, inferior to the umbilicus, in the left pararectal area whereas the two 5-mm trocars were placed in the left and right lower quadrant, proximal to the anterior–superior iliac spine. For bladder dissection, its vascular peduncles were secured with mechanical stapler and divided. In this way, the lateral plane was dissected, bilaterally. Finally, the urethra was divided distal from the prostatic apex using cold scissors. The pelvic lymphadenectomy was performed around the iliac vessels and obturatory fossa bilaterally. Two tubular drains were used, one in the right or left renal lodge and the other in the pelvic cavity. Urinary diversion as a unilateral ureterocutaneostomy was constructed by pulling the left or the right ureter through the hand port incision (specifically using the 12-mm trocar on the left or right side). The ureter was catheterized with a mono J stent. All specimens were placed in an endobag, removed through a midline incision and sent to the pathological examination. The operative field was inspected for bleeding or injury.
==fine methodsresults==
==inizio results==
Regarding perioperative data, we used six trocars and, in all three patients, the mean operative time was almost 4 hours, with blood loss (mL) less than 1000 mL. Regarding intraoperative data, in one patient the hospital stay (days) was 13 days but in two other patients it was less than 10 days. The surgical margins were free of tumor and the follow-up period was 16 months. As regards the pathological stages, one patient was affected by T1G3 bladder cancer while in two other cases the bladder tumor was infiltrated in the muscle (T2G3). In all patients the tumor of the upper urinary tract (affecting the renal pelvis in one patient while the ureter in the remaining cases) presented this pathological stage: T1G3. In all cases the pathological examination did not reveal any pelvic lymph nodes affected by neoplasia. After discharge, the patients returned to their normal activities without limitations after 3 weeks. More than a year after surgery, the patients are still alive, showing no tumor relapse of at the established instrumental controls.
==fine results==
==inizio discussions==
We successfully performed laparoscopic radical nephroureterectomy and cystectomy with pelvic lymph node dissection in a single-session, without the need for conversion to open surgery. According to literature data, minimally invasive surgery can minimize the complications and improve the recovery [7–9]. Performing a similar surgery with a laparoscopic approach is very demanding. To have oncological safety, intraoperatively, particular attention must be paid to avoid tumor leakage. In addition, the sample must be extracted en bloc immediately into an endobag, with the bladder neck closed to avoid contact of the urine with the abdominal cavity. Another important oncological aspect is the extent of lymphadenectomy. According to literature data, extended lymph node dissection during radical cystectomy is possible even when a minimally invasive approach is chosen [12]. We removed more than 20 lymph nodes in all three cases. Several studies showed that the oncological safety of a laparoscopic approach is similar to that of open surgery [10, 11]. Although an open surgery including nephroureterectomy and radical cystectomy involve one large midline incision with greater morbidity and longer convalescence, the laparoscopic approach implicates very small trocar incisions and an incision of ∼4–5 cm to remove the specimen. In effect, the specimen can be removed through a small lower midline incision, Pfannenstiel incision or transvaginally in female patients. We preferred a small midline incision for the specimen removal due to the lower risk of evisceration. According to small series, performing in a single session laparoscopic nephroureterectomy and cystectomy is feasible, with good oncological results and early recovery [7–9, 10, 11]. A large-scale prospective study will be necessary to provide more information on this surgery in the future.
==fine discussions==
==inizio conclusion==
In conclusion, the laparoscopic approach is widely spreading in urology and, in some cases, it has become a standard of care. In selected cases, performing in a single-session laparoscopic radical cystectomy and nephroureterectomy is oncologically safe and technically reproducible, offering oncological and functional results similar to those of open surgery. In addition, choosing a minimally invasive approach, the cosmetic results are better, also with faster post-operative recovery and lower bleeding rates.
==fine conclusion==
==inizio reference==
1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin 2016;66:7–30.
2. Cosentino M, Palou J, Gaya JM, Breda A, Rodriguez-Faba O, Villavicencio-Mavrich H. Upper urinary tract urothelial cell carcinoma: location as a predictive factor for concomitant bladder carcinoma. World J Urol 2013;31:141–5.
3. Stein JP, Lieskovsky G, Cote R, Groshen S, Feng AC, Boyd S, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol 2001;19:666–75.
4. World Health Organization (WHO) Consensus Conference on Bladder Cancer, Hautmann RE, Abol-Enein H, Hafez K, Haro I, Mansson W, et al. Urinary diversion. Urology 2007;69: 17–49.
5. Margulis V, Shariat SF, Matin SF, Kamat AM, Zigeuner R, Kikuchi E, et al. Outcomes of radical nephroureterectomy: a series from the upper tract urothelial carcinoma collabora- tion. Cancer 2009;115:1224–33.
6. Witjes JA, Compérat E, Cowan NC, De Santis M, Gakis G, Lebret T, et al. EAU guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2013 guidelines. Eur Urol 2014;65:778–92.
7. Tang K, Li H, Xia D, Hu Z, Zhuang Q, Liu J, et al. Laparoscopic versus open radical cystectomy in bladder cancer: a system- atic review and meta-analysis of comparative studies. PLoS One 2014;9:e95667.
8. Khan MS, Challacombe B, Elhage O, Rimington P, Coker B, Murphy D, et al. A dual-centre, cohort comparison of open, laparoscopic and robotic-assisted radical cystectomy. Int J Clin Pract 2012;66:656–62.
9. Veccia A, Antonelli A, Francavilla S, Simeone C, Guruli G, Zargar H, et al. Robotic versus other nephroureterectomy techniques: a systematic review and meta-analysis of over 87,000 cases. World J Urol 2020;38:845–52.
10. Rassweiler J, Godin K, Goezen AS, Kusche D, Chlosta P, Gaboardi F, et al. Radical cystectomy – pro laparoscopic. Urologe A 2012;51:671–8.
11. Liu F, Guo W, Zhou X, Ding Y, Ma Y, Hou Y, et al. Laparo- scopic versus open nephroureterectomy for upper urinary tract urothelial carcinoma: a systematic review and meta- analysis. Medicine (Baltimore) 2018;97:e11954.
12. Desai MM, Berger AK, Brandina RR, Zehnder P, Simmons M, Aron M, et al. Robotic and laparoscopic high extended pelvic lymph node dissection during radical cystectomy: technique and outcomes. Eur Urol 2012;61:350–5.
==fine reference==
