Extraperitoneal vs transperitoneal laparoscopic cystectomy: optimized surgical techniques and long-term outcomes in a single-center retrospective cohort study

Abstract

Objective

To evaluate and compare the long-term oncologic outcomes and perioperative performance of extraperitoneal laparoscopic radical cystectomy (ELRC) versus transperitoneal laparoscopic radical cystectomy (TLRC) in patients with bladder cancer (BC).

Patients and methods

This retrospective single-center cohort study included 298 BC patients who underwent ELRC (n = 202) or TLRC (n = 96) between January 2020 and January 2025. Primary endpoints included overall survival (OS), cancer-specific survival (CSS), progression-free survival (PFS), and recurrence-free survival (RFS). Secondary endpoints were operative time, estimated blood loss, gastrointestinal recovery, and perioperative complications. Kaplan–Meier survival analysis, Cox regression, and subgroup analysis were used to evaluate outcomes and risk factors.

Results

The mean follow-up was 25.6 months for ELRC and 30.7 months for TLRC. There were no significant differences in projected OS (HR = 0.89, P = 0.562), CSS (HR = 0.87, P = 0.492), PFS (HR = 1.09, P = 0.693), or RFS (HR = 1.16, P = 0.453) between the two groups. ELRC was associated with significantly shorter operative time, less blood loss, faster gastrointestinal recovery, and lower incidence of ileus and infections (all P < 0.05). Multivariable analysis identified pathological T stage and ASA score as independent predictors of OS. Subgroup analysis showed no significant impact of urinary diversion type or tumor stage on survival outcomes between the two approaches.

Conclusion

LRC may be a feasible alternative to TLRC, with potential advantages in perioperative recovery and reduced postoperative complications, while demonstrating comparable oncologic outcomes. Prospective multicenter studies with longer-term follow-up are warranted to confirm these findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-025-03966-0.

Introduction

Radical cystectomy (RC) remains the standard of care for muscle-invasive bladder cancer (MIBC) and select cases of high-risk non-muscle-invasive disease [1]. With advancements in surgical technology, RC has evolved from an open approach to minimally invasive techniques, notably laparoscopic radical cystectomy (LRC), which offer potential advantages in perioperative recovery and reduced morbidity [2].

Traditionally, urologists have preferred an extraperitoneal approach during open RC to minimize gastrointestinal complications [3]. However, most laparoscopic RCs have adopted the transperitoneal route due to its superior visualization and working space [4]. Despite these advantages, transperitoneal LRC (TLRC) is associated with higher risks of postoperative ileus, peritonitis, and complications related to intra-abdominal adhesions, especially in cases involving urinary diversion and neobladder leakage [5]. Enhanced Recovery After Surgery (ERAS) protocols, introduced in the late 1990 s [6] and adapted for RC in subsequent years, have significantly improved postoperative outcomes by promoting early mobilization, early oral intake, and multidisciplinary perioperative care [7]. Nevertheless, the anatomical challenges of TLRC, particularly gastrointestinal disturbances and urinary complications, continue to impact patient recovery and quality of life (QOL) [8]. To address these limitations, extraperitoneal laparoscopic radical cystectomy (ELRC) has been proposed [9]. By avoiding peritoneal entry, ELRC potentially reduces intestinal handling, minimizes bowel-related complications, and facilitates reoperation when needed. Despite these theoretical advantages, comparative data between ELRC and TLRC, particularly regarding long-term oncologic outcomes and perioperative performance, remain limited.

Therefore, this study aimed to compare ELRC and TLRC in terms of oncologic efficacy and perioperative outcomes in patients undergoing RC for bladder cancer. We hypothesized that ELRC would achieve comparable long-term survival outcomes while improving perioperative recovery and reducing complication rates.

Patients and methods

Study design

This study was a single-center retrospective cohort analysis involving bladder cancer (BC) patients who underwent either ELRC or TLRC procedures. Data were collected from the Department of Urology, the Affiliated Hospital of Qingdao University, from January 2020 to January 2025. The study protocol was approved by the Ethics Committee of the Affiliated Hospital of Qingdao University (approval number: QYFYEC2023-67) and was registered with the “Chinese Clinical Trial Registration and Information System” (registration number: MR-37-23-039856). All participants provided informed consent in compliance with the Declaration of Helsinki.

Patient population

Total 298 BC patients, aged between 18 and 85 years, were enrolled in this study. Among these patients, 202 (67.79%) underwent ELRC, while 96 (32.21%) underwent TLRC. Patients were stratified according to the 2023 updated European Association of Urology (EAU) guidelines. A definitive pathological diagnosis was obtained for all patients before opting for radical cystectomy. Preoperative evaluations included enhanced computed tomography (CT) urography, chest CT, and abdominal ultrasonography to detect nodules or distant metastases. Magnetic resonance imaging (MRI) or 18 F-FDG PET/CT was employed when CT results were inconclusive. The decision to perform ELRC or TLRC was made based on a combination of surgeon preference, patient anatomy, and clinical characteristics. Patients with no history of major intra-abdominal surgery, lower BMI (< 40 kg/m²), and organ-confined disease without bulky pelvic lymphadenopathy were considered suitable candidates for ELRC. TLRC was preferred in cases where complex pelvic anatomy was present. Additionally, during the early study period, TLRC was more commonly used due to the limited availability of standardized extraperitoneal instrumentation and training.

Inclusion criteria were as follows: (1) Age between 18 and 85 years, irrespective of sex, with an expected life expectancy of at least 24 months; (2) Informed consent was waived due to the retrospective design, but patients were informed of data usage according to institutional policy; (3) American Society of Anesthesiologists (ASA) classification I–IV; (4) Clinical diagnosis of BC confirmed by imaging and pathology; (5) No significant abnormalities in vital organs such as liver, kidney, bone marrow, and heart, indicated by laboratory parameters including aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤ 2.5 upper limit of normal (ULN), albumin ≥ 25 g/L, serum creatinine ≤ 1.5 ULN, white blood cells ≥ 3.5 × 10^9/L, neutrophils ≥ 1.5 × 10^9/L, hemoglobin ≥ 90 g/L, platelets ≥ 80 × 10^9/L, and electrocardiogram without significant clinical abnormalities.

Exclusion criteria included: (1) History of major abdominal surgery or chronic bowel disease; (2) Body mass index (BMI) > 40 kg/m²; (3) Severe cardiovascular disease; (4) Immunodeficiency or history of organ transplantation; (5) History of severe central nervous system (CNS) disorders; (6) Concurrent urological diseases that contraindicate radical cystectomy; (7) Pregnancy or lactation; (8) Uncontrolled epilepsy, CNS disorders, or psychiatric disorders; (9) History of cerebral infarction or hemorrhage within the past six months; (10) Severe recurrent uncontrolled infections or other severe uncontrolled comorbidities.

Exclusion criteria during the study period were as follows: (1) Significant missing primary data; (2) Poor compliance, defined as failure to adhere to planned follow-ups or missing more than two follow-ups; (3) Participants deemed unsuitable for continuing the study due to adverse events, as judged by the investigator; (4) Participants or their legal representatives voluntarily requesting withdrawal from the study or discontinuation of treatment at any stage; (5) Sudden preoperative onset of severe comorbidities, making the patient unsuitable or unable to undergo the planned surgical procedure; (6) Changes in patient conditions necessitating emergency rather than elective surgery, confirmed by the attending physician; (7) Receipt of treatment deviating from the study protocol.

Preoperative management

For patients with ileal conduit and ileal orthotopic neobladder (ION), bowel preparation was needed. Oral antibiotic was used for 3 days before operation. Liquid diet was administered for 2 days before operation. Oral laxative was performed for 1 day prior to surgery. Stable blood pressure and blood glucose < 10mmol/L were required. Under ERAS, high energy drinks were recommended for 4 h before operation (exclude diabetes). Antibiotic prophylaxis was administered intravenously 30 min before surgery. Bowel preparation was performed only for patients undergoing ileal orthotopic neobladder or ileal conduit. Patients receiving cutaneous ureterostomy did not undergo bowel preparation, as the procedure does not involve bowel manipulation. All patients were managed using an ERAS protocol developed in accordance with international guidelines, including the ERAS Society recommendations for urologic surgery. Key components included early ambulation, early enteral nutrition, multimodal analgesia, and avoidance of nasogastric tubes and prolonged drainage.

Surgical technique

Building on prior foundational work and incorporating insights from both domestic and international literature and guidelines, our team continuously refined and optimized the surgical approach. A standardized protocol for ELRC was established, allowing for systematic comparison. The key procedural steps were defined as follows: (1) Expansion of the extraperitoneal space; (2) Expansion of the iliac fossa; (3) Mobilization of the spermatic cord; (4) Transection of the spermatic cord; (5) Transection of the umbilical artery; (6) Dissection and transection of the ureter; (7) Dissecting the peritoneum along the vas deferens; (8) Dissecting the opposite side; (9) Converging posterior to the prostate; (10) Dissecting the peritoneum along the posterior aspect of the bladder; (11) Transection of the dorsal vein complex (DVC); (12) Transection of the urethra; (13) Pelvic lymphadenectomy; and (14) Urinary diversion. A 2–3 cm infraumbilical midline incision was made to create an extraperitoneal working space using blunt finger dissection and a balloon dilator. A total of five trocars were placed in a fan-shaped distribution: 10 mm camera port infraumbilically. Two 12 mm working ports at the bilateral lower quadrants (midclavicular line, ~ 2 cm below the umbilicus). Two 5 mm assistant ports lateral to the rectus margin. Meticulous dissection was carried out to preserve the integrity of the peritoneum, especially in step 3, 7 and 8. After bladder excision and lymphadenectomy, a transperitoneal approach was utilized to facilitate urinary diversion for an ileal neobladder or an ileal conduit by opening the peritoneum under direct visualization.

Intraoperatively, careful attention was given to preserving the integrity of the peritoneum, thereby maintaining optimal visibility within the operative field. Following confirmation of hemostasis, surgical specimens were extracted via a lower midline abdominal incision. A detailed animated representation of the full procedure is provided in Supplementary video and Supplementary video 2.

The TLRC technique employed in this study was consistent with approaches previously reported in the literatures[10, 11]. After establishing pneumoperitoneum via a periumbilical 10 mm port, four additional ports were inserted under direct vision. The peritoneal cavity was entered, and the sigmoid colon was mobilized to access the left ureter. The bladder and surrounding structures were dissected intraperitoneally. The peritoneum was routinely opened, and pelvic lymphadenectomy was performed. Urinary diversion was performed via the transperitoneal approach. All surgeries were performed by two senior urologic surgeons with more than 10 years of experience in laparoscopic radical cystectomy. To reduce potential variability and learning curve bias, both surgeons received structured training and jointly developed a standardized protocol before implementing the ELRC technique in clinical practice. Initially, TLRC was the standard approach, but as surgical proficiency and confidence with ELRC increased, the surgical team transitioned to ELRC as the preferred method. Both ELRC and TLRC procedures were distributed evenly between the two surgeons. All patients received perioperative care in accordance with standardized ERAS protocols.

Postoperative management

After operation, parenteral nutrition was generally administered for the first 3 day. A small amount of water was allowed by oral intake at 24 h after surgery, which could improve intestinal function. Somatostatin was just used for one time after operation, if no ileus. Antibiotic prophylaxis was administered for 5 days after surgery. Cough, pounding back and blowing balloons were used for improving pulmonary function and nebulization was administered if necessary. Removal time of drains and catheter were illuminated in Fig. 1. Wound and drains should be kept clean and sterilized according to the need. Intraperitoneal drain would be removed from 4 to 7 days after operation. Extraperitoneal drains would be removed from 10 to 14 days after surgery (less than drainage fluid 30 ml per day for 3 days). 8. As for ION patients, Single-J stents would be removed for 1 month after surgery. The catheter was removed for 1week after single-J stents removal. As for ileal conduit patients, single-J stents would be removed for 1 month after surgery. For cutaneous ureterostomy patients, single-J stents would be replaced every 3–6 months.

Fig. 1.

The position of drains and catheter after ELRC. 1 was the intraperitoneal drain, which should be removed for 5–7 day after operation. 2 were bilateral extraperitoneal negative pressure drains. One-sided negative pressure drain was removed first for 10 days after operation. Then the other side drain was removed another 3 days. 3 were single-J stents that was removed for 1 month after surgery. 4 was a catheter that was removed for 1 week after single-J stents removal. Drains were removed on condition of less than 30 ml drainage fluid per day for 3 days

Follow‑up and outcome

Follow-up was conducted every three months during the first two years after surgery and included computer tomography (CT) scan, physical examination, vital signs monitoring, routine blood and urine tests, and a standardized questionnaire for adverse events. CT urography (CTU) was repeated every six months. After two years, low-risk patients underwent annual CTU follow-up, while high-risk patients continued biannual CTU surveillance. This protocol was based on internal institutional policy rather than strict adherence to EAU or AUA guidelines. The primary endpoint of this study was overall survival (OS). Secondary endpoints included progression-free survival (PFS), cancer-specific survival (CSS), recurrence-free survival (RFS), and perioperative outcomes. Recurrence was defined as either local (within the surgical field) or distant. Disease progression was defined as lymph node involvement or distant metastasis. Urinary continence was evaluated at 1, 3, 6, and 12 months after surgery. Urinary continence outcomes were assessed only in patients undergoing ileal orthotopic neobladder reconstruction. Daytime continence was defined as the use of 0–1 pad per day. Nighttime continence was defined as ≤ 1 pad per night with no involuntary leakage during sleep. Continence status was determined through outpatient visits or structured telephone interviews using standardized follow-up questionnaires at 3, 6, and 12 months postoperatively. The assessment focused on patients who underwent ileal orthotopic neobladder reconstruction. Treatment-emergent adverse events (TEAEs) and serious adverse events (SAEs) were documented and evaluated both during hospitalization and follow-up using the Clavien-Dindo classification system [12]. Complications were graded according to the Clavien–Dindo classification system, with major complications defined as Grade III or above.

Statistical analysis

The statistical analysis was conducted utilizing R version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria) along with GraphPad Prism (GraphPad Software, San Diego, CA, USA). Continuous variable results were summarized either as means (with standard deviations [SD]) or medians (along with interquartile ranges [IQR]), based on the normality of the data evaluated through the Shapiro-Wilk test. Normally distributed data were compared using Student’s t-test; otherwise, the Mann–Whitney U test was employed. Categorical variables were compared using the χ² test or Fisher’s exact test, as appropriate. Kaplan-Meier analysis was utilized to estimate survival rates, while the log-rank test assessed differences between patient groups. The Cox proportional hazards regression model was employed to calculate hazard ratios (HR) and 95% confidence intervals (95% CIs) as well as for both uni- and multivariate survival analyses, adjusting for potential confounders including age, sex, ASA score, pathological T stage, urinary diversion type, and follow-up time. All statistical tests were two-sided, with a significance threshold set at P < 0.05.

Result

The demographic characteristics of the patients are summarized in Table 1. A total of 310 patients were initially reviewed. After applying the inclusion and exclusion criteria, 12 patients were excluded, including 6 patients with incomplete or missing clinical data, and 6 patients lost to follow-up within the first 3 months, thus considered non-compliant with postoperative surveillance. The final cohort consisted of 298 patients. Of these, 202 patients (67.79%) underwent the ELRC, while 96 patients (32.21%) underwent the TLRC. The ELRC group included 174 males and 28 females, with a mean age of 68.69 ± 10.23 years and a mean BMI of 23.67 ± 3.60. In comparison, the TLRC group comprised 82 males and 14 females, with a mean age of 66.28 ± 10.83 years and a mean BMI of 23.15 ± 2.80. The mean ASA scores are also listed in Table 1. Among ELRC patients, the prevalence of hypertension, diabetes, and cardiovascular disease was 25.25%, 12.87%, and 11.88%, respectively; these rates were 29.17%, 15.50%, and 10.42%, respectively, in the TLRC group. Clinical T-stage data are also provided in Table 1. Statistical analysis revealed no significant differences in baseline demographic variables between the two groups.

Table 1.

Demographic characteristics

	Total	ELRC	TLRC	P value
n, (%)	298	202(67.79%)	96(32.21%)
Sex				0.867
Male, n (%)	256	174 (86.14%)	82 (85.42%)
Female, n (%)	42	28 (13.86%)	14 (14.58%)
Age(yr)		68.69 ± 10.23	66.28 ± 10.83	0.121
BMI(Kg/m2)		23.67 ± 3.60	23.15 ± 2.80	0.170
ASA, n (%)				0.068
1	2	0	2 (2.08%)
2	58	43 (21.29%)	15 (15.63%)
3	238	159 (78.71%)	79 (82.29%)
4	0	0	0
Hypertension, n (%)	79	51 (25.25%)	28 (29.17%)	0.474
Diabetes, n (%)	38	26 (12.87%)	12 (15.50%)	0.928
Cardiac disease, n (%)	34	24 (11.88%)	10 (10.42%)	0.710
Clinical stage, n (%)				0.321
cTis	8	5 (2.48%)	3 (3.13%)
cT1	40	31 (15.35%)	9 (9.38%)
cT2	162	113 (55.94%)	49 (51.04%)
cT3	58	36 (17.82%)	22 (22.92%)
cT4	30	17 (8.42%)	13 (13.54%)

Data reported as mean ± standard deviation

P < 0.05 indicates statistical significance

BMI Body mass index, ASA American society of anesthesiologists, ELRC Extraperitoneal laparoscopic radical cystectomy, TLRC Transperitoneal laparoscopic radical cystectomy

Perioperative outcomes are detailed in Table 2. The mean follow-up duration was 25.59 ± 16.47 months for the ELRC group and 30.70 ± 20.71 months for the TLRC group. ELRC demonstrated statistically significant advantages in operative time, estimated blood loss, number of lymph nodes retrieved, time to postoperative oral intake, and total cost. However, there was no significant difference in the length of hospital stay between the two groups—an outcome that differed from our expectations. We hypothesize that this may be attributed to variations in urinary diversion methods. Subgroup analysis stratified by urinary diversion type showed in Supplementary Table S3-S5. As illustrated in Fig. 2B, the ELRC group included a higher proportion of patients who underwent ION reconstruction, a procedure known to extend hospitalization compared to cutaneous ureterostomy. Furthermore, there were no significant differences between the ELRC and TLRC groups in postoperative hemoglobin levels, serum albumin levels, or overall cost, indicating comparable outcomes in these clinical parameters.

Table 2.

Perioperative data

	ELRC	TLRC	P value
Operative time (min)	212.80 ± 64.55	248.92 ± 47.43	< 0.001
Estimated blood loss (mL)	139.36 ± 84.85	193.02 ± 68.49	< 0.001
Hemoglobin (g/L)	107.82 ± 17.25	108.26 ± 19.98	0.696
Albumin (g/L)	30.08 ± 3.24	29.94 ± 2.80	0.723
Lymph nodes (n)	14.00 ± 6.12	11.89 ± 5.57	< 0.001
Positive lymph nodes (n)	28 (9.4%)	20 (6.7%)	0.126
No. of positive margins (n)	2 (0.99%)	1 (1.04%)	-
No. of blood transfusions (n)	8 (3.96%)	8 (8.33%)	-
Time to PO intake (h)	55.42 ± 66.56	56.66 ± 19.01	< 0.001
Hospital stay (d)	16.92 ± 8.09	15.71 ± 5.70	0.824
Cost (US dollar)	2974.85 ± 1401.79	3058.77 ± 1437.89	0.746
Follow-up (mo)	25.59 ± 16.47	30.70 ± 20.71	0.085

Data reported as mean ± standard deviation

P < 0.05 indicates statistical significance

ELRC Extraperitoneal laparoscopic radical cystectomy, TLRC transperitoneal laparoscopic radical cystectomy

Fig. 2.

A Forest plots displaying subgroup analyses of overall survival based on pathological stage and urinary diversion in the ELRC and TLRC group. B Kaplan–Meier survival curves showing subgroup analysis for overall survival of patients who underwent cutaneous ureterostomy or ileal orthotopic neobladder in the ELRC and TLRC group. ELRC= extraperitoneal laparoscopic radical cystectomy. TLRC = transperitoneal laparoscopic radical cystectomy. HR = hazard ratio. 95%CI = 95% confidence intervals. P < 0.05 indicates statistical significance

Postoperative pathological findings and complication data are summarized in Table 3. In the ELRC group, 16 patients were diagnosed with carcinoma in situ (Tis), and 31 were staged as Ta–T1. Additionally, 103 patients had T2, 35 had T3, and 17 had T4. A total of five patients in this group were found to have concurrent prostate cancer. In the TLRC group, six patients had Tis, nine had Ta–T1, 47 were classified as T2, 21 as T3, and 13 as T4. Similarly, five patients were diagnosed with coexisting prostate cancer. No statistically significant differences were observed between the two groups in terms of postoperative pathological staging.

Table 3.

Oncological parameters and complications

	Total	ELRC	TLRC	P value
T stage, n(%)				0.462
Tis	22	16 (7.92%)	6 (6.25%)
Ta-T1	40	31 (15.35%)	9 (9.38%)
T2	150	103 (50.99%)	47 (48.96%)
T3	56	35 (17.33%)	21 (21.88%)
T4	30	17 (8.42%)	13 (13.54%)
Prostate cancer	10	5 (1.7%)	5 (1.7%)
Clavien-Dindo class, n(%)				0.306
1	167	111(54.95%)	56(58.3%)
2	28	22(10.89%)	6(6.25%)
3	4	4(1.98%)	0(0%)
4–5	8	5(2.18%)	3(3.13%)
Perioperative complications
Infection	33	12 (5.94%)	21 (21.88%)	< 0.001
Ileus	65	31 (15.35%))	34 (35.42%)	< 0.001
Ureteral leak	26	16 (7.92%)	10 (10.42%)	0.476
Ureteral stricture	9	8 (3.96%)	1 (1.04%)	0.311
Intestinal fistula	31	18 (8.91%)	13 (13.54%)	0.221
Lymphatic fistula	10	7 (3.47%)	3 (3.13%)	-

- = no statistically significant values

P < 0.05 indicates statistical significance

ELRC Extraperitoneal laparoscopic radical cystectomy, TLRC Transperitoneal laparoscopic radical cystectomy

Complications were categorized using the Clavien-Dindo classification system. As illustrated in Table 3, postoperative ileus was the most common perioperative complication in the ELRC group; however, its incidence remained significantly lower compared to the TLRC group (P < 0.001). In contrast, perioperative infections were the most frequently observed complication in the TLRC group and occurred at a significantly higher rate than in the ELRC group (P < 0.001). In the multivariable analysis (table S6), ELRC showed a significant advantage in reducing the incidence of infection, ileus, and intestinal fistula. Despite these specific differences, the overall incidence of perioperative complications between the two surgical approaches did not differ significantly (P = 0.306). Most complications resolved within 30 days after surgery.

Urinary continence outcomes during the first postoperative year are presented in Table S1. ELRC patients demonstrated a statistically significant advantage in daytime continence at the 3-month follow-up compared to those in the TLRC group. However, this benefit diminished over time, and by one year postoperatively, the majority of patients in both groups had achieved satisfactory daytime continence—98.51% in the ELRC group and 95.00% in the TLRC group. These findings suggest that both surgical approaches yield comparable long-term continence outcomes for patients undergoing ION, with no statistically significant differences observed.

To comprehensively compare long-term postoperative outcomes between the two groups, Kaplan–Meier survival analyses were conducted for OS, CSS, PFS, and RFS. As shown in Fig. 3, no statistically significant difference in OS was observed between the ELRC and TLRC groups (HR = 0.89, 95% CI: 0.61–1.31, P = 0.562). Similarly, projected CSS did not significantly differ between the ELRC and TLRC cohorts (HR = 0.87, 95% CI: 0.59–1.29, P = 0.492). Projected PFS also showed no significant variation (HR = 1.09, 95% CI: 0.72–1.65, P = 0.693), and projected RFS results between the two groups were likewise statistically comparable (HR = 1.16, 95% CI: 0.79–1.70, P = 0.453). Based on data, the projected mean OS, CSS and RFS in the ELRC group were 54.9%, 52.7%, and 52.5%, respectively. In comparison, the TLRC group showed projected mean OS, CSS, and RFS rates of 50.9%, 50.9%, and 44.4%, respectively. Due to an insufficient follow-up period for PFS, a 3-year comparison was conducted instead, revealing PFS of 57.2% in the ELRC group and 45.2% in the TLRC group, however, the difference was not statistically significant (P = 0.692). The median follow-up duration was 25.6 months in the ELRC group and 30.7 months in the TLRC group. A total of 84 deaths and 28 recurrences were recorded in the ELRC group, compared with 39 deaths and 54 recurrences in the TLRC group. Overall, these findings indicate that the two surgical approaches yield similar long-term survival and recurrence outcomes.

Fig. 3 .

Kaplan–Meier survival curves for overall survival, cancer-specific survival, progression-free survival, and recurrence-free survival in the ELRC and TLRC groups. ELRC = extraperitoneal laparoscopic radical cystectomy. TLRC = transperitoneal laparoscopic radical cystectomy. HR = hazard ratio. The values in parentheses represent the 95% confidence intervals. P < 0.05 indicates statistical significance

Subgroup analyses were conducted to assess the effect of pathological stage and urinary diversion type on projected OS in the ELRC and TLRC groups. As shown in Fig. 2A, the forest plot indicates that patients with Tis stage disease in the TLRC group were more likely to experience death, while those with T1–T3 stages in the ELRC group demonstrated a potential trend toward higher mortality. However, these trends did not reach statistical significance. Moreover, the wide CI observed for T1 and T3 subgroups—attributable to the imbalance in sample sizes between groups—highlight the need for larger sample cohorts in future studies to validate these findings. Due to the limited number of patients undergoing ileal conduit in the TLRC group, subgroup analysis (Fig. 2B) was only performed for those who received cutaneous ureterostomy or ION. The results indicated that within the same urinary diversion, the type of surgical approach (ELRC vs. TLRC) had no significant impact on OS.

Following the EAU guidelines, univariate and multivariate Cox regression analyses were conducted to identify confounding variables associated with OS, including sex, age, pathological T stage, tumor grade, ASA score, Clavien-Dindo classification, lymph node status, lymphovascular invasion (LVI), and variant histologies. As shown in Table S2, tumor T stage emerged as the most significant predictor of OS in the ELRC group, with a univariate HR of 0.52 (95% CI: 0.33–0.83, P < 0.01) and a multivariate HR of 0.49 (95% CI: 0.31–0.79, P < 0.01). Additionally, an ASA score greater than 2 was also identified as an independent risk factor for poorer OS in the ELRC group (HR = 2.21, 95% CI: 1.03–3.71, P = 0.04). In the TLRC group, ASA > 2 was likewise a significant predictor of overall survival, with univariate analysis yielding an HR of 0.52 (95% CI: 0.05–0.88, P = 0.03), and multivariate analysis confirming the association (HR = 0.18, 95% CI: 0.04–0.81, P = 0.03). After incorporating lymph node status, LVI, and variant histology into the univariable and multivariable analysis, LVI (P < 0.01) were identified as independent predictors of OS.

Discussion

With increasing emphasis on QOL among patients undergoing RC, urologists are actively exploring alternative surgical approaches. This study aimed to evaluate the long-term oncologic outcomes and perioperative performance of ELRC compared with TLRC in a large, single-center cohort. Our results demonstrate that ELRC is associated with significantly improved perioperative outcomes—shorter operative time, reduced intraoperative blood loss, faster gastrointestinal recovery, and lower rates of postoperative ileus and infection—while providing oncologic outcomes comparable to those of TLRC. The findings suggest that avoiding peritoneal violation during ELRC may lead to less bowel manipulation, which could explain the reduced incidence of postoperative ileus and faster return of gastrointestinal function. These observations are in line with the theoretical benefits of preserving peritoneal integrity, which minimizes intra-abdominal inflammation and adhesion formation. Importantly, the reduced complication rate did not compromise the oncologic efficacy of the procedure. Despite these advantages, some confounding factors must be acknowledged. The ELRC group had a significantly larger sample size and different distribution of urinary diversions, which could influence perioperative metrics such as recovery time and length of stay. Although multivariable analyses were conducted to control for confounders, future studies with more balanced cohorts or propensity score matching would better validate these findings. Survival outcomes showed no significant differences between ELRC and TLRC groups. However, the median follow-up time limits the robustness of long-term oncologic conclusions. The reported survival rates are projections based on early follow-up data, which must be interpreted with caution. Additional follow-up is necessary to confirm the durability of these outcomes. ELRC did not compromise functional outcomes in patients receiving orthotopic neobladder. The continence rates at one year were similar between ELRC and TLRC groups and aligned with prior data [13]. Although not the primary endpoint of this study, these functional outcomes further support the feasibility of ELRC as a minimally invasive alternative to TLRC.

The perioperative management and complications treatment of radical cystectomy, as the most complicated operation in urology, usually perplexed and alarmed surgeons [14]. Infection was the most common complication. The first objective is to fig. out the source of infection. Hypouresis was a key indicator for infection after TLRC, which was due to stents or catheter blockage. Single-J stents irrigation or replacement was recommended, if urine volume decreased. Certainly, bladder irrigation should be performed every day for ION patients. Anemia and hypoproteinemia were other common complications after TLRC, which decreased patients’ recovery evidently [15]. The clinical manifestation was edema of scrotum for men or malaise and sweat for women. Mind anemia and hypoproteinemia were treated by diet guide and oral protein powder. As for severe anemia and hypoproteinemia, blood and serum albumin transfusion were a preferred option. Pelvic lymphocele, which was frequently reported in previous study [16], was practically solved by placing bilateral negative pressure drains. Leakage of urine usually resulted in abdominal infection or peritonitis for RC patients [17]. As for ELRC patients, mild leakage of urine was not needed for intervention, because urine was restricted in extraperitoneal space. Severe leakage of urine (> 800 ml per day last for 1 week) was needed a reoperation. Formerly, Komyakov BK et al. explored to extend defects of the ureter with the appendix [18]. Even though ELRC decreased the rate of ileus, patients without exhaust and defecation for 3 days after surgery should be given enough attention. Although the rate of major complications was low in our cohort, the median length of hospital stay (LOS) was longer than expected for a minimally invasive approach. This discrepancy is likely attributable to institutional and national healthcare practices in China, where extended hospitalization is often preferred due to sociocultural expectations and logistical considerations.

Incontinence is a complication that greatly affected the QOL of ELRC and ION patients. Previous studies[19, 20] showed that daily continence was 80–90% and night continence was 60–80% by LRC. In our center, benefiting from ELRC, daily continence was 95% and night continence was 80%, residual urine was 50 ml at the 6th month after surgery. Recurrence is a potential threat for all RC patients. Some researchers [21] showed there were 18% patients with cancer recurrence following robot-assisted RC within 90 days after surgery. In other study, 31% patients suffered disease recurrence at a median follow-up of 46 months [22]. During the follow-up period, the number of recurrence events was limited, and no statistically significant difference in RFS was observed between groups, as shown in the Kaplan–Meier analysis. In addition to traditional oncologic and perioperative outcomes, a recent study has proposed composite endpoints such as the Trifecta and Pentafecta to more comprehensively assess the quality of radical cystectomy [23]. Trifecta typically includes negative surgical margins, absence of major complications (Clavien–Dindo grade ≥ III), and absence of recurrence within 12 months. Pentafecta expands this by adding 90-day mortality and adequate lymph node yield. While our current study did not prospectively define these composite endpoints, a post hoc evaluation revealed that a higher proportion of ELRC patients achieved all Trifecta components compared to the TLRC group. Similarly, Pentafecta outcomes, though limited by incomplete lymph node data in some cases, appeared more favorable in the ELRC cohort. This trend reinforces the notion that ELRC may offer superior perioperative safety and technical completeness without compromising oncologic control.

ELRC and ION was not recommended for patients without self-care or poor living environment [24]. Neobladder fistula, severe infection and urinary tract obstruction were resulted from inappropriate postoperative care. Renal failure due to chronic hydronephrosis after ELRC and ION was a bothering problem, which would be improved by an intermittent self-catheterization. The narrow extraperitoneal space contributed to a high bladder pressure that would deteriorate renal failure. Positive surgical margin rates are low compared to other previous studies [7]. Several factors may explain the low incidence of positive surgical margin in our cohort: (1) A substantial proportion of our patients had non–muscle-invasive or organ-confined tumors (Tis–T2), which generally carry a lower risk of margin positivity; (2) All operations were performed by experienced, high-volume urologic oncologists familiar with radical pelvic surgery, which may contribute to more precise dissection and en bloc removal; (3) In every case, intraoperative frozen sections of the urethral and ureteral margins were routinely performed and reviewed by dedicated pathologists. Any suspicious or positive margins led to further resection until negative margins were confirmed. This routine intraoperative margin evaluation likely played a crucial role in minimizing positive surgical margin; and (4) Our institution employs a standardized and meticulous protocol for margin evaluation, both grossly and microscopically, which may help ensure accurate identification of residual disease.

We made a “U-type” pouch by linear cutters, of which the advantages are short time, accurate anastomosis, and low incidence of urine leakage [5]. But clips of linear cutter would accidentally expose in neobladder, which was prone to lead to stone. The rate of neobladder stone was 4.94% in our report, and in other study the stone rate was 9.2% [25]. 2 out of 20 ION patients suffered stone, in which the neobladder was made by 3–0 V-loc anastomotic sutures [26]. So, whether used linear cutter was depended on surgeons’ experiences. Chronic hydronephrosis was another late complication of ELRC and ION, which resulted in irreversible kidney injury. The reason of hydronephrosis was ureteric anastomotic stricture.

Analgesics for postoperative ELRC patients was very meaningful in clinic [27]. Improper pain management would cause unacceptable results. Patients resisted early ambulation due to fierce pain, which decreased the recovery of gastroenteric function and caused deep venous thrombosis. Meanwhile, patients expended more energy under a pain state, most of which originally contributed to wound healing. Patient-controlled analgesia was reported to an effective option for RC patients [28]. In our center, intravenous non-steroidal anti-inflammatory drugs were used to RC patients for 3–5 days after RC. Somatostatin Analogs was used for reducing mucus production in ION patients [29]. However, the dose and using time was still not reach a consensus. We explored to abandon somatostatin analogs after ELRC and ION, but it did not bring a satisfying consequence. Some patients developed ileus in a short time. We found most patients exhausted on the second day after ELRC by ERAS management, and then stop somatostatin analogs might be a good choice, which decreased ileus and did not affect intestinal function recovery.

This study did have some defects. First, as a retrospective analysis, it may be subject to selection bias, and the findings should be interpreted with caution until validated by prospective studies. Second, due to the retrospective design, data collection on urinary function was incomplete, potentially leading to gaps in key outcome measures. One limitation of this study is the follow-up protocol, which involved frequent CT urography in the first 2 years. Although this was part of our institutional practice for enhanced surveillance, it does not fully align with current international guidelines and may affect the generalizability of our results. Although Kaplan–Meier analysis was used to estimate survival outcomes over a 5-year period, our actual follow-up duration was limited to a maximum of five years, with a median closer to 25–30 months. Although the 3-year PFS was numerically higher in the ELRC group, the lack of statistical significance and the limited number of oncologic events suggest that the study may be underpowered to detect subtle differences. Therefore, the conclusion of ‘comparable oncologic outcomes’ should be viewed as preliminary and interpreted with appropriate caution. And the relatively low number of oncologic events in both groups reduces the statistical power of our survival analyses and limits the strength of conclusions regarding long-term outcomes. Longer-term follow-up and larger sample sizes are needed to confirm these findings. Notably, there were imbalances in group size and urinary diversion distribution between the ELRC and TLRC cohorts, with more patients undergoing ileal orthotopic neobladder in the ELRC group and more ileal conduit procedures in the TLRC group. These differences may have influenced perioperative outcomes such as gastrointestinal recovery and hospital stay. Although subgroup analyses were performed to mitigate this bias, we acknowledge that these imbalances limit the strength of direct comparisons. Future studies with propensity score matching or randomized controlled designs are warranted to validate our findings under more controlled conditions. Another potential limitation is the influence of the surgical learning curve. Although all procedures were conducted by experienced laparoscopic surgeons, the transition from TLRC to ELRC occurred over the study period, introducing a possible temporal bias. We acknowledge that improvements in operative metrics may partially reflect growing familiarity with the extraperitoneal technique rather than an inherent procedural advantage.

Conclusion

This study indicates that ELRC may represent a feasible alternative to TLRC, potentially offering improved perioperative recovery and a lower incidence of postoperative complications, without compromising oncologic efficacy. Nevertheless, the relatively small number of oncologic events and the limited follow-up duration necessitate cautious interpretation of these findings, which warrant validation through larger-scale, prospective investigations with extended follow-up periods.

Abbreviations

ASA

American society of anesthesiologists

BC

Bladder cancer

CSS

Cancer-specific survival

CTU

Computed tomography urography

DVC

Dorsal vein complex

EAU

European association of urology

ELRC

Extraperitoneal laparoscopic radical cystectomy

ERAS

Enhanced recovery after surgery

ION

Ileal orthotopic neobladder

MRI

Magnetic resonance imaging

OS

Overall survival

PFS

Progression-free survival

PET/CT

Positron emission tomography / computed tomography

QOL

Quality of life

RC

Radical cystectomy

RFS

Recurrence-free survival

SAEs

Serious adverse events

TEAEs

Treatment-emergent adverse events

TLRC

Transperitoneal laparoscopic radical cystectomy

Authors’ contributions

Conception and design: Guanqun Zhu, Ke Wang. Surgery: Ke Wang, Xiaokun Yang. Data acquisition: Yuxuan He, Shicheng Wang, Rui Zhang, Zaiqing Jiang, Guoyi Jiang. Data analysis and interpretation: Jiao Huang, Rui Zhang, Zongliang Zhang, Kai Zhao, Xinbao Yin, Woong Jin Bae. Drafting the manuscript: Guanqun Zhu, Jiao Huang. Critically revised the manuscript for intellectual content: Ke Wang, Woong Jin Bae. Supervision: Ke Wang. All authors have readed and approved the final manuscript.

Funding

This research was supported by a grant of the National Natural Science Foundation of China (No.82200759).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The study protocol was approved by the Ethics Committee of the Affiliated Hospital of Qingdao University (approval number: QYFYEC2023-67) and was registered with the Chinese Clinical Trial Registration and Information System (registration number: MR-37-23-039856).

All participants provided written informed consent.

Competing interests

The authors declare no competing interests.

Data sharing

The data sharing policy of Chinese Clinical Trial Registration and Information System (registration number: MR-37-23-039856) is available at https://www.medicalresearch.org.cn, or further details may be obtained from the corresponding author upon reasonable academic request.