Muscular invasive bladder cancer is a highly aggressive malignancy characterized by rapid metastasis and progression, and surgical resection is the preferred method[11, 12]. Bladder cancer is one of the most common malignant tumors of the urinary system. With the aging of the population in China, the incidence of bladder cancer continues to increase, posing a serious threat to people's health. Once bladder cancer develops into muscular invasive bladder cancer, the prognosis is significantly worse than that of non-muscular invasive bladder cancer[13, 14]. Radical total cystectomy is the treatment of muscular layer of invasive bladder cancer standard solution, as a result of the surgery, including total resection of bladder and urinary tract reconstruction of multiple steps, operation area surrounding tissue nerve vascular abundance, and must be completed within the narrow pelvic surgery takes longer, intraoperative bleeding, often cause larger surgical trauma to patients, and postoperative recovery slow, high incidence of complications, is the most difficult of urology, one of the highest risk of surgery[15, 16].
Ureterostomy is one of the commonly used surgical methods for postoperative urinary flow redirection. Through preoperative positioning, doctors can choose an ideal stoma location for patients. Accurate positioning of stoma is conducive to nursing staff and patient self-care, improving the quality of nursing, and thus improving the patient's quality of life[17, 18]. If the location of the stoma is poorly selected, it will lead to the occurrence of complications such as stoma retraction and stenosis. The uneven position will make it difficult to paste the bag, cause urine leakage, cause inconvenience to the patients and cause skin damage around the stoma. At the same time, due to the frequent replacement of the bag, the patient's economic burden will be increased. Improper location of the stoma may affect the firmness of the paste between the stoma and the skin. When the patient changes position, urine may easily leak into the surrounding skin of the stoma, resulting in redness, ulceration, pain and infection of the skin. Based on clinical experience, the doctor positioned the patient during the operation. Since the patient needs to lie flat during the operation, the abdomen of the patient is relatively flat, and the expected position of the stoma has a big deviation from the actual position, which will bring inconvenience to postoperative care[19, 20]. Therefore, standardized and correct preoperative positioning of the stoma is particularly important, which can avoid the occurrence of the above situation caused by improper selection of stoma location, so that patients can master the paste of the stoma pocket, protect the skin around the stoma, improve the patient's self-care ability and family care, and thus improve the patient's postoperative life quality.
In recent years, RARC has been popularized, and the learning curve of robotic solid organs is 10~80 cases (including complex cases), which means that urologists can quickly become familiar with and use robotic surgery[21]. The results of this study showed that the operation time of the LRC group was higher than that of the ORC group, the number of lymph node dissection was lower than that in the ORC group and the RARC group, the drainage tube extraction time was lower than that in the ORC group, and the intraoperative blood transfusion rate in the ORC group was higher than that in the LRC group and the RARC group. The postoperative red blood cell decline, postoperative hemoglobin decline, postoperative albumin decline in the RARC group were all lower than those in the ORC group and the LRC group, and the postoperative red blood cell decline, postoperative hemoglobin decline in the LRC group were all lower than those in the ORC group. It shows that RARC has little trauma to patients and quick recovery after operation. Analysis of the reasons is that the bladder and prostate are rich in blood flow, the ORC incision is large, and the tissues and organs are stretched and the gastrointestinal tract is more affected. At the same time, the amount of blood loss during the operation is also large, which may cause the operation field to be blurred, which affects the accuracy of the operation, damages the neurovascular bundle or accidentally injures the urethral sphincter. RARC magnifies the image by more than 10 times through the image processing system and presents a 3D effect to make the anatomical level of blood vessels and nerves clearer. At the same time, the stability and flexibility of the robotic arm can achieve finer hemostasis in the abdominal cavity, avoiding the blurring of the surgical field[22, 23].
Postoperative complications are inevitable after radical cystectomy, and at least one complication appears recently after radical cystectomy for bladder cancer. A number of studies have confirmed that postoperative complications are generally believed to be significantly correlated with preoperative cardiac function assessment, urinary diversion, and intraoperative blood loss[24, 25]. Postoperative complications can be roughly divided into short-term complications and long-term complications. Short-term complications are directly related to surgery, including wound complications, infections, and digestive system symptoms[26]. The incidence of complications in these patients is closely related to the amount of intraoperative blood loss, gender, and the way of urinary diversion. The results of this study showed that the total incidence of complications in the LRC group was 24.5%, the total incidence of complications in the ORC group was 32.7%, and the total incidence of complications in the RARC group was 15.0%. It shows that the incidence of complications is higher in patients undergoing ORC.
A multicenter study involving 503 patients with total cystectomy revealed no significant difference in recurrence-free survival, cancer-specific survival and overall survival between LRC and ORC during the 13 years follow-up[27]. This study suggests that the research and this paper is the likely cause of the differences while operation method is roughly same, but there is a performer in the operation of technical proficiency and operation difference, at the same time, the research into 504 cases including urothelial carcinoma, squamous carcinoma, adenocarcinoma, in this paper, all patients were diagnosed by pathology for advanced carcinoma of the urinary tract, tumor cell metastasis or recurrence in the same way, so the result is different, but LRC is still a safe and effective treatment. At present, there is not much evidence to prove the difference in cancer prognosis of patients treated with ORC or LRC or RARC[28, 29]. However, some articles pointed out that laparoscopic operation may increase the rate of tumor metastasis and recurrence, which needs our attention[30]. The follow-up time of this study was long, and the results showed that the median survival time of ORC group was higher than that of LRC group and RARC group. This study suggests that ORC may have a longer survival period under the same baseline conditions, but ORC does have a longer survival period than the other two, this may be related to the longer operation time of LRC and RARC, more CO2 hemolysis during operation, and oxidative stress response. Although there is no clear evidence to prove this conjecture, there are reports in the literature that acidic environment significantly affects tumor progression and recurrence and the effect of radiotherapy and chemotherapy. At the same time, thrombosis and shedding may also be an important risk factor when making a closed pneumoperitoneum. Some articles pointed out that RARC surgery has a higher rate of extrarenal or peritoneal metastasis than ORC, which may be the reason why ORC has a longer survival time than the other two[31, 32]. In this study, univariate analysis showed that age, operation method, tumor stage, pathological grade, operation time, number of lymph nodes removed, and drainage tube extraction time were all related to patient survival. Multivariate logistic analysis showed that operation methods, tumor staging, pathological grade, and number of lymph nodes dissected are all independent factors affecting patient survival. The reasons were analyzed as follows: the higher the tumor stage and pathological grade, the deeper the tumor infiltration and the less thorough the surgical resection; moreover, it was difficult for drugs to achieve effective concentration in the deep layer during postoperative perfusion therapy, thus weakening the clinical effect and increasing the possibility of recurrence. Since the lymphatic system is one of the important ways for the metastasis of bladder tumor cells, once invaded by tumor cells, it is easily transported to other lymph nodes, endangering other organs. Therefore, the more lymph nodes are cleared, the less chance of recurrence and metastasis after surgery.