100 cases randomized control
CHEN Haigo, PAN Jiahua, CAO Ming, HU Jiong, XUE Wei, ZHOU Li-Xin, LIU Dong-Ming, HUANG Yiran*
Correspondence should be addressed to Huang Yiran [email protected]
Abstract
OBJECTIVE: Conventional radical total cystectomy in cis male often leads to massive intraoperative bleeding due to difficulties in dealing with the apical prostate and lateral bladder ligaments. Moreover, because of its unsatisfactory handling of the external urethral sphincter, it tends to lead to urinary incontinence in patients undergoing in situ neocystectomy. We attempted to evaluate the clinical value of a combined cis-reverse radical total cystectomy with a randomized control versus the conventional cis-exclusive radical total cystectomy alone. Subjects and methods: 100 male patients with invasive bladder cancer were randomly selected between January 2004 and January 2008, 22 of whom underwent cis-combined radical total cystectomy + Bricker, 28 patients underwent cis-combined radical total cystectomy + Studer in situ cystectomy; 21 patients underwent cis-combined radical total cystectomy + Bricker as the control group The cascade radical total cystectomy + Studer in situ cystectomy was performed in 29 patients as the control group. Their intraoperative probability of massive bleeding, bleeding volume, cystectomy time, preservation of erectile function, and postoperative complications were compared. For patients who underwent in situ neocystectomy their postoperative urinary incontinence was compared. SPSS 10.0 software was used for statistical analysis.
RESULTS: In the cis-reversal combined radical total cystectomy group, 18% of patients had intraoperative bleeding greater than 400 ml, while in the control group, 44% of patients had intraoperative bleeding greater than 400 ml (P=0.030). For the 31 patients with bleeding greater than 400 ml, the mean bleeding in the two groups was 1725 ml and 1350 ml, respectively (P=0.478). In the cis-reversal combined radical total cystectomy group, the mean cystectomy time was 3.07 hours, while in the control group, the mean cystectomy time was 3.65 hours (P=0.007). The number of patients who had erectile function and were able to complete intercourse before surgery was 13 and 16 in both groups, respectively, and at 6 months postoperatively 15.38% (2/13) of patients in the cis-retrograde combined total cystectomy group retained erectile function compared with 12.5% (2/16) of patients in the cis-total cystectomy group, P=0.617 (Fish’s exact test). For patients undergoing Studer in situ cystectomy, the incidence of urinary incontinence at 3 months postoperatively was 3.57% in the cis-reverse combined total cystectomy group compared with 27.58% in the cis-total cystectomy group, which was statistically different (P=0.025). One patient in the parasternal total cystectomy group developed true urinary incontinence. There was no intraoperative tumor dissemination in either group. Chen Hego, Department of Urology, Shanghai Renji Hospital
CONCLUSION: The combined cis- and retrograde radical total cystectomy can ensure the accurate grasp of the surgical operation plane while facilitating the clearer treatment of the lateral bladder ligament and the prostatic apical area, and perfect protection of the external urethral sphincter, thus significantly reducing the probability of massive intraoperative bleeding, effectively shortening the operation time, reducing the surgical trauma, reducing the probability of postoperative incontinence in patients with in situ neobladder, and facilitating the postoperative recovery of patients. At the same time, it is also more conducive to avoiding intraoperative tumor dissemination and reducing the risk of intraoperative rectal injury without increasing surgical complications, which is a safe and effective method of radical cystectomy.
[Keywords] Cis-reversal combined radical total cystectomy, Studer in situ cystectomy, bleeding, operative time
A randomized comparison of antero-retrograde and anterograde male radical cystectomy in 100 cases
Chen Haige, Pan Jiahua, Cao Ming, Hu Jiong, Xue Wei, Zhou Lixin, Liu Dongming, Huang Yiran
Corresponding author: Huang Yiran [email protected]
Abstract
Purpose: For the radical cystectomy in male, the massive hemorrhage is the most important per-operative complication due to the difficulties of the treatment of the bladder lateral pedal. In addition, the treatment of the urethral external sphincter is not satisfactory in the anterograde approach which may complicate the treatment of the bladder lateral pedicles and the prostate apex. In addition, the treatment of the urethral external sphincter is not satisfactory in the anterograde approach which may complicate the urinary incontinence in the patients with neobladder. We tried to perform the radical cystectomy in an atero-retrograde approach instead of the classical anterograde approach in order to evaluate its clinical value. patients with muscle invasive bladder cancer were included in this randomized study in which 22 patients were treated by antero-retrograde radical cystectomy+Bricker diversion, 28 patients were treated with antero-retrograde radical cystectomy+Studer neobladder, while 21 patients were The incidence rate of the massive hemorrhagia was 1.5 percent. rate of the massive hemorrhage, the blood loss, the bladder resection time, the erectile function and the post-operative complications rate were In addition, for the patients with cystectomy+Studer, the post-operative incontinence rate at 3 months was calculated with this The post-operative incontinence rate at 3 months was calculated with this software.
Result: In antero-retrograde cystectomy group there were 18% of the patients with a blood loss more than 400ml while in the control group there were 44% respectively (P=0.030). For the patients with a blood loss more than 400ml, the average blood loss was 1725ml and 1350ml (P=0.478).The bladder resection time of the antero- The bladder resection time of the antero- retrograde approach was 3.07 hours while in the control group was 3.65 hours respectively (P=0.007).There were 29 patients who had normal erection There were 29 patients who had normal erection before the surgery, but 6 months after the procedure, the erectile function was conserved only in 2 of 13 patients in the antero-retrograde approach group The erectile function was conserved only in 2 of 13 patients in the antero-retrograde approach group and in 2 of 16 patients in anterograde approach group, P=0.617(Fish’s test). There was no difference between the two groups in the post-operative complications. For the radical cystectomy+Studer group, the incontinence rate in 3 For the radical cystectomy+Studer group, the incontinence rate in 3 months was 3.57% in antero-retrograde approach, while for the anterograde approach it was 27.58%, respectively. Conclusion: The antero-retrograde approach of radical cystectomy is a safe and reliable procedure which can reduce the For the patients with neobladder urine diversion, the antero-retrograde approach ensures lower incontinence risk. For the patients with neobladder urine diversion, the antero-retrograde approach ensures lower incontinence risk.
[Key words】Antero-retrograde radical cystectomy, cystectomy+studer, blood loss, bladder resection time
Radical cystectomy is the standard of care for invasive bladder tumors and high-risk superficial bladder tumors [1]. In men, radical cystectomy requires complete removal of the bladder, prostate, seminal vesicles, and peri-vesical adipose tissue along with iliac vascular lymph node dissection and, if the tumor involves the urethra, urethral mucosal evacuation. Currently, radical cystectomy is becoming a widely accepted standard of care in the treatment of invasive bladder tumors, and total cystectomy is a reasonable option even in patients of advanced age [2]. Conventional parsimonious radical total cystectomy deals with the lateral bladder ligament and Denovillier’s hiatus under non-direct vision, coupled with late control of the deep dorsal penile plexus, more bleeding when dissecting the lateral bladder ligament and dealing with the prostate section, more difficult surgical maneuvers, longer operative time and increased risk of rectal injury or tumor dissemination under non-direct vision. In addition, in patients requiring in situ neocystectomy, paracentesis radical total cystectomy is more difficult to expose and protect the external urethral sphincter, thus causing a greater risk of postoperative stress incontinence or true urinary incontinence. Therefore, we randomly selected 100 male patients with invasive bladder cancer and attempted to perform cis-radical combined radical total cystectomy + Bricker in 22 patients and cis-radical combined total cystectomy + Studer in situ cystectomy in 28 patients; and performed cis-radical total cystectomy + Bricker in another 50 patients as a control group. The aim was to compare the amount of surgical bleeding, time to cystectomy, surgical complications, preservation of sexual function, and postoperative complications of stress incontinence and true incontinence in patients with in situ neobladder, and to evaluate the efficacy of cis-retrogressive combined radical total cystectomy.
Subjects and methods
1. Subjects: From January 2004 to January 2008, 50 male patients with invasive bladder cancer with a mean age of 68 years (45-85 years) were randomly selected, 22 of whom underwent cis-combined radical total cystectomy + Bricker and 28 of whom underwent cis-combined radical total cystectomy + Studer in situ bladder. 13 of the 50 patients A total of 50 men with invasive bladder cancer were randomly selected as the control group, with a mean age of 64 years (44-84 years). 21 of them underwent cis-radical total cystectomy + Bricker and 29 underwent cis-radical total cystectomy + Studer in situ cystectomy. 16 of the 50 patients had normal preoperative erectile function and were able to complete sexual intercourse. Sixteen of the 50 patients had normal preoperative erectile function and were able to complete sexual intercourse successfully. All patients had no urethral involvement. Pathology was confirmed by preoperative TURBT.
2. Surgical approach: the extraperitoneal route was taken. The anterior bladder space and adipose tissue on both sides of the bladder were separated, bilateral iliac vessels were exposed, and bilateral pelvic lymph node dissection was performed. In the cis-reversal combined radical cystectomy group, we first free the spermatic cord, ligate and cut the vas deferens after completing lymph node dissection of the iliac vessels. At the level of the common iliac vessels, the bilateral ureters were freed against the posterior peritoneum, and the atretic umbilical artery and superior cystic artery were ligated and severed successively. The ureters were separated along the level of bilateral ureters towards the seminal vesicles up to the top of the seminal vesicles in the posterior wall of the bladder. During the separation process, a portion of the lateral bladder ligament was simultaneously ligated and severed in a stepwise fashion to the level of the top of the seminal vesicles. At this point, the paralleling step is essentially completed. Next, the posterior pubic space is exposed and the preprostatic adipose tissue is pushed away. The pelvic fascia is sharply opened on both sides of the prostate near the pelvic fascial pelvic antrum and separated toward the pubic prostatic ligament. The pubic prostatic ligament is ligated and severed to completely expose the prostatic acinus. A figure-of-eight suture is placed near the tip of the prostate to control the superficial branches of the dorsal penile vein, while the superficial branches of the dorsal penile vein on the surface of the prostate envelope are clamped closed with a titanium clip and completely disconnected between them. The Santorini’s plexus, which runs behind the pubic symphysis, is then sutured to the depth of the perichondrium and left in place after tying the knot. The suture is then pushed behind the pubic bone toward the tip of the prostate and the dorsal penile vein plexus is opened. Both sides of the prostate are freed and titanium clips are used to stop bleeding. The external urethral sphincter, which wraps around the tip of the prostate in a U-shape, is pushed away and the bladder and prostate are pulled backward to fully expose the posterior urethra and then the anterior wall of the urethra is circumferentially incised to expose the urinary catheter left in place at the beginning of the procedure. The catheter was controlled with a clamp and then cut at its distal end, and the catheter was lifted posteriorly and superiorly, and the posterior wall of the urethra was fully freed and cut with a right-angle forceps. The Denonvillier’s fascia was then opened. The catheter is pulled and the prostate is separated from the anterior rectal wall in Denonvilliers’ gap under direct vision to the level of the bilateral seminal vesicles. At the same time, the lateral ligaments of the prostate and the lateral ligaments of the bladder are separated, ligated and severed retrogradely under direct vision, and are joined at the level of the top of the seminal vesicles where the lateral ligaments of the bladder are severed by the retrograde separation. The incision is extended upward, the peritoneum is opened, the umbilical ureter is severed, and the entire bladder, the peritoneal regurgitation at the top of the bladder, and the prostatic seminal vesicle tissue are removed.
Urinary diversion or neobladder surgery was performed.
3. Statistical methods: Intraoperative bleeding rate, mean intraoperative bleeding volume, mean cystectomy time, preservation of postoperative sexual function in patients with preoperative erectile function, incidence of postoperative urinary incontinence after Studer in situ cystectomy, and incidence of other postoperative complications in both groups were statistically analyzed with SPSS 10.0 software.
Results
The mean age of the 50 patients who underwent a combined cis-retrograde radical total cystectomy was 68 years, and the postoperative pathology reported high-grade invasive metastatic cell carcinoma in 37 patients, low-grade invasive metastatic cell carcinoma in 12 patients, and high-grade invasive metastatic cell carcinoma with partial indolent cell carcinoma in 1 patient. Of these, 35 patients had high-grade invasive metastatic cell carcinoma, 13 patients had low-grade invasive metastatic cell carcinoma, 1 patient had adenocarcinoma of the bladder, and 1 patient had high-grade invasive metastatic cell carcinoma with partial squamous cell carcinoma.
In the cis-reverse combined radical total cystectomy + Bricker procedure group, nine patients had intraoperative bleeding greater than 400 ml, accounting for 18% of the total number, whereas in the cis-radical total cystectomy group, 22 of 50 patients (44%) had intraoperative bleeding greater than 400 ml. The difference was statistically significant according to Pearson chi-square test X2 = 4.695, P = 0.03 (Table 1). According to risk analysis, the relative risk of retrograde radical cystectomy versus paracentral radical cystectomy with intraoperative bleeding greater than 400 ml was 0.279.
Intraoperative bleeding greater than
400 ml Number
Intraoperative bleeding less than
Number of 400 ml
Total number of patients
X2
P
Retrograde radical total cystectomy group
9
41
50
4.695
0.03
Shunning radical total cystectomy group
22
28
50
Total number
31
69
100
Table 1 Comparison of the probability of massive intraoperative bleeding (x2 test)
For a total of 31 patients in the two groups with bleeding greater than 400 ml, the mean bleeding in the cis-retrograde combined total cystectomy group and the cis-radical total cystectomy group were 1725 ml and 1350 ml, respectively. the difference in mean bleeding between the two groups was not statistically significant. p=0.478
The mean cystectomy time was 3.07 hours in the cis-reverse combined radical total cystectomy group and 3.66 hours in the group undergoing cis-radical total cystectomy, with a statistically significant difference. p=0.007.
The number of patients with intact preoperative erectile function and successful completion of intercourse in both groups was 13 (in the cis-reverse combined radical total cystectomy group) and 16 (in the cis-radical total cystectomy group), respectively. At 6 months postoperatively, 15.38% (2/13) of patients in the cis-combined radical total cystectomy group retained erectile function, whereas 12.5% (2/16) of patients in the cis-combined radical total cystectomy group retained erectile function, with no statistically significant difference, P=0.617 (Fish’s exact test) (Table 2).
Table 2 Comparison of postoperative preservation of erectile function (Fish’s test)
Preservation of postoperative
Number of erectile function
Patients with postoperative loss of erectile function
Total number
Fisher’s
Precision testing
Cis-reversal combined with radical total cystectomy group
2
11
13
0.617
Cis-radical total cystectomy group
2
14
16
Total number
4
25
29
In the case of the postoperative erectile function preservation rate in the total cystectomy group, its n was conserved in group surgery, but after the procedure, 2 of 13 patients in the antero-retrograde approa
For the 57 patients who underwent Studer in situ cystectomy after total cystectomy, 7 of the 29 patients who underwent cis total cystectomy still had symptoms of stress urinary incontinence three months after surgery, using more than three diapers per day, and one patient had true incontinence requiring long-term penile clips; among the patients who underwent combined cis total cystectomy, only one patient still had stress urinary incontinence three months after surgery. No patient developed true incontinence, and Fisher’s exact test showed a significant difference (p=0.025) (Table 3).
Table 3 Comparison of the probability of urinary incontinence at 3 months after radical total cystectomy + Studer’s procedure (Fisher’s test)
Number of patients with combined incontinence at 3 months postoperatively
Number of patients without incontinence at 3 months postoperatively
Total number
Fisher’s
Precision test
Retrograde radical total cystectomy + Studer procedure group
1
27
28
0.025
Retrograde radical total cystectomy + Studer group
8
21
29
Total number
9
48
57
Regarding postoperative complications, in the patients who underwent a cis-reversal combined radical total cystectomy + Bricker, there were 3 cases of urinary fistula, 2 cases of incisional fat liquefaction and 1 case of intestinal obstruction. In the cis-radical total cystectomy + Bricker group, six patients also had surgical complications: three cases of urinary fistula, two cases of incisional liquefaction, and one case of upper gastrointestinal bleeding. A chi-square analysis of the postoperative complication rates in the two groups showed no statistical difference (Table 4). p=0.924. The relative risk of postoperative complications with cis-reverse combined radical cystectomy versus cis-radical cystectomy was 0.938 according to the risk analysis.
Table 4 Comparison of the probability of developing postoperative complications after radical total cystectomy + Bricker procedure (x2 test)
Number of people presenting with postoperative complications
No postoperative complications
Number of people
Total number
X2
P
Retrograde radical total cystectomy + Bricker procedure group
6
16
22
0.09
0.924
Conservative radical total cystectomy + Bricker procedure group
6
15
21
Total number
12
31
43
Among the patients who underwent Studer in situ cystectomy, 9 of 28 patients in the cis-reversal combined total cystectomy group had short-term postoperative complications, including 2 cases of incisional fat liquefaction, 3 cases of intestinal obstruction, 2 cases of fever after removal of single J-tube, 1 case of urinary fistula and 1 case of urinary retention after catheter removal; among the 29 patients in the cis total cystectomy group, 7 patients had short-term postoperative complications, as follows 2 cases of incisional fat liquefaction, 2 cases of intestinal obstruction, 2 cases of urinary fistula, and 1 patient had urinary retention after catheter removal, requiring intermittent catheterization at home. There was no statistical difference between the two. (Table 5)
Table 5 Comparison of the probability of complications after radical total cystectomy + Studer operation (x2 test)
Number of postoperative complications
No postoperative complications
Number of people
Total number
X2
P
Retrograde radical total cystectomy + Studer’s procedure group
9
19
28
0.452
0.510
Conservative radical total cystectomy + Studer’s procedure group
7
22
29
Total number
16
41
53
Discussion
In all patients involved in this study, we performed radical total cystectomy using the extraperitoneal route. Traditional transabdominal radical total cystectomy opens the peritoneum from the beginning of surgery, and although it can detect the presence of metastatic lesions in the liver and mesentery, the longer opening of the peritoneal cavity tends to lead to a significant loss of body fluids, and the prolonged exposure of the digestive tube delays the recovery of the patient’s postoperative GI function. Due to the rapid development of current imaging technology, we are able to perform more accurate clinical staging of patients preoperatively. For suspicious metastases in the abdominal cavity suggested by CT, the application of functional imaging such as PET-CT has greatly improved the detection rate and further improved the accuracy of preoperative clinical staging. For all patients enrolled in this study, we ruled out the presence of intra-abdominal metastases by imaging means before surgery, and extended the incision to enter the abdominal cavity after performing whole bladder, prostate and seminal vesicle resection and pelvic lymph node dissection, which significantly reduced the exposure time of intra-abdominal organs. Thus, it is safe and reliable to use the extraperitoneal route for radical total cystectomy followed by opening the abdominal cavity.
Compared with the conventional paracentral radical total cystectomy, our combined paracentral and retrograde radical total cystectomy has its unique advantages.
First of all, after dissecting the vas deferens bilaterally, a blunt downward separation along the plane of the vas deferens can be easily grasped in the correct surgical plane, thus allowing a smoother separation to the top of the seminal vesicles in the posterior wall of the bladder and a partial dissection of the lateral bladder ligament. Once the top of the seminal vesicle is reached, we discontinue the paralleling separation in favor of the prostate in order to avoid the risk of rectal injury and tumor dissemination associated with the nonrectal separation of Denovillier’s hiatus, to reduce bleeding during treatment of the apical prostate and the lateral bladder ligament, and to more satisfactorily treat the external urethral sphincter in patients with proposed in situ neobladder.
In radical total cystectomy, management of the apical prostate is the critical step that is most likely to cause intraoperative blood loss and injury to the external urethral sphincter. Our approach to the apical prostate greatly reduces intraoperative bleeding and allows us to smoothly push away and preserve the U-shaped external urethral sphincter around the apical prostate in a clear field on both sides and anteriorly, avoiding the potential damage to the external urethral sphincter that can occur with non-direct vision operations. Therefore, in our study, no patient in the cis-reversal combined radical total cystectomy + Studer group had combined true urinary incontinence in March postoperatively, and only one patient had combined stress urinary incontinence, and the probability of postoperative urinary incontinence was significantly lower in the cis-reversal combined total cystectomy + Studer procedure compared with the cis-total cystectomy (P=0.025).
Second, direct visual management of the lateral bladder ligaments on both sides also greatly reduced intraoperative blood loss. In particular, in male yellows, the reduced surgical field of view increases the difficulty of surgical operation due to their generally small true pelvic diameter. In this case, the cis-reversal combined radical total cystectomy allows the operator to deal with the most bleeding-prone lateral bladder ligaments and the prostatic collateral ligaments under direct vision, and also provides a larger surgical operating space, which is even more superior. Of the 50 patients in whom we performed a cis-retrograde combined radical cystectomy, only 9 patients had intraoperative bleeding of 400 ml or more, whereas 22 of the 50 patients (44%) who underwent a cis-radical total cystectomy had intraoperative bleeding greater than 400 ml. According to Pearson chi-square test, P=0.03, the difference was statistically significant. According to risk analysis, the relative risk of intraoperative bleeding greater than 400 ml for cis-combined radical cystectomy was 0.279, that is, the risk of intraoperative bleeding greater than 400 ml for cis-combined radical cystectomy was approximately 3.6 times greater than that for cis-combined radical cystectomy.
The mean blood loss in the cis-combined radical total cystectomy group was 1725 ml in the 9 patients with surgical blood loss greater than 400 ml compared with 1350 ml in the 22 patients with blood loss greater than 400 ml in the control group. the difference between the two groups was not statistically significant (p=0.478). It can be seen that although cis-reversal combined radical total cystectomy can reduce the probability of massive intraoperative bleeding, there was no significant difference in the amount of bleeding between the two once the more massive intraoperative bleeding occurred, which may be related to unsatisfactory suturing of Santorini’s plexus and unclear separation gap due to tumor invasion of peri-vesical tissue.
Again, a comparison of the operative times for the two groups showed that the mean cystectomy time was 3.07 hours in the cis-reverse combined radical total cystectomy group, while the mean cystectomy time was 3.66 hours in the cis-radical total cystectomy group, with a statistically significant difference of 35 minutes (P=0.007). This shows that the clear exposure of the surgical field, the reduction in surgical bleeding, and the reduced difficulty in the management of the lateral bladder ligaments greatly reduced the time required for cystectomy.
At the same time, in muscle-infiltrating bladder cystic tumors, achieving oncological radicalization is the goal of total cystectomy. In the present study, we did not use radical cystectomy with preservation of the sexual nerve, so the postoperative patients had a lower rate of preserved erectile function. A total of 29 patients in both groups had intact preoperative erectile function and were able to complete sexual intercourse successfully. At 6 months postoperatively, there was no statistical difference in the retention of erectile function between the patients in the cis-reverse combined radical total cystectomy group and the patients in the cis-radical total cystectomy group, 15.38% (2/13) and 12.5% (2/16), respectively.
In addition, there was no statistical difference between the cis-reverse combined radical total cystectomy + Bricker and cis-radical total cystectomy + Bricker groups in terms of the incidence of recent postoperative complications (P=0.924). And there was also no statistical difference in the incidence of short-term postoperative complications between the two groups of cis-reverse combined radical total cystectomy + Studer and cis-radical total cystectomy + Studer (P=0.5210). All patients who developed postoperative complications improved after conservative treatment, no patient required a second operation, and no patient died from short-term postoperative complications. Therefore, radical total cystectomy is still a relatively safe surgical technique as long as the indications for surgery are strictly controlled and guaranteed by skilled surgical and anesthetic techniques.
Finally, since radical total cystectomy is the standard treatment for invasive bladder tumors without distant metastases, it is always the goal of the urologist to strive for radical tumor cure and avoid tumor dissemination caused by surgery while continuously improving surgical techniques and reducing surgical complications. Cis-radical total cystectomy is difficult to accurately grasp the Denovillier’s hiatus, which often results in bladder perforation and tumor dissemination as well as rectal injury, while combined cis-radical cystectomy avoids blunt separation of the Denovillier’s hiatus under non-direct vision, reducing the risk of bladder perforation due to wrong surgical separation plane. The risk of tumor dissemination due to bladder perforation caused by incorrect surgical separation plane was reduced. Of the 50 patients who underwent combined cis-radical cystectomy, all achieved complete resection of the tumor and none had tumor dissemination due to bladder perforation caused by incorrect separation plane.
Conclusion
The combination of cis- and retrograde radical total cystectomy can significantly reduce the probability of massive intraoperative bleeding, effectively shorten the operative time, reduce surgical trauma, improve the protection of the external urethral sphincter, and reduce the risk of in situ neobladder. It also reduces the probability of postoperative complications of urinary incontinence and is more conducive to the patient’s postoperative recovery. Especially for male yellow men with a relatively small pelvis, it provides more space for surgical operation, which further reflects its application value. At the same time, cis-reversal combined radical total cystectomy with direct vision separation of Denovillier’s hiatus is a safe and effective method of radical cystectomy because it helps avoid intraoperative tumor dissemination and reduces the chance of intraoperative rectal injury without increasing surgical complications.
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