LAUSR

Multivisceral resection (MVR) with partial bladder resection is accepted as a reasonable choice for advanced sigmoid colon cancer with bladder involvement [1, 2]. However, surgery is often challenging, because bulky tumors occupying the upper pelvic space and adhesions around the primary tumor which make it hard to discriminate between tumor invasion and inflammation. Therefore, in most of the reported cases, open surgery was performed [3]. We adopt a fascial space priority approach for laparoscopic en bloc MVR with bladder sparing in selected patients of locally advanced sigmoid cancer with bladder involvement and attained promising outcome. The basic principle of a fascial space priority approach, as we have explained in our previous articles [4, 5], is that the tumor and the tissues involved are resected en bloc. As is shown in the video, during surgery, the non-vascular spaces surrounding the mass are separated following a posterior (the retrorectal space)-lateral (the space between the ureter and the internal iliac vessels and the space between the bladder and the obturator lymph nodes)—anterior (the vesicocervical space and the vesicovaginal space) sequence. Informed consent was obtained both form the patient and the ethics committee of our hospital. The main advantage of a fascial space priority approach is that the dissection is always kept in the normal fascial spaces, the ureter can be explored and protected, the bulky mass can be mobilized and the vessels supplying the target pelvic organs are ligated during the separation of the avascular spaces. This is a reproducible process and is a feasible and safe surgical strategy for patients with sigmoid cancer with bladder involvement. One of the limitations of a fascial space priority approach is that it is currently carried out only in our institution, the number of cases still limited, and long-term results are still being studied. Although the patient had no signs of recurrence at 12 months of follow-up, further studies are needed to determine whether bladder sparing surgery should be performed and whether laparoscopy should be an option when vesico-intestinal fistula is suspected. MVR with partial bladder resection as an aggressive surgical procedure requiring specialized training. The video and approach we provided here could be a training reference not only for colorectal surgeons but also for gynecologists and urologists.