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

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). 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. 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. 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.