Robot-assisted laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion: initial experience in Korea

In this paper, we report our initial experience of robot-assisted laparoscopic radical cystoprostatectomy (RLRC) with an ileal conduit urinary diversion (ICUD). Our patient was a 59-year-old man presenting with a clinical T4 invasive transitional cell carcinoma of the bladder and prostate. A RLRC was performed with the da Vinci() robot system (Intuitive Surgical, Mountain View, CA), which has a total of seven degrees of motion (six degrees of freedom and grip), and EndoWrist (Intuitive Surgical) instrumentation. The specimen was extracted through the 8-cm-sized incision in the umbilical trocar site. The ICUD was achieved through a removal site of a specimen by an extracorporeal technique. The total operative time was 340 minutes and the estimated blood loss was 600 mL. The pathologic examination showed a stage T4a, with negative surgical margins. A RLRC can be an alternative to the open technique. We are the first group to perform RLRC in Korea and to report on our technique and outcome.     

完全腹腔镜下根治性膀胱切除回肠膀胱术的疗效观察

目的:探讨完全腹腔镜下根治性膀胱切除回肠膀胱术的可行性,并总结手术技巧。方法:回顾性分析3例膀胱肿瘤患者行完全腹腔镜下根治性膀胱切除回肠膀胱术的临床资料。结果:3例手术均获成功,手术时间分别为480、450和420min,出血量分别为400、750和330ml,肠道功能恢复时间分别为56、62和78h,引流管于术后8~15天拔除。术后住院时间分别为17、13和15d,术后4周拔除单J管。术中、术后均无并发症,无尿瘘、肠瘘或肠梗阻等发生。随访3~6个月,肾功能正常,无肾积水,未见肿瘤复发、转移等。结论:完全腹腔镜下根治性膀胱切除回肠膀胱术安全可行,但手术难度大,需熟练掌握腹腔镜操作技术后方可开展。     

Bricker's ileal conduit urinary diversion with a simple non-refluxing uretero ileal anastomosis

Fifty consecutive patients had ileal conduits constructed with a technically and quick simple antireflux ureteroileal anastomosis. Complications related to the ureteral implantation were studied retrospectively, and at follow-up (8 months-12 years later, median 3 years) conduit dysfunction and ureteral reflux were assessed in 18 patients out of the 25 patients who were still alive. Early complications and signs of late upper urinary tract deterioration were similar to those found after other operative techniques had been used. One patient had a postoperative urinary leak from the uretero ileal anastomosis. which was treated successfully by two weeks drainage. Hydronephrosis deteriorated in 18 (26%) of the renal units, remained unchanged in 39 (57%) and improved in 11 (16%). Increases in plasma creatinine concentrations up to 200 mumol/l were found in eight patients, and in one patient it increased from 300 to 420 mumol/l. Partial ureteral reflux was present in three (2 patients) of 33 ureters studied and minimal conduit dysfunction was found in 8 patients. In conclusion we find this method of urinary diversion to be quick, easy, and safe.     

机器人辅助根治性膀胱切除术+体内回肠膀胱术手术经验分享(附光盘)

虽然开放根治性膀胱切除术(open radical cystectomy,ORC)是治疗肌层浸润性膀胱癌的金标准,但机器人辅助根治性膀胱切除术(robot-assisted radical cystectomy,RARC)的应用报道目前越来越多。RARC在达到和ORC一样的瘤控手术效果的同时更为微创。机器人手术系统的巨大优势是开放和传统腹腔镜无法比拟的,例如手术视野、灵巧性、精确性和稳定性。因此,RARC在背深静脉复合体缝合,新膀胱和尿道吻合,神经血管束的保留等操作方面有得天独厚的优势。机器人手术系统的应用也使完全体内尿流改道成为可能。     

Transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy: case report

Background  Laparoscopic gastrojejunostomy allows effective palliation and rapid recovery for the patient with limited survival due to advanced pancreatic cancer presenting with gastric outlet obstruction. Transumbilical single-incision laparoscopic surgery (SILS) offers excellent cosmetic results and may be associated with decreased postoperative pain, reduced need for analgesia, and thus accelerated recovery. The authors report the first transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy. Methods  Preliminary experience with transumbilical single-incision, intracorporeal anastomosis for gastrojejunostomy for a patient with gastric outlet obstruction caused by advanced pancreatic cancer is reported. Results  Transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy was performed with a linear endoscopic stapler using an omega loop. The operative time was 117 min. No intra- or postoperative complications were recorded. Conclusion  Transumbilical single-incision laparoscopic intracorporeal anastomoses are feasible using the endoscopic linear stapler. Transumbilical single-incision gastrojejunostomy for gastric outlet obstruction may improve cosmetic results and allow accelerated recovery for patients with limited survival. This anastomosis technique of single-incision laparoscopic surgery for other digestive tract procedures needs further evaluation.     

Antireflux ureteroileal anastomosis in ileal conduit urinary diversion and in ileocystoplasty following cystoprostatectomy

Ureteroileal anastomosis, in which intraintestinal ureteral segment was implanted in a mucosal sulcus, was used in ileal conduit urinary diversion on 17 patients and in ileocystoplasty for total replacement of the bladder on 4 patients. Conduitography or cystography, performed 3 months after operation, demonstrated reflux in 1 out of 39 reimplanted ureters (2.6%). Six months after surgery one anastomosis was stenotic and was treated by percutaneous balloon dilatation. Four ureters were slightly dilated and a stone had developed in one ureter. The method seems to be effective and easy to perform.     

Comparative analysis of laparoscopic and robot-assisted radical cystectomy with ileal conduit urinary diversion

PURPOSE: To compare our experience with laparoscopic radical cystectomy (LACIC) and robot-assisted laparoscopic radical cystectomy (RACIC) with ileal conduit urinary diversion. PATIENTS AND METHODS: Prospective data were gathered on 20 consecutive patients undergoing LACIC performed between August 2002 and July 2005, and on 14 consecutive patients undergoing RACIC performed between March 2005 and December 2006. Radical cystectomy with pelvic lymphadenectomy was performed laparoscopically or robotically, and an ileal conduit urinary diversion was performed extracorporeally. RESULTS: There was no significant difference in terms of preoperative factors or baseline tumor characteristics and no significant difference in mean operative time (410 min v 419 min) between groups. There was less blood loss (212 mL v 653 mL; P < 0.0001) and fewer transfusions (42.8% v 70%; P < 0.0011) in the RACIC group. There was one intraoperative complication (7%) and no conversions in the RACIC group. There were three (15%) intraoperative complications all leading to conversion in patients undergoing LACIC. Three (21%) patients in the RACIC group and 10 (50%) patients in the LACIC group had at least 1 post-operative complication. The mean number of days to oral intake was less in the RACIC group (2.3 v 6.1; P = 0.012). There was no significant difference in the number of lymph nodes excised (P = 0.09) between groups. Bilateral extended lymphadenectomy was performed in 10 (71%) RACIC patients with a mean of 22.3 lymph nodes harvested and in 16 (80%) LACIC patients with a mean of 16.5 lymph nodes harvested. There were no positive margins in patients in the LACIC group and one (7.1%) among patients in the RACIC group--a patient with pT4 disease. CONCLUSION: Both laparoscopic and robot-assisted radical cystectomies can be performed safely without compromising oncologic standards for surgical margins and extent of lymphadenectomy. In this early experience, the robot-assisted approach appears to have a shorter learning curve, and it is associated with less blood loss, fewer postoperative complications, and earlier return of bowel function than LACIC.     

Laparoscopic radical cystectomy with ileal conduit urinary diversion

OBJECTIVE: To report on the surgical technique of laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion. METHODS: A 79 years old man with histologically proven transitional cell carcinoma of the bladder stageT 2b NxMx underwent a laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion. The cystoprostatectomy was performed with laparoscopic technique. Creation of the ileal conduit and the stoma were performed through a mini-laparotomy. Specific technical aspects are described. RESULTS: The procedure was completed laparoscopically. The creation of the ileal conduit and stoma were performed through a mini-laparotomy. The surgical margins were free of disease. There were no intra or postoperative complications. The operative time was 290 min. Estimated blood loss was 380 mL. Hospital stay was 6 days. At 3 months there is no evidence of disease. The patient resumed his normal activity. CONCLUSION: Laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion is a feasible option for organ-confined carcinoma of the bladder. The procedure is technically demanding and should be performed in centers with large experience in laparoscopic surgery.     

Urinary fistula into ureteral stump after ileal conduit diversion

Despite ileal conduit diversion for urinary incontinence, an adolescent male with meningomyelocele continued to void per urethram postoperatively. Urologic investigation disclosed spontaneous fistulization from a ureteroileal anastomosis to a ligated ureteral stump, with resultant urinary drainage to the bladder. This unusual complication of ileal conduit diversion has not been reported previously. More attention should be directed to securing a watertight ureteroileal anastomosis. A careful single layer anastomosis is recommended to minimize urinary leakage without increasing the risks of stenosis and obstruction.     

Modified autosuture technique for ileal conduit construction in urinary diversion

The autosuture stapling technique in ileal conduit formation is modified to exclude the proximal staple line from the urinary stream, so as to prevent calculus encrustation on the staples. We have also selected the open-lumen technique of bowel anastomosis, rather than the closed-lumen technique, and have found no increase in complications with this method. In particular, no problems with excessive faecal contamination were encountered.