Laparoscopic hand assisted radical cystectomy with ileal conduit urinary diversion

PURPOSE: Hand assisted laparoscopy was originally described in the early 1990s. Since then many studies have shown that hand assisted techniques have the same advantages of laparoscopy including decreased need for postoperative narcotics and rapid return to routine activities. Laparoscopic techniques are advancing rapidly and intracorporeal laparoscopic cystectomy is reported. To our knowledge we report the first case of hand assisted, laparoscopic radical cystectomy with ileal conduit urinary diversion. MATERIALS AND METHODS: A 68-year-old male with rapidly recurring grade III transitional cell carcinoma elected to undergo hand assisted radical cystectomy. We performed a radical cystectomy with bilateral pelvic lymph node dissection removing the specimen through the hand port site. The ileal loop urinary diversion was constructed by pulling the small bowel through the hand port incision. We made another separate hole for the stoma and a drain was placed through a port site. The incisions were closed in the standard fashion.RESULTS: Operative time was 7 hours with 750 cc of blood loss and no complications. All surgical margins were negative. The patient did well and was discharged from the hospital on postoperative day 7 with return to normal activity without limitations at 4 weeks. CONCLUSIONS: To our knowledge this is the first reported case of hand assisted laparoscopic radical cystectomy with ileal loop diversion. Hand assistance facilitated this technically demanding surgery resulting in a good outcome without significant added operative time.     

Laparoscopic radical cystectomy and continent orthotopic ileal neobladder performed completely intracorporeally: the initial experience

PURPOSE: We introduce the operative technique of laparoscopic radical cystectomy and orthotopic ileal neobladder with a Studer limb performed completely intracorporeally. MATERIALS AND METHODS: The procedure was performed in 1 man and 1 woman. Using a 6 port transperitoneal approach, radical cystectomy in the female patient and radical cystoprostatectomy in the male patient were completed laparoscopically with the urethral sphincter preserved. Bilateral pelvic lymphadenectomy was done. A 65 cm. segment of ileum 15 cm. from the ileocecal junction was isolated, and ileo-ileal continuity was restored using Endo-GIA staplers (U.S. Surgical, Norwalk, Connecticut). The distal 45 cm. of the isolated ileal segment were detubularized, maintaining the proximal 10 cm. segment intact as an isoperistaltic Studer limb. A globular shaped ileal neobladder was constructed and anastomosed to the urethra. Bilateral stented ureteroileal anastomoses were individually performed to the Studer limb. All suturing was done exclusively using free-hand laparoscopic techniques and the entire procedure was completed intracorporeally. An additional case is described of Indiana pouch continent diversion in which the pouch was constructed extracorporeally. RESULTS: Total operative time for laparoscopic radical cystectomy and orthotopic neobladder was 8.5 and 10.5 hours, respectively, with a blood loss ranging from 200 to 400 cc. Hospital stay was 5 to 12 days and surgical margins of the bladder specimen were negative in each case. Both patients with orthotopic neobladder had complete daytime continence. Postoperative renal function was normal and excretory urography revealed unobstructed upper tracts. During followup ranging from 5 to 19 months 1 patient died of metastatic disease, while the other 2 are doing well without local or systematic progression. CONCLUSIONS: Laproscopic radical cystectomy and orthotopic ileal neobladder performed completely intracorporeally are feasible.     

Hand‐assisted laparoscopic radical cystectomy and extracorporeal urinary diversion: Experience with 31 cases

Objectives: To report our techniques and experience with hand‐assisted laparoscopic radical cystectomy and extracorporeal urinary diversion for bladder cancer. Methods: Between May 2004 and November 2007, 31 patients (mean age 61.3 years, range 40–79) underwent hand‐assisted laparoscopic radical cystectomy with extracorporeal urinary diversion for bladder cancer. Five patients had previously undergone abdominal surgeries. Data were collected with respect to patient demographics, perioperative outcomes and short‐term oncological follow up. Results: Twenty‐four patients underwent an ileal conduit and seven patients underwent an orthotopic neobladder. Mean operative time was 365.7 min (range 245 to 530). Estimated blood loss was 250.9 cc (range 100 to 500), with a transfusion rate of 9.7%. Oral liquids were resumed at 4.3 days and the mean hospital stay was 19.7 days. There were no intraoperative complications. Postoperative early complications (within 30 days of surgery) occurred in six patients (19.4%). Two wound infections, one urinary leak, one wound dehiscence, one bowel obstruction and one alimentary tract hemorrhage were all treated conservatively. Late complications occurred in three patients (two parastomal hernias and one ureteroenteric stricture). With a mean follow up of 18 months, 27 patients had no evidence of disease. One patient died because of cancer and one died for unrelated causes. One was alive with local recurrences and one with lung metastasis. Conclusions: Hand‐assisted laparoscopic radical cystectomy is a safe, reproducible and minimally invasive option for bladder cancer patients.     

膀胱肿瘤膀胱切除及尿流改道13年总结(附56例报告)

目的 评价膀胱切除治疗膀胱癌的疗效及四种不同方式尿流改道的远期效果。方法 回顾分析1992年至2004年膀胱癌行膀胱切除及尿流改道术56例临床资料。结果 随访1—10年，5年生存率58．8％，生存超过10年者1例，大部分患者对正位可控肠代膀胱控尿满意。结论 膀胱切除并不能提高5年生存率，对部分浸润性膀胱癌可选择地采用保留膀胱手术；正位可控回肠膀胱术是最理想的尿流改道方式。     

Laparoscopic assisted radical cystectomy with ileal neobladder: a comparison with the open approach

PURPOSE: To date, there have been only a few reports regarding the feasibility of the laparoscopic approach to radical cystectomy. In none of these cases has the laparoscopic approach been contrasted with a contemporary cohort of open cystectomy and diversion. Recently, we initiated laparoscopic assisted radical cystoprostatectomy and ileal neobladder (LACINB) wherein the cystoprostatectomy and pelvic lymph node dissections are performed laparoscopically and the reconstructive portion is performed via a 15 cm Pfannenstiel incision. We present and compare our initial series of LACINB with radical cystectomy performed by the open approach (OCINB) during the same period. MATERIALS AND METHODS: Between September 2001 and February 2003, 13 men underwent LACINB and 11 underwent OCINB at our institution. RESULTS: There was no statistically significant difference in operative time, blood loss or complication rates between the LACINB and OCINB groups. However, postoperative analgesic use was significantly less in the LACINB group. Time to start of a liquid diet, solid diet and length of hospitalization were also significantly less in the LACINB group vs the OCINB group. All margins in both groups were negative for bladder cancer, although 1 patient in the LACINB group had an incidentally found prostate cancer with a positive apical margin. CONCLUSIONS: LACINB is a feasible and reproducible procedure, which results in decreased postoperative pain and quicker recovery without a significant increase in operative time. However, longer followup is needed to assess long-term oncological and functional outcomes.     

Robotic-assisted laparoscopic radical cystectomy with extracorporeal urinary diversion: initial experience

BACKGROUND: The use of robotic technology for laparoscopic prostatectomy is now well established. The same cannot yet be said of robotic-assisted laparoscopic radical cystectomy (RARC), which is performed in just a few centres worldwide. OBJECTIVE: We present our technique and experience of this procedure using the da Vinci surgical system. DESIGN, SETTING, AND PARTICIPANTS: From 2004 to 2007, 23 patients underwent RARC and urinary diversion at our institution. SURGICAL PROCEDURE: We report the development of our technique for RARC, which involves posterior dissection, lateral pedicle control, anterior dissection, and lymphadenectomy prior to either ileal conduit urinary diversion or Studer pouch reconstruction performed extracorporeally. MEASUREMENTS: Demographic and perioperative data were recorded prospectively. Oncologic and functional outcomes were assessed at 3- to 6-mo intervals. RESULTS AND LIMITATIONS: To date, 23 patients have undergone this procedure at our institution. Of those, 19 had ileal loop urinary diversion and 4 were suitable for Studer pouch reconstruction. Mean total operative time plus or minus (+/-) standard deviation (SD) was 397+/-83.8min. Mean blood loss +/-SD was 278+/-229ml with one patient requiring a blood transfusion. Surgical margins were clear in all patients with a median +/-SD of 16+/-8.9 lymph nodes retrieved. The complication rate was 26%. At a mean follow-up +/-SD of 17+/-13 (range 4-40) mo, one patient had died of metastatic disease and one other is alive with metastases. The remaining 21 patients are alive without recurrence. CONCLUSIONS: RARC remains a procedure in evolution in the small number of centres carrying out this type of surgery. Our initial experience confirms that it is feasible with acceptable morbidity and good short-term oncologic results.     

Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion

OBJECTIVE: To develop a technique of nerve-sparing robot-assisted radical cystoprostatectomy (RRCP) for patients with bladder cancer. PATIENTS AND METHODS: Robotic assistance should enhance the ability to preserve the neurovascular bundles during laparoscopic radical cystectomy. Thus we undertook RRCP and urinary diversion using a three-step technique. First, using a six-port approach and the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), one surgeon carried out a complete pelvic lymphadenectomy and cystoprostatectomy using a technique developed specifically for robotic surgery. The neurovascular bundles were easily identified and dissected away, the specimen entrapped in a bag and removed through a 5-6 cm suprapubic incision. Second, a different surgical team exteriorized the bowel through this incision and created a neobladder extracorporeally. Third, the neobladder was internalized, the incision closed and the primary surgeon completed the urethro-neovesical anastomosis with robotic assistance. RESULTS: RRCP was carried out in 14 men and three women by the primary surgeon (M.M.). The form of urinary reconstruction was ileal conduit in three, a W-pouch with a serosal-lined tunnel in 10, a double-chimney or a T-pouch with a serosal-lined tunnel in two each. The mean operative duration for robotic radical cystectomy, ileal conduit and orthotopic neobladder were 140, 120 and 168 min, respectively. The mean blood loss was < 150 mL. The number of lymph nodes removed was 4-27, with one patient having N1 disease. The margins of resection were free of tumour in all patients. CONCLUSIONS: We developed a technique for nerve-sparing RRCP using the da Vinci system which allows precise and rapid removal of the bladder with minimal blood loss. The bowel segment can be exteriorized and the most complex form of orthotopic bladder can be created through the incision used to deliver the cystectomy specimen. Performing this part of the operation extracorporeally reduced the operative duration.     

Factors influencing the choice of urinary diversion in patients undergoing radical cystectomy

Study Type – Preference (case studies)
Level of Evidence 4

OBJECTIVE

To examine the rate at which patients undergo various types of urinary diversion (UD) and the reasons why they had the given reconstruction, analysed in the context of a standardized preoperative protocol for patients undergoing radical cystectomy (RC) at our institution, as there is wide variation in the distribution of patients undergoing continent (CUD) vs incontinent (ICUD) after RC.

PATIENTS AND METHODS

Between September 2004 and December 2008, 200 patients had RC with UD by one surgeon. Each patient was given standardized preoperative counselling; the charts were reviewed retrospectively to determine the relative frequencies of the various types of UD, and the reasons why patients had an ICUD assessed, including medical contraindications and personal choice.

RESULTS

During preoperative counselling, 149 patients (75%) were assessed as being eligible for a CUD, while 51 (25%) had one or more contraindication; 140 (70%) ultimately had a CUD, and the remaining 60 (30%) a ICUD. Of the 149 patients eligible for a CUD, only nine (6%) chose to undergo ICUD for personal reasons.

CONCLUSION

Few patients choose to have an ICUD in the absence of an absolute medical contraindication. Proper patient selection and thorough, standardized preoperative counselling result in a higher rate of CUD than ICUD after RC.     

Laparoscopic cystectomy with extracorporeal-assisted urinary diversion: experience with 34 patients

OBJECTIVES: Open radical cystectomy remains the gold standard for nonmetastatic muscle invasive bladder cancer. Laparoscopic cystectomy has been described as a feasible procedure and is still being evaluated. We describe our initial experience with this laparoscopic surgical approach in 34 patients. METHODS: From February 2002 to October 2004, 18 men and 16 women underwent laparoscopic cystectomy with extracorporeal-assisted urinary diversion for transitional cell carcinoma of the bladder (n=27), invasive cervical carcinoma (n=4), and atrophic bladder (n=3). We report here on specific technical details and present initial results of our series. RESULTS: The mean operating time was 244 min, the mean blood loss 325 ml, and the transfusion rate 5.9%. All procedures were completed laparascopically without conversion to open techniques. No major complications occurred during or after the operation. In case of urothelial malignancy (n=27), the histopathologic analysis of the removed specimen revealed organ-confined transitional cell carcinoma of the bladder in 66.7% (pT1:14.8%; pT2: 51.9%) and locally advanced disease in 33.3% (pT3: 25.9%; pT4: 7.4%). In two cases final histology proved positive surgical margins. Extended lymphadenectomy detected lymph node metastasis in two patients. CONCLUSIONS: We demonstrate that the combination of laparoscopic cystectomy and extracorporeal urinary diversion is possible and remains a safe, feasible, and repeatable surgical technique. To determine the oncologic outcome long-time follow-up will be necessary.     

Mid-term oncological control after laparoscopic radical cystectomy in men: a single-centre experience

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

? To assess the mid‐term (3 years of follow‐up) oncological control of laparoscopic radical cystectomy (LRC) for high‐grade muscle‐invasive bladder cancer in a well studied male population.

PATIENTS AND METHODS

? We assessed 40 men with bladder cancer (mean [range] age 66.5 [50–75] years) who underwent LRC and extended pelvic lymphadenectomy at our institution between April 2004 and September 2008. ? Of the 40 patients, 13 (32.5%) had a complete laparoscopic procedure (ileal conduit: seven patients; neobladder: five patients; bilateral ureterostomy: one patient) and 27 (67.5%) had an LRC procedure only (ileal conduit: 15 patients; neobladder: 12 patients).

RESULTS

? No major complications were observed intraoperatively. ? The mean operating time was 407 min and the mean blood loss was 720 mL. Four patients (10%) required conversion to open surgery. The mean (range) hospital stay was 10.2 (7–25) days. One patient died of myocardial infarction in the postoperative period. ? Pathological analysis showed organ‐confined tumours (stage pT0/pT1/pT2/pT3a) in 22 patients (55%) and extravesical disease (pT3/pT4) in 18 (45%). Of the 40 patients, six (15%) had lymph node involvement. The mean (range) number of nodes removed was 19.9 (5–40). ? At a mean (range) follow‐up period of 36 (0–72) months, 26 patients were alive with no evidence of disease (disease‐free survival rate 67%).

CONCLUSION

? Laparoscopic radical cystectomy is a safe, feasible, and effective alternative to open radical cystectomy (ORC). The 3‐year oncological efficacy was comparable with that of ORC.     

Radical cystectomy and orthotopic urinary diversion in male patients with pT4a urothelial bladder carcinoma: Oncological outcomes

The aim of the present study was to evaluate the oncological outcomes of radical cystectomy followed by orthotopic urinary diversion in male patients with urothelial bladder carcinoma involving prostatic stroma (pT4a). A total of 1964 patients with urothelial bladder carcinoma who underwent cystectomy between 1971 and 2008 were retrospectively analyzed. Among them, male patients with pT4aN0M0 disease at cystectomy and orthotopic urinary diversion were identified and included in the analysis. Exclusion criteria were perioperative mortality and primary urethrectomy. The outcomes were urethral recurrence, local recurrence, recurrence‐free survival and overall survival. Univariate and log–rank statistics were used to examine associations between variables and outcome. A total of 33 patients (1.7%) entered the study with a median age of 71 years. Median follow up was 4.8 years (range 0.1–21 years). A total of two urethral recurrences (6%) occurred at a median of 2.4 years after cystectomy. No patient had local recurrence. The 5‐year recurrence‐free survival and overall survival was 56% ± 10% and 56% ± 9%, respectively. The probability of urethral and local recurrence after orthotopic diversion in pT4a urothelial bladder carcinoma patients is low. Thus, orthotopic urinary diversion appears to be oncologically safe in this patient population.     

Management of benign ureteral strictures following radical cystectomy and urinary diversion for bladder cancer

PURPOSE: Ureteral obstruction due to benign strictures is a significant complication of radical cystectomy and urinary diversion for bladder cancer that can lead to renal function loss and infection related morbidity. Treatment may be performed surgically or with minimally invasive techniques. We describe the 10-year experience at our department with various treatment modalities for post-cystectomy benign strictures. MATERIALS AND METHODS: The study group consisted of 28 patients treated for benign ureteral strictures following radical cystectomy for bladder cancer. Their medical records were reviewed for clinical presentation, diagnostic procedures, treatment and long-term outcome. RESULTS: The study group represented 12.7% of all 221 patients treated at our department with radical cystectomy for bladder cancer in 1994 to 2004. Ureteral strictures were asymptomatic in 71.4% of cases. Median time to diagnosis was 7.0 months and 75% of the patients were diagnosed within year 1 after cystectomy. Treatment consisted of stenting, dilation and open surgical revision with removal of the strictured segment and reanastomosis. Median followup was 62.5 months. The stenting procedures served as the long-term definitive treatment in 45% of cases, whereas balloon dilation uniformly failed. Although open surgical revision was technically challenging, it had a long-term success rate of 93%. CONCLUSIONS: Benign ureteral strictures commonly occur during postoperative year 1 and they are usually asymptomatic. Early diagnosis and prompt drainage are required to prevent consequent renal parenchymal loss and infectious complications. Although minimally invasive procedures are viable treatment alternatives, open surgical revision is still the preferred long-term definitive treatment.     

Simple cystectomy in patients requiring urinary diversion

PURPOSE: Urinary diversion is an alternative treatment for conditions such as radiation and interstitial cystitis, neurogenic bladder and severe incontinence. The subsequent complication rate may reach 60% due to the retained nonfunctional bladder. The subsequent cystectomy rate may be as high as 20% because of pyocystis, hematuria, pelvic pain and rarely bladder cancer. We describe simple cystectomy involving bladder removal without the adjacent structures, avoiding deep pelvic dissection. MATERIALS AND METHODS: Ileal conduit or continent diversion and simple cystectomy were performed for crippling bladder symptoms secondary to neurogenic bladder, pelvic radiation, hematuria and/or severe incontinence in 12 women and 7 men with a mean age of 63 years. We performed urinary diversion and simple cystectomy only when all conservative means of treatment had failed. The majority of patients had multiple co-morbidities, previous surgeries and pelvic radiation. An average of 5 conservative procedures (range 2 to 10) had been done before simple cystectomy. None of these patients had urothelial malignancy. Simple cystectomy was done concomitantly with urinary diversion in 13 cases and later as a separate procedure in 6 due to complications of a retained nonfunctional bladder. RESULTS: Mean followup was 15 months. No mortality was associated with surgery. For simple cystectomy only mean operative time was 30 minutes and mean estimated blood loss was 300 cc. Median time from symptom presentation to cystectomy was 35 months and mean hospital stay was 7 days. In all cases symptoms were dramatically alleviated. No morbidity was directly attributable to simple cystectomy. CONCLUSIONS: Simple cystectomy is well tolerated and should be performed at urinary diversion to avoid later complications of the retained bladder. Technically this procedure is not demanding and is relatively easy to perform even after previous pelvic radiation.     

Laparoscopic versus open radical cystectomy for the management of bladder cancer: Mid-term oncological outcome

Objective:   To compare the mid-term oncological outcome of laparoscopic radical cystectomy (LRC) with those of open radical cystectomy (ORC).
Methods:   From June 2003 to February 2008, 36 LRCs were carried out at our institute for the treatment of bladder cancer. Clinical and oncological data were retrospectively analyzed. A match-pair comparison with an historical series of 34 patients who were submitted to ORC between 1996 and 2003 was carried out.
Results:   Median follow-up of the LRC group was 21 months (3–56 months). Pathological stage or grade was similar in the two groups. There was no significant difference between the LRC and ORC groups in terms of 3-year overall (64.2% vs 72.6%, respectively; P  = 0.682), cancer-specific (73.0% vs 75.3%, respectively; P  = 0.951), and recurrence-free survival (70.5% vs 72.5%, respectively; P  = 0.715) rates. In a subgroup analysis according to stage, there was also no significant difference in the 3-year disease-specific survival after LRC or ORC for organ-confined (pT1 and pT2; 85.7% vs 83.9%, respectively; P  = 0.256) or extravesical disease (pT3 and pT4; 73.3% vs 63.8%, respectively; P  = 0.825).
Conclusion:   These findings suggest that LRC provides mid-term oncological outcomes similar to those of ORC in the management of bladder cancer.     

改良腹腔镜根治性膀胱切除术加Studer原位回肠新膀胱重建初步研究

目的:总结11例腹腔镜根治性膀胱切除、标准淋巴结清扫加Studer原位回肠新膀胱重建的经验,评价此术式肿瘤学结果与功能性结果。方法:2008年7月～2011年5月,选择11例肌层浸润性膀胱肿瘤患者实施腹腔镜根治性膀胱切除加下腹壁小切口行Studer原位回肠新膀胱重建术,对手术时间、淋巴结数量、围手术期并发症、出血量、输血量、生存率、上尿路形态与功能、控尿情况进行分析。结果:平均手术时间为6.17(5.5～7.5)h,平均出血量为300(0～800)ml,仅1例输血400ml,平均清扫淋巴结数15(5～30)个,无围手术期死亡,围手术期并发症发生率为18.19%(2/11)。上尿路检查,提示18.19%(2/11)术后拔出双J管后出现双侧肾盂及输尿管的轻度暂时性扩张,其中1例血肌酐上升。随访15(1～67)个月,1例鳞癌死于广泛转移,91%(10/11)无复发生存。患者日间完全控尿率达到90%(9/10);夜间完全控尿率70%(7/10),小于1块尿垫20%(2/10)。结论:选择适当病例行改良的腹腔镜根治性膀胱切除、标准淋巴结清扫加下腹壁小切口行Studer原位回肠新膀胱重建术取得了满意肿瘤学与功能性结果;Studer原位回肠新膀胱顺向蠕动输入袢能够保护上尿路形态与功能。