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.     

Laparoscopy-assisted robotic radical cystoprostatectomy with ileal conduit urinary diversion for muscle-invasive bladder cancer: initial two cases

BACKGROUND AND PURPOSE: The use of the da Vinci robot is being investigated in the discipline of urologic surgery. We describe our experience with its use during radical cystoprostatectomy in two patients with organ-confined bladder cancer. PATIENTS AND METHODS: Laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion was performed using the da Vinci robot. Both patients were informed about this new approach, and informed consent was obtained. RESULTS: There were no intraoperative or postoperative complications. The operative time was 10 and 12 hours. A clear liquid diet was started on the third postoperative day. Final histopathology examination in both patients revealed T(3a)N(0)M(0) transitional-cell carcinoma. The hospital stay was 6 days. Both patients returned to normal activity within 2 weeks. CONCLUSION: Robot-assisted laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion for muscle-invasive bladder cancer is feasible.     

体外协助尿流改道的腹腔镜全膀胱根治性切除术

目的 探讨体外协助尿流改道的腹腔镜全膀胱根治性切除术的疗效.方法 2006年6月～2012年6月施行体外协助尿流改道的腹腔镜全膀胱根治性切除术28例,全膀胱切除和盆腔淋巴结清扫均在腹腔镜下完成,标本自下腹部小切口取出,体外协助尿流改道采用回肠膀胱术（Bricker手术）和原位回肠新膀胱2种术式,其中Bricker手术22例、原位回肠新膀胱术6例.结果 均一次手术成功,腹腔镜盆腔淋巴结清除及全膀胱切除手术时间150～240 min,平均180 min;体外协助尿流改道时间90～270 min,平均150 min;术中出血200 ～900 ml,平均350 ml;肠功能恢复时间3～4d.6例原位回肠新膀胱2～4周拔除导尿管,能正常排尿,无尿潴留和肾功能损害发生.26例随访6～36个月,平均15个月,1例术后23个月死于复发及远处广泛转移,2例死于其他内科疾病,其余患者一般情况良好,未见肿瘤复发及转移.结论 体外协助尿流改道的腹腔镜全膀胱根治性切除术疗效满意.     

Laparoscopic radical cystectomy and ileal conduit reconstruction: preliminary experience

PURPOSE: We present our preliminary experience with laparoscopic radical cystoprostatectomy for muscle-invasive carcinoma of the urinary bladder. Patient and operative data and the surgical technique are presented. PATIENTS AND METHODS: Laparoscopic radical cystoprostatectomy and bilateral pelvic lymph node dissection were performed using five or six ports by a transperitoneal approach. An ileal conduit urinary diversion was constructed at the site of specimen retrieval. RESULTS: The procedure was successful in nine of ten patients with a mean blood loss of 533 mL and an average transfusion of 1.3 units per patient. The mean operating time was 6.48 hours and an average of 33 mg of morphine equivalents was required for analgesia. The mean hospital stay was 10.8 days. One patient had surgical margins positive for cancer, while none had histologic evidence of pelvic nodal metastasis. There were five minor and major intraoperative and postoperative complications. The remaining patient, treated early in our experience, developed hypercarbia necessitating conversion to open surgery. No metastases have been seen after a mean duration of follow-up of 19 months. CONCLUSIONS: Laparoscopic radical cystoprostatectomy with open ileal conduit urinary diversion is a feasible alternative to traditional open radical cystectomy. Urinary diversion can be performed through the small incision necessary to extract the surgical (radical cystoprostatectomy) specimen from the abdomen. With our modified technique, it also is feasible to reduce the cost.     

Laparoscopic ileal conduit: five-year follow-up

OBJECTIVES: To report the techniques used for intracorporeal laparoscopic construction of an ileal conduit urinary diversion and long-term patient follow-up after this procedure. METHODS: A 28-year-old man with cerebral palsy, a neurogenic bladder, and voiding dysfunction was referred for definitive management of his urinary tract after several episodes of pyelonephritis. A conduit urinary diversion was performed using a 5-port, transabdominal approach. An appropriate length of ileum was used for diversion, and ureterointestinal anastomoses were performed using a modified Bricker technique. All aspects of the procedure were performed intracorporeally, including isolation of conduit, bowel reanastomosis, ureteral mobilization, and ureterointestinal anastomosis. A 12-mm port site was enlarged and used as the stoma, which was constructed in routine fashion. RESULTS: Five years after surgery, this patient had normal and stable renal function, with a serum creatinine of 0.8 mg/dL. Serial imaging studies continued to reveal prompt and symmetric renal function and no evidence of obstruction or reflux. CONCLUSIONS: Laparoscopic ileal conduit construction is feasible and can provide durable results. Although technically challenging, ongoing technical refinements will make performance of reconstructive laparoscopy more widely applicable. Larger series with substantial follow-up will help illuminate the place of laparoscopic noncontinent urinary diversion in the surgical armamentarium.     

Laparoscopic radical cystectomy with ileal conduit diversion

Remaining the gold standard treatment of muscle-invasive bladder cancer and high-risk superficial tumors, the radical cystectomy has been translated into a fully laparoscopic protocol, actually gaining more and more acceptance worldwide. In this article, a transperitoneal antegrade laparoscopic protocol is described for radical cystectomy performed in both genders. After removal of the specimen, generally through a mini-laparotomy, most of the teams perform the maneuvers for urinary diversion through an ileal conduit as an open procedure, although a completely laparoscopic procedure has been successfully achieved. Laparoscopic cystectomy will face the proof of time if oncologic rules about surgical management of transitional cell carcinoma are carefully respected to avoid any cell spillage. When obvious laparoscopic advantages for the patients are encountered with laparoscopic cystectomy, it seems unlikely that a full laparoscopic protocol, including the diversion, may gain wide acceptance; in that case, the true laparoscopic benefits would be wasted by unjustified lengthening of operative time and by compromising the quality of uretero-ileal anastomoses.     

Laparoscopic radical cystectomy with extracorporeal urinary diversion: Preliminary experience

AIM: We present our experience with the fi rst eight patients who underwent laparoscopic radical cystectomy with bilateral pelvic lymphadenectomy and extracorporeal urinary diversion. Patients, operative data and the surgical techniques are presented. METHODS: Between June 2003 and April 2004, seven men and one woman with organ-con fi ned muscle-invasive transitional cell carcinoma of the bladder underwent laparoscopic radical cystectomy with urinary diversion. The age range was 41-73 years. Laparoscopic radical cystectomy and bilateral pelvic lymphadenectomy were performed using fi ve ports by a transperitoneal approach. An ileal conduit diversion or ileal W-neobladder was constructed through the site of specimen retrieval. RESULTS: We performed eight radical cystectomies with ileal conduits (six cases) or orthotopic ileal W-neobladders (two cases). Conversion to open surgery was necessary in one due to technical dif fi culty in urethroneobladder anastomosis. Mean operating time was 560 min (range 455-680). Mean estimated blood loss was 675 mL (range 400-1050). Two of the eight patients needed blood transfusion (800 mL each). Mean days to oral intake and ambulation was 4.4 (range 2-6) and 4.1 (range 3-5), respectively. Mean hospital stay was 12.8 days (range 7-28). Mean follow up was 6.1 months (range 4-14). Histopathological examination of the specimens revealed stage T2N0M0 in fi ve cases, T3aN0M0 in one, T3aN1M0 in one and T3bN1M0 in one. No metastases have been detected and all are alive and free of disease. CONCLUSION: Laparoscopic radical cystectomy is feasible, although dif fi cult and technically demanding, and our results are promising. With more experience and improvement of the surgical technique, laparoscopic radical cystectomy with urinary diversion may become an alternative surgical method for treating the selected patients with localized muscle invasive bladder cancer.     

Is adjuvant chemotherapy for bladder cancer safer in patients with an ileal conduit than a neobladder?

OBJECTIVE: To assess the safety of adjuvant chemotherapy in patients with neobladder reconstruction in comparison to ileal conduit, as radical cystectomy and urinary diversion is an effective curative surgical treatment for muscle-invasive and high-risk superficial bladder cancer, and adjuvant chemotherapy is usually considered for patients with clinical stage > T2 and nodal metastasis. PATIENTS AND METHODS: We analysed retrospectively patients who had had a radical cystectomy and urinary diversion between 1992 and 2004. Patients with high-risk disease who had adjuvant chemotherapy were identified and stratified based on the type of urinary diversion (ileal conduit or neobladder). The chemotherapy regimen, complications from the adjuvant chemotherapy and other relevant data were analysed. RESULTS: Overall, 343 patients had radical cystectomy, 40 had adjuvant chemotherapy; 25 had an ileal conduit and 15 had a neobladder. Patient characteristics including age, stage and follow-up were similar. In all, 55% of patients had grade 1 toxicity, 23% grade 2, 18% grade 3, and 13% grade 4. No patients had serious organ toxicity and none died. There were no significant differences in the toxicity among the two groups. CONCLUSIONS: Adjuvant chemotherapy appears to be safe in patients with a neobladder and equally safe in patients with an ileal conduit. Hence neobladder reconstruction should not be denied to patients with bladder cancer who are at high risk of recurrence and who might require adjuvant chemotherapy.     

LAPAROSCOPIC INTRACORPOREALLY CONSTRUCTED ILEAL CONDUIT AFTER PORCINE CYSTOPROSTATECTOMY

PURPOSE: We present our technique of laparoscopic ileal conduit creation after cystoprostatectomy in a porcine model performed in a completely intracorporeal manner. METHODS AND METHODS: After developing the technique in 5 acute animals laparoscopic cystoprostatectomy with intracorporeally performed ileal conduit urinary diversion was performed in 10 surviving male pigs. A 5-port transperitoneal technique was used. All steps of the technique applied during open surgery were duplicated intracorporeally. Specifically cystectomy, isolation of an ileal conduit, restoration of bowel continuity and mucosa-to-mucosa stented bilateral ileoureteral anastomosis formation were performed by exclusively intracorporeal laparoscopic techniques. RESULTS: Surgery was successful in all 10 study animals without intraoperative or immediate postoperative complications. Blood loss was minimal and average operative time was 200 minutes. Stenosis of the end ileal stoma specifically at the skin level was noted in 6 animals. Three deaths occurred 2 to 3 weeks postoperatively. At sacrifice renal function was normal in all surviving animals. No ileo-ureteral anastomotic strictures were noted on pre-sacrifice radiography of the loop or at autopsy examination of the anastomotic sites. CONCLUSIONS: Laparoscopic ileal conduit urinary diversion after cystoprostatectomy may be performed completely intracorporeally in the porcine model. Clinical application of this technique is imminent.     

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.     

Laparoscopic radical cystectomy for cancer: oncological outcomes at up to 5 years

OBJECTIVE: To report the oncological outcomes at < or = 5 years after laparoscopic radical cystectomy (LRC), as open RC is the reference standard treatment for muscle-invasive bladder cancer, but interest in LRC is increasing at selected centres worldwide and as yet there are no long-term follow-up data. PATIENTS AND METHODS: Between December 1999 and January 2005, 37 patients (mean age 66 years) had LRC with urinary diversion for invasive bladder cancer; 26 patients (70%) also had an extended pelvic lymphadenectomy. Overall and cancer-specific survival data were obtained from patient charts, radiographic reports, telephone contact, and a check of the Social Security Death Index. RESULTS: Most tumours were transitional cell carcinoma (32, 86%), high-grade (grade III in 29, 78%) and high-stage (> or =pT2 in 26, 70%). Two patients had a positive surgical margin. The median (range) number of lymph nodes excised was 14 (2-24); seven patients (17%) had node-positive disease (pN1). Follow-up data were available for 35 patients (95%); eight (22%) completed > or = 5 years of follow-up, and the mean (range) follow-up was 31 (1-66) months. At the last follow-up, 24 patients (65%) were alive with no evidence of disease and 11 (30%) were dead, two (5%) from metastasis and nine (24%) from unrelated causes. The 5-year actuarial overall, cancer-specific and recurrence-free survival was 63%, 92% and 92%, respectively. CONCLUSION: To our knowledge, this is the first report of < or = 5-year follow-up after LRC; the data suggest that LRC provides oncological outcomes comparable to contemporary series of open RC.     

Robot-assisted Bricker ileoureteral anastomosis during intracorporeal laparoscopic ileal conduit urinary diversion for prostatocutaneous fistula: case report

BACKGROUND AND PURPOSE: The da Vinci robot is useful during minimally invasive surgery in performing intracorporeal suturing. We report one case of its application during laparoscopic ileal conduit urinary diversion for prostatocutaneous fistula. METHODS: A 58-year-old paraplegic man with a neurogenic bladder and bowel and a long history of urinary incontinence developed a prostatocutaneous fistula after numerous procedures to correct the incontinence. He underwent laparoscopic ileal conduit urinary diversion to improve his quality of life. The da Vinci robot was used to perform the ileoureteral anastomosis. RESULTS: The operative time was 10 hours. The estimated blood loss was <100 mL. There were no intraoperative complications. The patient was started on a clear liquid diet on postoperative day 3. There was no narcotic use because of the patient's neurologic status. The patient was discharged home on day 6. CONCLUSION: Laparoscopic urinary diversion remains a technically challenging procedure. The da Vinci robot is useful during laparoscopic ileal conduit construction.     

腹腔镜下全膀胱切除原位回肠新膀胱重建术(附5例报告)

目的:介绍腹腔镜下全膀胱切除原位回肠新膀胱重建术的经验。方法:采用腹腔镜下全膀胱切除原位回肠新膀胱重建术治疗浸润性膀胱癌患者5例。方法是经腹壁小切口取出切除物,行回肠去管成形新膀胱,然后在腹腔镜下将新膀胱与尿道连续吻合。结果:5例患者手术成功,手术时间4.5~7.2h。腹腔镜手术中以超声刀及双极电凝行膀胱侧韧带、前列腺血管蒂及前列腺尖部切断止血,未使用钛夹、术中出血量180~550ml,平均输血400ml。术后4~5天恢复饮食,3周拔除输尿管支架管,4周拔除尿管。患者白天可完全控制排尿,2例夜间偶有尿失禁。1例术后尿漏,经引流治愈。结论:腹腔镜下全膀胱切除术具有创伤小、出血少、恢复快等优点;而回肠新膀胱和尿道连续吻合具有操作方便、省时、缝合紧密、可防止尿漏等优点。     

腹腔镜下根治性膀胱切除回肠新膀胱术（附15例报告）

目的介绍腹腔镜下根治性膀胱切除回肠新膀胱术的方法及经验。方法本组15例，均为男性，年龄45～62岁，平均54岁。术前均明确诊断为浸润性膀胱癌。采用腹腔镜下行膀胱癌根治性切除，然后取长约40cm回肠于体外缝制贮尿囊及输尿管贮尿囊吻合，体内行贮尿囊尿道吻合术。结果手术时间5．5～8h，平均6．5h；出血量200～1100ml，平均550ml。术后8周静脉尿路造影以及代膀胱造影检查显示：双肾显影良好，无输尿管返流及梗阻，代膀胱充盈良好，容量约300ml。术后3个月全部患者日间控尿良好，7例患者夜间控尿良好，夜间排尿2～3次。结论腹腔镜下膀胱全切除、体外建成贮尿囊及输尿管再植、体内贮尿囊尿道吻合术创伤小、出血少、术后尿控率高、恢复快。     

Hand-assisted laparoscopic cystoprostatectomy and urinary diversion

PURPOSE: We report the first series of patients who have undergone hand-assisted laparoscopic cystoprostatectomy and diversion (HALCD). PATIENTS AND METHODS: Seven patients with muscle-invasive bladder cancer elected to have their surgery by hand-assisted laparoscopy. The bladder was excised using a hand-assisted laparoscopic technique, and the ileal conduit was constructed through the midline incision created for the hand. RESULTS: The operative time was relatively short (mean 7.6 hours), blood loss was low (420 mL), and the postoperative stay was short (4.6 days). Long-term follow-up is pending. CONCLUSION: Laparoscopic techniques for radical cystectomy are currently being explored at several major medical centers. Hand-assisted laparoscopy offers the distinct advantages of palpation, retraction, speed, and minimal morbidity.     

Surgical and pathological outcomes of robotic-assisted radical cystectomy for bladder cancer in the community setting

Robotic-assisted radical cystectomy (RARC) with urinary diversion is commonly performed in community hospitals. While little data exist on RARC outcomes in this setting, community hospitals may improve access to care for bladder cancer patients. We conducted a retrospective review of 76 patients who underwent RARC between 2006 and 2016 by two robotic-trained surgeons in two local community hospitals. A total of 76 patients (60 males and 16 females; ages 46–89) underwent RARC with extended pelvic lymphadenectomy and urinary diversion (69 ileal conduits, 7 neobladders) for muscle-invasive bladder carcinoma (79%), recurrent high-grade carcinoma (17%), unresectable tumor (2%), or refractory gross hematuria from chemotherapy (2%). Median-estimated surgical blood loss (EBL) was 400 mL, and median operating time was 386 min. Transfusion rate was 22% and median length of hospital stay was 6 days. Our 90-day complication rate was 47%, with no mortalities in the 90-day post-operative period. The majority of complications (58%) were Clavien grade 1–2. We observed a significant difference in incidence of complications among patients receiving neobladder vs. ileal conduit (p = 0.002). On pathology, zero patients had positive bladder specimen margins. Among 28 patients with at least 3-year follow-up, overall survival was 85.7%, and among 9 patients with at least 5-year follow-up, overall survival was 100%. Contrary to some studies, our findings suggest similar short-term surgical and pathologic outcomes for RARC performed in the community hospital setting compared to high volume centers. We defined several criteria for low volume centers to effectively and safely perform RARC.     

Case report: Laparoscopy-assisted urinary undiversion: transforming an ileal conduit into an orthotopic continent neobladder

PURPOSE: To describe the technique of laparoscopy-assisted undiversion of an ileal conduit into a continent orthotopic ileal neobladder performed on a patient with a previous radical cystoprostatectomy and ileal conduit. CASE REPORT: A 57-year-old man presented with a prolapsed stoma and a history of a right radical nephroureterectomy for grade 3 ureteral transitional-cell carcinoma and a radical cystoprostatectomy and ileal conduit urinary diversion for in-situ bladder carcinoma, performed 12 and 8 years ago, respectively. After the ileal stoma was resected, five trocars were placed transperitoneally. Partial resection of the distal ileal conduit was performed, leaving in place the proximal segment with its left ureteroileal anastomosis. Flexible urethroscopy revealed a contracting external sphincter, and random urethral frozen-section biopsies ruled out tumor. A 45-cm segment of ileum was isolated and exteriorized through the stoma site, and an ileal neobladder was created extracorporeally, suturing the proximal ileal-conduit segment, with its ureteroileal anastomosis, to it. The ileal neobladder was reintroduced into the abdomen and anastomosed laparoscopically to the urethral stump with six 2-0 polyglactin sutures. The total operative time was 7 hours with a blood loss of 100 mL. There were no intraoperative complications. The hospital stay was 7 days. At a follow-up of 24 months, the patient had total daytime continence and normal renal function, and intravenous urography revealed an unobstructed urinary tract. CONCLUSION: Laparoscopy-assisted ileal-conduit undiversion into an orthotopic ileal neobladder is technically feasible. It can be considered an alternative to open surgery for patients who have undergone urinary diversion.     

Laparoscopic radical cystectomy with urinary diversion: completely intracorporeal technique

Laparoscopic radical cystectomy with urinary diversion performed using intracorporeal techniques exclusively is a new development in the growing field of minimally invasive urology. This report details step by step the completely intracorporeal laparoscopic technique of cystectomy, bilateral pelvic lymphadenectomy, and urinary diversion with creation of an ileal conduit or neobladder, including the isolation of ileum, restoration of bowel continuity, retroperitoneal transfer of the left ureter to the right side, bilateral stented ureteroileal anastomoses, and urethroileal anastomosis in case of orthotopic diversion. Although at present, this is still a technique in development at high-volume medical centers, it holds promise as a minimally invasive yet appropriately radical form of treatment for patients with muscle-invasive bladder cancer. Definition of its true role awaits greater experience and long-term comparisons of the outcomes with those of traditional open surgery.     

Peritonealkarzinose nach roboterassistierter radikaler Zystektomie

Among patients with metastatic urothelial cancer of the bladder, 16-25% develop peritoneal carcinomatosis. In the majority of cases peritoneal carcinomatosis is associated with multiple metastatic sites. Peritoneal metastases as the single site of metastatic deposits are rare and they have been described following laparoscopic radical nephroureterectomy or cystectomy. We report on a patient who developed peritoneal carcinomatosis as the single site of metastases 8 months after robotic-assisted radical cystectomy, extended pelvic lymphadenectomy and extracorporeal formation of an ileal neobladder for organ-confined, muscle-invasive and poorly differentiated bladder cancer. The indication for robotic-assisted radical cancer surgery for urothelial carcinoma of the upper or the lower urinary tract in patients with locally advanced or poorly differentiated cancer should be made with caution.     

Ileal conduit in era of systemic chemotherapy

The records of 62 patients with invasive transitional cell carcinoma of the bladder whose planned treatment was radical cystectomy with ileal conduit urinary diversion and postoperative systemic chemotherapy were reviewed. Seven of the patients received radical cystectomy but not postoperative chemotherapy as planned, 3 of them (5%) for reasons directly related to complications from the urinary diversion. Fifty-five patients received the planned postoperative chemotherapy. Complications during chemotherapy that were related to the ileal conduit were urinary tract infection in 37 percent and stenosis at the ureteroileal anastomosis requiring percutaneous nephrostomy in 3.6 percent. Chemotherapy was not discontinued in any patient, however, because of complications specifically related to the urinary diversion. We conclude that the ileal conduit is well tolerated by patients who require systemic chemotherapy and is, today, the simplest, safest, and best diversion method when systemic chemotherapy is to follow radical cystoprostatectomy.