Laparoscopic assisted radical cystectomy: the montsouris experience after 84 cases

PURPOSE: Radical cystectomy is the gold standard treatment for transitional cell carcinoma of the bladder, and the laparoscopic approach is currently being evaluated worldwide. We report our preliminary results of this laparoscopic surgical approach. MATERIALS AND METHODS: Between May 2001 and February 2005, we have performed a total of 84 laparoscopic assisted prostatocystectomies or cystectomies for transitional cell carcinoma of the bladder on 71 male and 13 female patients. The 2002 TNM staging for these tumors were: pTa-1: 13 cases; pT2: 59 cases; pT3: 11 cases; pT4: 1 case. Technical aspects are described and the initial results are reported. RESULTS: The median operating time was 280 min. The median blood loss was 550 cc with a transfusion rate of 5%. There has been no conversion to an open technique. Complications: No death, one pulmonary embolism, two urinary fistulas, three haematomas, one pyelonephritis. ONCOLOGICAL RESULTS: The pathology reports confirmed that all the surgical margins were free of tumor invasion. After 18 months of follow up no trocar seeding was observed. CONCLUSION: Laparoscopic assisted cystectomy is a feasible technique which results in decreased bleeding and less postoperative pain. Long term follow-up is needed to confirm the oncologic 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.     

腹腔镜膀胱根治性切除术围手术期并发症分析

目的探讨腹腔镜下膀胱根治性切除术围手术期并发症发生情况。方法统计本院2016年12月至2018年12月104例膀胱癌患者行腹腔镜下根治性膀胱切除术(LRC)围手术期的并发症以及手术时间、术中出血量、术后住院时间等情况。围手术期并发症定义为手术30 d内发生的并发症。结果平均手术时间327 min,平均出血量478 mL,接受输血者16例(15.4%),平均输血量415 mL。术后平均住院时间17.9 d。尿流改道方式上,Bricker回肠膀胱术68例,输尿管皮肤造口术36例。围手术期并发症发生率47.1%(49例),包括肠梗阻、尿路感染、肺炎、下肢静脉血栓、肺栓塞等。结论腹腔镜下膀胱根治性切除术仍有较高的并发症发生率,常见并发症为肠梗阻,尿路感染等,术前应积极治疗基础疾病,术中严格操作,术后采取相应预防措施以防止出现严重并发症。并根据患者情况选择合适的手术方案。     

机器人辅助腹腔镜根治性膀胱切除体外尿流改道术

统使外科医生能够更加精确、高效地完成腹、盆腔手术,在微创泌尿外科领域值得推广、应用.     

Robot-assisted laparoscopic hysterectomy: technique and initial experience

BACKGROUND: Our study objective was to develop a technique for robot-assisted laparoscopic hysterectomy and to evaluate feasibility of the technology to address the technical limitations of conventional laparoscopy. METHODS: The study design was a case series analysis in a university hospital. Sixteen consecutive patients underwent robot-assisted laparoscopic hysterectomy and were assessed for outcomes. Robot-assisted hysterectomy technique was refined and is described. RESULTS: There were no conversions to laparotomy. The mean uterine weight was 131.5 g (range 30 to 327 g). Median operating time was 242 minutes (range 170 to 432). Average estimated blood loss was 96 mL (range 50 to 300 mL). One patient experienced a delayed thermal bowel injury, 2 developed postoperative infections, and 1 developed a vaginal cuff hematoma that was managed expectantly. The median length of hospital stay was 1.5 days. CONCLUSIONS: Robot-assisted laparoscopic hysterectomy is a feasible and promising new technique that may overcome surgical limitations seen with conventional laparoscopy.     

腹腔镜膀胱癌根治术尿道改流留置外、内支架管与无管化的对比研究

目的比较腹腔镜膀胱癌根治术尿道改流（RCUD）中留置外、内支架管与无管化术后的效果。 方法回顾性分析100例于2015年1月至2021年1月在中山大学附属第三医院泌尿外科行RCUD膀胱癌患者的资料。根据术中的处理方法不同分为外支架管组（48例）、内支架管组（9例）和无管组（43例）。统计学分析三组患者的基本资料、围手术期指标以及术后并发症等情况。 结果RCUD术后尿漏总发生率为15%,外支架组明显低于无管组（6.3% vs 25.6%,P=0.031）,内支架管组的发生率为11.1%;尿培养阳性率为29%,外支架管组明显低于无管组（18.8% vs 41.9%,P=0.047）,内支架管组的发生率为22.2%;三组患者间内支架管组手术时间更短[（365±88）min vs （469± 120）min vs （457±98）min,P=0.034];内支架管组术后住院时间更短[（9.0±2.3）d vs （20.6±12.6）d vs（21.3±11.1）d,P=0.013]。患者RCUD术后肠梗阻发生率（P=0.097）、伤口愈合不良发生率（P= 0.113）、输尿管肠吻合口狭窄（UEAS） （P=0.978）、术后30 d再入院率（P=0.919）和总并发症评分（P=0.801）组间差异无统计学意义。 结论膀胱癌根治术中使用内支架管安全可靠,可明显缩短手术时间和术后住院时间。与无管化相比,放置外支架管可明显降低术后尿漏的发生率和术后尿路感染风险。     

Robot-assisted laparoscopic gastrectomy with D2 dissection for adenocarcinoma: initial experience with 17 patients

Robot-assisted gastrectomy has been practised so far in very few centres in the world. The aims of this study were to assess the feasibility of robot-assisted gastrectomy for adenocarcinoma with D2 lymph nodal dissection and to analyze our preliminary results. Between January 2006 and August 2008, as many as 17 patients (11 females, 6 males) underwent laparoscopic robot-assisted surgery for non-metastatic adenocarcinoma of the stomach by a 3-armed da Vinci^® Robotic Surgical System. The mean age of patients was 65.9 years. This series included eight patients with early gastric cancer (EGC) and nine with advanced gastric cancer (AGC). A 4/5 laparoscopic subtotal gastrectomy (LSG) with D2 nodal clearance was the procedure of choice for 16 distal cancers. Laparoscopic total gastrectomy (LTG) with D2 lymphadenectomy was performed for one AGC of the middle third of the stomach. No intraoperative complication was registered. Conversion to laparotomy was required in two patients with distal cancer. The mean operating time (excluding converted patients) was 352 min (348 for LSG). Morbidity consisted in one pancreatic leak that healed conservatively. One death occurred postoperatively for haemorragic stroke. On average, 25.5 ± 4 lymph nodes were collected (range 10–40). The resection margin was 6.4 ± 0.6 cm (range 4.2–8), and the margin was tumour free in all the specimens. The mean hospital stay of totally laparoscopic subtotal gastrectomy was 10 ± 1.2 days (range 8–13). The mean follow-up was 14 months (range 1–29) and three patients with AGC showed recurrence after LSG and died of disease. Robotics in gastrectomy for cancer is a feasible and safe procedure, yielding adequate D2 nodal clearance with respect of oncologic principles. Robotic techniques can represent a remarkable tool to improve laparoscopic surgeon’s ability and precision in small surgical fields, i.e. during D2 dissection. This study demonstrated the feasibility of robot-assisted gastrectomy for cancer although further studies are required to validate our preliminary results, especially as far as patients’ benefits are concerned.     

浸润性膀胱癌腹腔镜下根治性膀胱切除术43例

目的 探讨腹腔镜下根治性膀胱切除的手术方法和临床体会.方法 自2003年12月至2006年10月我们对43例浸润性膀胱癌患者实施了腹腔镜根治性膀胱切除术.手术采用经腹腔入路5部位穿刺法.结果 43例手术中,18例行输尿管皮肤造口术,25例行回肠膀胱术.2例因术中损伤直肠中转开腹行直肠修补术,1例术后放置肛管引流1周,另1例则行乙状结肠造瘘术.41例手术获得成功,腹腔镜下切除全膀胱连同淋巴结清扫的手术时间为140～270 min,平均195.4 min;术中出血150～700 ml,平均273.7 ml,术中术后输血3例;术后2～3 d下床活动;术后病理示3例盆腔淋巴结阳性.结论 腹腔镜根治性膀胱切除术治疗浸润性膀胱癌安全可行,能明显减小手术创伤、减少手术并发症、缩短患者恢复时间.     

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.     

Robot-assisted laparoscopic mesh repair of incisional hernias with exclusive intracorporeal suturing: a pilot study

Background The da Vinci robot laparoscopic incisional hernia repair with intracorporeal suturing may offer an alternative to transabdominal sutures and tackers. Methods From 2003 to 2005, 11 patients (median age, 71 years; median body mass index [BMI], 28) with small and medium-sized incisional hernias (median fascial defect, 19.6 cm²) were treated with the da Vinci robot system using intracorporeal mesh fixation with interrupted sutures. This pilot study aimed to assess the feasibility and report the morbidity with special reference to postoperative pain and long-term recurrence. Results The median operative time was 180 min. There was no conversion to open or standard laparoscopy and no postoperative mortality. The overall morbidity rate was 27%. One patient underwent reoperation on postoperative day 3 for peritonitis secondary to small bowel injury. The median visual analog pain score on postoperative day 1 was 3. Seven patients (63%) needed parenteral paracetamol until postoperative day 2. The median hospital stay was 3 days. During a median follow-up period of 25 months, no patient experienced recurrent hernia. One patient had a trocar-site herniation at 6 months. No patient experienced chronic suture site pain or discomfort. Conclusion This is the first report of robot-assisted laparoscopic incisional hernia with exclusive intracorporeal suturing for mesh fixation in humans. The findings show that this technique is feasible and may not be associated with chronic postoperative pain. Further evaluation is needed to assess the benefit to the patient, but this investigation may be the basis for a future, prospective, randomized study.     

Risk groups in bladder cancer patients treated with radical cystectomy

Objective

To stratify patients with bladder cancer into homogeneous risk groups according to statistically significant differences found in PFS (progression-free survival). To identify those patients at increased risk of progression and to provide oncological follow-up according to patient risk group.

Materials and Methods

A retrospective study of 563 patients treated with radical cystectomy (RC). In order to determine which factors might predict bladder tumour progression and death, uni- and multivariate analyses were performed. The risk groups were identified according to “inter-category” differences found in PFS and lack of differences, thus revealing intra-category homogeneity.

Results

Median follow up time was 37.8 months. Recurrence occurred in a total of 219 patients (38, 9%). In 63% of cases this was distant recurrence. Only two variables retained independent prognostic value in the multivariate analysis for PFS: pathological organ confinement and lymph node involvement. By combining these two variables, we created a new “risk group” variable. In this second model it was found that the new variable behaved as an independent predictor associated with PFS.Four risk groups were identified: very low, low, intermediate and high risk:• Very low risk: pT0 N0• Low risk: pTa, pTis, pT1, pT2 and pN0• Intermediate risk: pT3 and pN0• High risk: pT4 N0 or pN1-3.

Conclusions

We retrospectively identified 4 risk groups with an independent prognostic value for progression-free survival following RC. Differences in recurrence patterns after RC between risk groups have led us to set different intervals in monitoring for cancer.     

Chronic urinary retention after radical cystectomy and orthotopic neobladder in women: Risk factors and relation to time

Purpose

To investigate the long-term cumulative incidence of chronic urinary retention (CUR) after radical cystectomy (RC) and orthotopic neobladder (ONB) in women and the possible risk factors.

保留神经的全膀胱切除术对盲结肠代膀胱控尿功能的影响

目的　探讨保留神经全膀胱切除术对盲结肠代膀胱控尿功能的影响。　方法　膀胱全切盲结肠代膀胱术共 73例 ,其中保留神经组 4 8例 ,非保留神经组 (对照组 ) 2 5例。术后随访 3～ 2 8个月 ,通过问卷和尿垫试验对比术后控尿能力。　结果　拔除尿管后 ,保留神经组白天和夜间可控率分别为 6 5 %和 4 0 % ;对照组为 34%和 2 6 %。术后达到白天和夜间可控所用的平均时间保留神经组分别为 2个月和 4个月 ;对照组为 5个月和 10个月。术后 12个月时 ,保留神经组白天和夜间可控率分别为 96 %和 87% ;对照组为 79%和 6 4 %。两组差异有显著性意义 (P <0 .0 1)。　结论　保留神经膀胱全切盲结肠代膀胱术可以提高术后控尿功能 ,减少尿失禁发生率。     

无线智能腔镜在腹腔镜膀胱癌根治术中的运用

目的 研究无线智能腔镜在腹腔镜膀胱癌根治术中的运用。方法 选取2021年5月至2022年6月安徽医科大学附属第一医院泌尿外科收治的38例高级别浸润性膀胱癌患者,19例行传统高清腹腔镜下膀胱癌根治术,19例行无线智能腔镜下膀胱癌根治术;比较两组在术前准备时间、手术时间、出血量、清晰度、握持感、图像延迟的差异。结果 在手术时间、出血量、清晰度、图像延迟上比较高清腹腔镜手术组与无线智能腹腔镜手术组差异无统计学意义（P>0.05）;在术前准备时间上无线智能腹腔镜组短于传统高清腹腔镜组（P<0.05）;无线智能腔镜组术者术中的握持感要优于传统高清腹腔镜组（P<0.05）。结论 无线智能腔镜手术系统在膀胱癌根治术中是一种安全、有效的腹腔镜系统,可以降低术前准备时间、提高术者对腔镜镜头的握持感。     

腹腔镜根治性全膀胱切除+原位回肠新膀胱术对膀胱癌患者的临床疗效及并发症分析

摘 要：目的 比较腹腔镜根治性膀胱全切除+原位回肠新膀胱术与开放手术的临床效果及安全性。方法 选择2010年1月至2015年3月在本院行膀胱全切除+原位回肠新膀胱术的70例患者作为研究对象,其中30例行腹腔镜下手术作为观察组,40例行开放手术作为对照组;对比两组患者围手术期情况、新膀胱功能及并发症发生情况。结果 观察组胃肠道功能恢复时间、术后住院时间明显缩短,术中出血量明显减少,与对照组相比差异具有统计学意义（P＜0.05）,手术时间则明显长于对照组（P＜0.05）;两组患者在控尿率、膀胱内压、膀胱容量、剩余尿量等方面差异无统计学意义（P＞0.05）,观察组最大尿流率显著高于对照组（P＜0.05）。两组患者术后主要并发症有肠梗阻、尿瘘、尿路感染、肺部感染、排尿困难、切口感染等;观察组总并发症发生率为16.7%,显著低于对照组（37.5%）,两组相比差异具有统计学意义（χ2=4.642,P＜0.05）。结论 腹腔镜根治性膀胱全切除+原位回肠新膀胱术具有创伤小、出血少、恢复快、新膀胱功能良好、术后并发生发生率低等优点,值得临床推广。     

Robot-assisted laparoscopic repair of ventral hernia with intracorporeal suturing

Background: This study presents a novel technique for laparoscopic ventral hernia repair using the da Vinci Robot and intracorporeal suturing. Thus, it offers an alternative to transabdominal sutures and tackers. Methods: A ventral hernia model was created in six pigs. The mesh was fixed to the circumference of the fascia using interrupted sutures. The outer border of the mesh was then fixed to the posterior fascia using running sutures. Results: There were no complications. The depth and location of the interrupted and running sutures were confirmed postmortem. Conclusions: The transabdominal sutures and tackers used in laparoscopic ventral hernia repair can be the focus for postoperative pain and adhesions. As an alternative, the da Vinci Robot can be used to facilitate intracorporeal suturing of the mesh directly to the fascial edge and to secure the circumference of the mesh to the posterior fascia. The preliminary results are promising and represent a safe method that can be implemented in humans.     

根治性膀胱切除术配合辅助化疗治疗膀胱癌的临床疗效及其多变量竞争风险分析

目的 探讨根治性膀胱切除术(RC)术后辅助化疗在膀胱癌治疗中的临床效果,为今后临床实践提供参考依据.方法 回顾性分析2005年1月至2015年1月间于本院行RC治疗的表浅性或浸润性膀胱移行细胞癌359例,观察其辅助化疗结果.结果 随访观察后行意向性分析,结果显示,辅助化疗是降低总体死亡率(95％ CI,HR:0.47,0.34 ～0.61,P＜0.0001)和癌特异死亡率(95％ CI,HR:0.82,0.63～ 0.92,P=0.0339)的独立预测因子,但与竞争死亡率无关.在规避与患者及肿瘤相关的混杂因素后,淋巴结阳性和膀胱外淋巴结阴性膀胱癌患者的顺铂方案辅助化疗结果相似,即均显示出死亡率降低的治疗效果.结论 长期随访结果显示根治性切除术后行辅助性化疗可能降低患者总体死亡率和癌特异死亡率.未来的研究热点应该聚焦于患者行RC后配合新辅助或辅助化疗的疗效对比研究.     

保留前列腺远端包膜在全膀胱切除肠代膀胱术中的应用

目的探讨膀胱癌患者根治性全膀胱切除术中保留前列腺远端包膜的价值.方法56例患者均为男性,平均年龄62岁.其中膀胱移行细胞癌53例,鳞状细胞癌3例;原发肿瘤40例,复发肿瘤16例.浅表性肿瘤27例,浸润性肿瘤29例.常规盆腔淋巴清扫术后,行保留前列腺远端包膜的全膀胱前列腺切除术.分别应用去管化回结肠或回肠作原位代膀胱20例和36例.随访观察手术效果和生活质量.结果回结肠代膀胱和回肠代膀胱的平均手术时间分别为350和380 min,术中出血量分别为580和540 ml.病理报告pT1N028例,pT2N025例,pT3N+3例.平均随访42个月(4～102个月),3例T3N+者分别于术后8、11、19个月死于癌肿,死于其他病变者5例.随访1年时,两种代膀胱白天控尿率分别为94%(17/18)和100%(30/30),夜间排尿1～2次后,保持干燥者占96%(46/48).术后最大尿流率分别为(15.8±2.6)ml/s和(14.7±3.2)ml/s.随访5年以上者28例,肿瘤特异5年生存率T1N0为94%(15/16),T2N0为83%(10/12).术前勃起功能正常31例中,术后维持正常勃起23例(74%).结论保留前列腺远端包膜的膀胱癌肠代膀胱术,能有效保留神经和括约肌功能,提高术后控尿和勃起能力,不影响肿瘤切除原则,值得临床推广应用.     

Quality of care in bladder cancer: trends in urinary diversion following radical cystectomy

Objective  Quality-of-care indicators have not yet been defined for patients with bladder cancer. Nonetheless, certain aspects of bladder cancer care can be evaluated to quantify the quality of care delivered. We sought to determine trends in continent urinary diversion to evaluate the adoption of this more optimal reconstruction. Methods  Subjects who underwent radical cystectomy for a primary diagnosis of bladder cancer were identified from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. We identified covariates independently associated with utilization of continent urinary diversion after radical cystectomy using multivariate logistic regression modeling. We then examined trends in diversion type based on patient and hospital characteristics and examined the impact of hospital volume on use of continent reconstruction. Results  Our weighted sample included 5,075 subjects (14.3%) who underwent continent urinary diversion and 30,295 subjects (85.7%) who underwent an ileal conduit. Independent correlates of continent diversion included younger age, male gender, having private insurance, and undergoing surgery at an urban teaching hospital. Hospitals performing continent diversions on more than 40% of their cystectomies had a yearly cystectomy volume of 0.8 surgeries. Subjects treated at high-volume hospitals trended toward lower rates of comorbid conditions. Conclusions  We identified substantial disparities in continent diversion which, based on yearly trends, are unlikely to improve in the near future. Continent reconstructions are not the exclusive domain of high-volume cystectomy centers. Yet efforts to increase rates of this complex reconstruction must concentrate on technique dissemination and better definition of the quality-of-life detriments incurred by cystectomy patients.