Laparoscopic radical cystectomy with ileal conduit diversion

The morbidity of laparoscopic radical cystectomy: analysis of postoperative complications in a multicenter cohort by the European Association of Urology (EAU)-Section of Uro-Technology

PURPOSE

To analyze postoperative complications after laparoscopic radical cystectomy (LRC) and evaluate its risk factors in a large prospective cohort built by the ESUT across European centers involved in minimally invasive urology in the last decade.

METHODS

Patients were prospectively enrolled, and data were retrospectively analyzed. Only oncologic cases were included. There were no formal contraindications for LRC: Also patients with locally advanced tumors (pT4a), serious comorbidities, and previous major abdominal surgery were enrolled. All procedures were performed via a standard laparoscopic approach, with no robotic assistance. Early and late postoperative complications were graded according to the modified Clavien-Dindo classification. Multivariate logistic regression was performed to explore possible risk factors for developing complications.

RESULTS

A total of 548 patients were available for final analysis, of which 258 (47%) experienced early complications during the first 90 days after LRC. Infectious, gastrointestinal, and genitourinary were, respectively, the most frequent systems involved. Postoperative ileus occurred in 51/548 (9.3%) patients. A total of 65/548 (12%) patients underwent surgical re-operation, and 10/548 (2%) patients died in the early postoperative period. Increased BMI (p = 0.024), blood loss (p = 0.021), and neoadjuvant treatment (p = 0.016) were significantly associated with a greater overall risk of experiencing complications on multivariate logistic regression. Long-term complications were documented in 64/548 (12%), and involved mainly stenosis of the uretero-ileal anastomosis or incisional hernias.

CONCLUSIONS

In this multicenter, prospective, large database, LRC appears to be a safe but morbid procedure. Standardized complication reporting should be encouraged to evaluate objectively a surgical procedure and permit comparison across studies.

Long-term evaluation of oncologic and functional outcomes after laparoscopic open-assisted radical cystectomy: a matched-pair analysis

PURPOSE

To evaluate peri- and postoperative morbidity, and long-term oncologic and functional results of our laparoscopic radical cystectomy (LRC) technique, comparing it with our standard open approach.

METHODS

Between 2000 and 2010, 54 patients underwent LRC for urothelial cell carcinoma of the bladder in two academic hospitals. The procedures were performed by two surgeons. Patients were matched 1:1 with patients who underwent open RC in the same years by the same surgical team. Differences in peri- and postoperative complications across the two groups were assessed using Wilcoxon's rank-sum or χ (2) test. Kaplan-Meier curves, log-rank tests and Cox regression models were constructed to assess differences in recurrence-free survival on long-term follow-up between the two groups.

RESULTS

Laparoscopic radical cystectomy was significantly associated with lower blood loss (p < 0.0001) and less frequent postoperative ileus (p = 0.03). Regarding more serious postoperative complications, no difference was found across the two cohorts. Median oncologic follow-up was 42 months (IQR 12-72 months) in the LRC cohort and 18 months (IQR 8-27 months) in patients undergoing open radical cystectomy (ORC). No statistically significant difference in recurrence-free survival was observed between the two groups (log rank p = 0.677). On univariate Cox regression, the surgical approach used was not significantly associated with risk of recurrence.

CONCLUSIONS

We found that LRC is safe and associated with lower blood loss and decreased postoperative ileus compared with ORC. Moreover, on long-term oncologic follow-up, LRC appeared non-inferior to ORC with no significant difference in recurrence-free survival. Nonetheless, these results must be confirmed by larger series and stronger long-term follow-up data are needed.

[Perioperative outcome of laparoscopic radical cystectomy: comparison to open radical cystectomy]

OBJECTIVES

This study is to elucidate the advantage of laparoscopic radical cystectomy (LRC) over open radical cystectomy (ORC) in an early perioperative period.

MATERIALS AND METHODS

We investigated the perioperative outcome of the consecutive patients who underwent radical cystectomy at Yokohama City University Hospital. The data of 11 patients who underwent LRC from February 2008 to May 2009 was compared with that of 11 patients who had ORC from October 2006 to April 2009.

RESULTS

The operative time was significantly longer in LRC (p = 0.00794); the mean operative time for LRC and ORC was 521 and 428 minutes respectively. The blood loss was significantly smaller in LRC (p = 0.0014); the mean volume of bleeding by LRC and ORC was 801 and 2,156 ml respectively. The date of the diet resumption after the operation comes significantly earlier in the case of LRC (p = 0.0142); the mean number of days to the resumption after LRC and ORC were 4.6 and 9.3 respectively. The top C-reactive protein (CRP) figure was significantly lower in LRC (p = 0.0124); the mean of peak CRP after LRC and ORC was 10.8 and 16.6 mg/dl respectively. As for postoperative complications, there were no significant differences between two groups (p = 0.375); the rate of complications occurred after LRC and ORC was 27 and 45% respectively. Also no significant differences were observed as to the number of dissected lymph nodes among these two groups (p = 0.262); the mean number in LRC and ORC was 10.9 and 13.7 respectively.

CONCLUSIONS

From our investigations it is appropriate to conclude that in an early perioperative period LRC has advantages over ORC: a smaller amount of blooding, an earlier date of the diet resumption, and a lower peak of CRP. LRC is less invasive than ORC, though the former takes longer time for an operation than the latter.

[Radical laparoscopic cystectomy]

Radical laparoscopic cystectomy is being adopted by most groups with proven experience in laparoscopic surgery, especially by those who have already completed the learning curves in radical laparoscopic prostatectomy. It is still considered a highly complex technique, which has not yet been mastered in many Urology Units. In this article, we review the surgical technique and available literature on this approach, with special emphasis on its indications, advantages and most frequent morbidity.

Status of robotic cystectomy in 2005

Minimally invasive approaches have been shown to offer considerable benefits to patients in the treatment of urologic malignancies. While open radical cystectomy remains the gold standard for the treatment of muscle invasive bladder cancer, the continued refinement of laparoscopic techniques and the success of robotic assistance in radical prostatectomy have led to great interest in minimally invasive approaches to radical cystectomy. We review the current experience with laparoscopic and robotic radical cystectomy and its role in the treatment of muscle invasive bladder cancer.