Laparoscopic radical cystectomy and extracorporeal urinary diversion: a single center experience of 48 cases with three years of follow-up

The Influence of Lymph Node Count on Oncological Outcome of Radical Cystectomy in Chemotherapy Pre-Treated and Chemotherapy-Naïve Patients with Muscle Invasive Bladder Cancer

Radical cystectomy (RC) with pelvic lymph node dissection (PLND) remains the mainstay of treatment for muscle-invasive bladder cancer (MIBC). The extent of PLND and number of removed lymph nodes (LNs) have been associated with improved staging and survival outcomes in several series of RC patients. Neoadjuvant chemotherapy (NAC) has become standard of care for cisplatin-eligible patients qualified to RC, yet few studies on PLND stratified cases according to the receipt of NAC. We aimed to address this issue and reevaluate the prognostic value of PLND nodal yields in series of patients who underwent RC on the verge of the NAC era. This single-center, retrospective, clinical follow-up study enrolled 439 consecutive patients, out of whom 83 received NAC. We analyzed survival outcome of RC according to the number of removed nodes between NAC and non-NAC subgroups. We found PLND thresholds of 10 and 15 LNs prognostically meaningful in our study cohort, and this association was particularly pronounced in the non-NAC subgroup. Higher numbers of LNs provided a 25% reduction in risk of all-cause mortality and correspondingly correlated with up to a 14% increase in 3-year overall survival. The receipt of NAC diminished the benefit of adequate PLND, as the number of retrieved LNs was not associated with survival in the NAC-RC cohort. Given the limitations of our study, additional research is needed to verify these findings.

Randomized Controlled Trial of Laparoscopic versus Open Radical Cystectomy in a Laparoscopic Naïve Center

Background

Laparoscopic radical cystectomy is a challenging surgical procedure; however, it has been largely abandoned in favor of the more intuitive robotic-assisted cystectomy. Due to the prohibitive cost of robotic surgery, the adoption of laparoscopic cystectomy is of relevance in low-resource institutes. Methodology. This is a randomized controlled trial comparing laparoscopic radical cystectomy (LRC) to open radical cystectomy (ORC) at a single institute. Each group included thirty patients. The trial was designed to compare both approaches regarding operative time, blood loss, transfusion requirements, length of hospital stay, time to oral intake, requirement of opioid analgesia, and complications.

Results

LRC was associated with less hospital stay (9.8 vs. 13.8 days, P=0.001), less time to oral solid intake (6 vs. 8.6 days, P=0.031), and lower opioid requirements (23.3% vs. 53.3%, P=0.033). There was a trend towards lower blood loss and transfusion requirements, but this did not reach statistical significance. Overall complication rates were comparable.

Conclusion

Laparoscopic radical cystectomy was associated with comparable postoperative outcomes when compared to ORC in the first laparoscopic cystectomy experience in our center. Benefitting from the assistance of an experienced laparoscopic surgeon is recommended to shorten the learning curve.

Systematic review of the association between socioeconomic status and bladder cancer survival with hospital type, comorbidities, and treatment delay as mediators

Objectives

Materials and methods

Results

Conclusions

Our laparoscopic cystectomy experiences

PURPOSE

We aimed to present our laparoscopic cystectomy experience and demonstrate that it is a feasible technique with safe oncologic principles.

METHODS

Total 19 patients who underwent laparoscopic radical cystectomy and pelvic lymph node dissection (PLND) in our urology clinic (Okmeydani Training and Research Hospital) were retrospectively evaluated. Demographic data, operation technique and complications, tumour pathology and follow-up details of patients were recorded.

RESULTS

Patients ranged from 40 to 73 years, with the average age of 60.8 and female/male rate was 2/17. The mean total operation time was 375 min (range 260-500). Mean hospitalisation time of patients was 10.3 days. The mean follow-up time was 11.2 months.

CONCLUSION

Minimally invasive approaches in urology are becoming the first line treatment by the time. Due to the high costs and limited availability, robotic surgery is still not exactly widespread in the world. Our series showed that conventional laparoscopic cystectomy is an appropriate approach until robotic surgery becomes widespread.

Laparoscopic versus open radical cystectomy in the treatment of locally advanced T3 and T4 bladder cancer: Perioperative and Mid-term oncological outcomes

OBJECTIVE

In this study, we aim to compare the perioperative and midterm oncological outcomes in patients with advanced bladder cancer and those who had laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC).

MATERIAL AND METHODS

We retrospectively reviewed medical records of patients who underwent LRC or ORC in a single center between 2008 and 2014 with a pathological diagnosis of pT3 and pT4 bladder cancer. Thirty-five and 39 patients were included in the study as part of the LRC and ORC groups, respectively.

RESULTS

There was no statistically significant difference between the two groups in terms of disease-free survival (LRC, 39.8±4.86 months; ORC, 45.47±8.92 months, P=0.896). Average estimated blood loss and length of hospitalization were significantly less in the LRC group. The overall survival rates of patients at 1, 2, and 3 years were 73%, 46%, and 46% in the ORC group and 78%, 65%, and 40% in the LRC group, respectively, and there was no statistically significant difference between the two groups. One patient in the ORC group experienced rectal injury in the form of a serosal tear, which was repaired primarily without any postoperative sequelae. There were no conversions in the laparoscopic group. Similarly, in 1 patient, rectal serosal tear was repaired preoperatively.

CONCLUSION

Our study showed that LRC provides midterm oncological outcomes similar to ORC in the treatment of locally advanced T3 and T4 bladder cancer. However, long-term oncological and functional outcomes are required.

Perioperative recovery in different urinary reconstruction approaches of radical cystectomy: Are the advantages of laparoscopy consistent?

Context:

Radical cystectomy (RC) has complicated surgical procedures and various ways of urinary reconstruction.

Aims:

The aim of this study is to investigate whether the advantages of laparoscopy over open surgery were consistent in the perioperative recovery of different methods of urinary diversion after RC in the general and the elderly (>65 years) population.

Settings and Design:

A retrospective study reviewed 452 (elderly 261) patients who received RC from the year 2005–2012.

Subjects and Methods:

Of all, 88 patients underwent laparoscopic RC (LRC) and 364 patients underwent open RC (ORC). There were 325 patients received ileal conduit (IC), whereas 127 patients received cutaneous ureterostomy (CU).

Statistical Analysis Used:

We used different statistical methods (t-test, Chi-square, etc.) to compare variables outcomes.

Results:

For IC urinary diversion, the general patients undergoing LRC had less intra-operative blood loss (566.5 vs. 1320.3 ml, P < 0.001), lower blood transfusion rate (11.4 vs. 34.1%, P < 0.001), shorter gastrointestinal recovery time (5.7 vs. 6.7 days, P = 0.002) and shorter length of hospital stay (LOS) (21.7 vs. 26.0 days, P = 0.003) than patients receiving ORC. Similar trends were observed in older patients. For CU urinary diversion, the general and the elderly patients receiving LRC had a shorter mean time to gastrointestinal recovery (P = 0.017, P < 0.001, respectively) than patients receiving ORC. No differences were found between LRC and ORC in intra-operative blood loss, allogeneic blood transfusion rate and LOS.

Conclusions:

In the general and the elderly population, laparoscopic approach could result in more rapid rehabilitation for RC patients, especially in the IC patients.

Anterior versus posterior approach laparoscopic radical cystectomy: a retrospective analysis

Objective

To investigate the mortality, operation time, cystectomy time, and complications of anterior approach laparoscopic radical cystectomy (ALRC) in Asian males in comparison with posterior approach laparoscopic radical cystectomy (PLRC).

Materials and methods

One hundred forty-seven male patients with bladder cancer (cT2-3NxM0) in our hospital from May 2011 to January 2018 having undergone laparoscopic radical cystectomy were studied, including 68 patients in PLRC group and 79 patients in ALRC group. Baseline patient characteristics, operative and postoperative characteristics, and postoperative complications were retrospectively collected and analyzed between the two groups.

Results

Patients in these two groups exhibited similar baseline characteristics (p > 0.05). Compared with PLRC group, ALRC group required similar operation time (317.3 ± 40.9 vs 321.9 ± 37.5) and cystectomy time (64.8 ± 8.7 vs 65.6 ± 14.0). The ALRC group required less cystectomy time (67.8 ± 10.1 vs 77.4 ± 14.9) when patients’ BMI > 24 or patients had large total tumor and blood clot volume (> 160 cm³). Also, estimated blood loss (EBL) of ALRC group was significantly less than that of PLRC group (477.8 ± 97.4 vs 550.4 ± 99.9). There existed no significant differences between the PLRC and ALRC groups in postoperative characteristics and complications.

Conclusion

This study revealed that ALRC required less cystectomy time for patients with higher BMI and larger tumor, suggesting less blood loss and similar perioperative complications. ALRC is recommend for male patients, of which BMI > 24 or total tumor and blood clot volume > 160 cm³.

Prospective study comparing laparoscopic and open radical cystectomy: Surgical and oncological results

INTRODUCTION

Laparoscopic radical cystectomy with lymphadenectomy and urinary diversion is an increasingly widespread operation. Studies are needed to support the oncological effectiveness and safety of this minimally invasive approach.

PATIENTS AND METHODS

A nonrandomised, comparative prospective study between open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) was conducted in a university hospital. The main objective was to compare cancer-specific survival. The secondary objective was to compare the surgical results and complications according to the Clavien-Dindo scale.

RESULTS

We treated 156 patients with high-grade invasive bladder cancer with either ORC (n=70) or LRC (n=86). The mean follow-up was 33.5±23.8 (range 12-96) months. The mean age was 66.9+9.4 years, and the male to female ratio was 19:1. Both groups were equivalent in age, stage, positive lymph nodes, in situ carcinoma, preoperative obstructive uropathy, adjuvant chemotherapy and type of urinary diversion. There were no differences between the groups in terms of cancer-specific survival (log-rank; P=.71). The histopathology stage was the only independent variable that predicted the prognosis. The hospital stay (P=.01) and operative transfusion rates (P=.002) were less for LRC. The duration of the surgery was greater for LRC (P<.001). There were no differences in the total complications rate (p=.62) or major complications (P=.69). The risk of evisceration (P=.02), surgical wound infection (P=.005) and pneumonia (P=.017) was greater for ORC. The risk of rectal lesion (P=.017) and urethrorectal fistulae (P=.065) was greater for LRC.

CONCLUSION

LRC is an equivalent treatment to ORC in terms of oncological efficacy and is advantageous in terms of transfusion rates and hospital stays but not in terms of operating room time and overall safety. Studies are needed to better define the specific safety profile for each approach.

Does previous abdominal surgery adversely affect perioperative and oncologic outcomes of laparoscopic radical cystectomy?

Background

Laparoscopic radical cystectomy (LRC) has been shown to have less estimated blood loss (EBL), transfusion rate, narcotic analgesic requirement, earlier return of bowel function, and shorter hospital stay. The aim of this study was to investigate the feasibility, peri-operative and oncologic outcomes of laparoscopic radical cystectomy (LRC) in patients with previous abdominal surgery (PAS).

Methods

We retrospectively reviewed 243 patients undergoing open radical cystectomy (ORC) or LRC with bilateral pelvic lymph node dissection and urinary diversion or cutaneous ureterostomy at a single center from January 2010 to December 2015. Demographic parameters, intra-operative variables, peri-operative records, pathologic outcomes, and complication rate were reviewed to assess the impact of PAS on peri-operative and oncologic outcomes.

Results

Patients in both ORC and LRC subgroups were homogeneous in terms of demography characteristics including age, gender, BMI, ASA score, and comorbidity. Estimated blood loss (EBL) was higher in patients with PAS undergoing ORC compared to those with no PAS (P = 0.008). However, there was no significant difference of EBL among patients undergoing LRC with or without PAS (P = 0.896). There was no statistical difference in peri-operative parameters and pathological outcomes. Patients with PAS undergoing ORC and ileal conduit had a higher vascular injury rate (P = 0.017). Comparing patients with PAS performed by LRC and ORC, the number of patients with the vascular injury was higher in ORC groups regardless of the type of diversion (ileal conduit, P = 0.001, cutaneous ureterostomy, P = 0.025). There is no significant difference in other complications.

Conclusion

The presence of adhesions from PAS is not a contraindication to LRC. Patients with PAS may benefit from LRC with lower estimated blood loss, fewer transfusion rates, and vascular injuries. Furthermore, the overall oncologic outcomes and complication rate are similar between LRC and ORC patients with PAS.

Systematic review of perioperative outcomes and complications after open, laparoscopic and robot-assisted radical cystectomy

Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications.

Essential content of evidence-based clinical practice guidelines for bladder cancer: The Japanese Urological Association 2015 update

The Japanese Urological Association revised the clinical practice guidelines for bladder cancer in April 2015. This was the first update carried out in the 6 years since the development of the initial clinical practice guidelines for bladder cancer in 2009. The descriptive content was revised, and additions were made with a focus on new-found evidence and advances in the latest medical practices, and on the basis of the increasingly aging population observed in the underlying social context in Japan. An algorithm for the treatment of bladder cancer has been presented as a new trial. In the present article, we will introduce the essential contents and clinical questions that address the present revisions.

Robot-assisted laparoscopic radical cystectomy with complete intracorporeal urinary diversion

Robot-assisted radical cystectomy with intracorporeal urinary diversion (RARC-ICUD) has only recently been explored as a viable surgical option for patients with muscle-invasive bladder cancer seeking satisfactory oncologic control while benefiting from minimally invasive surgical techniques. Inspired by earlier open and laparoscopic work, initial descriptions of RARC-ICUD were published in 2003, and have since been followed by multiple larger case series which have suggested promising outcomes for our patients. However, the rate of adoption has remained relatively slow when compared to other robot-assisted procedures such as the radical prostatectomy, likely owing to longer operative times, operative complexity, costs, and uncertainty regarding oncologic efficacy. The operative technique for RARC-ICUD has evolved over the past decade and several high-volume centers have shared tips to improve efficiency and make the operation possible for a growing number of urologists. Though there are still questions regarding economic costs, effectiveness, and generalizability of outcomes reported in published data, a growing dataset has brought us ever closer to the answers. Here, we present our current operative technique for RARC-ICUD and discuss the state of the literature so that the urologist may hold an informed discussion with his or her patients.

Prospective evaluation of complications in laparoscopic urology at a mid-volume institution using standardized criteria: Experience of 1023 cases including learning curve in 9 years

AIM:

To evaluate the laparoscopic operations performed in our department according to the modified Clavien classification system of complications.

MATERIALS AND METHODS:

Between September, 2005 and February, 2014, a total of 1023 laparoscopic cases were performed. This period was divided into three terms (Terms 1, 2 and 3 consisting of 38, 32 and 32 months, respectively). According to the European Scoring System (ESS), easy (E), slightly difficult (SD), fairly difficult (FD), difficult (D), very difficult (VD) and extremely difficult (ED) cases were 35, 88, 170, 390, 203 and 137, respectively. The perioperative complications were evaluated based on the 3 time periods, with a specific emphasis on determining the learning curve according to the modified Clavien classification system of complications.

RESULTS:

A total of 236 (23.1%) complications were observed according to the modified Clavien classification. The minor (Clavien I-II) and major (Clavien III, IV and V) complication rates were 20.5% (n = 210) and 2.4% (n = 26), respectively. Clavien I was the most frequently encountered type of complication (n = 120, %11.7). No significant difference was observed among all 3 time periods regarding total complication rates. The D cases had the highest complication rate compared to E, SD, FD, VD and ED cases among all three terms. The total number of complications increased significantly with increasing grade of technical difficulty according to the ESS.

CONCLUSION:

Complications encountered in our laparoscopic surgery experience were predominantly minor, and the rate of complications was not significantly increased during the learning curve. The present data can provide guidance and manage expectations for surgeons introducing laparoscopy into their practice.

Comparison of initial experiences of robot-assisted radical cystectomy with those of laparoscopic for bladder cancer

OBJECTIVE

The aim of the present study was to evaluate perioperative outcomes in initial experiences of robot-assisted laparoscopic radical cystectomy (RARC) in comparison with those of laparoscopic radical cystectomy (LRC) for muscle-invasive or high-risk non-muscle-invasive bladder cancer.

METHODS

We performed RARC on six patients with muscle-invasive or high-risk non-muscle-invasive bladder cancer starting in October 2011. During the same period, another five patients underwent LRC. Perioperative outcomes in initial experiences of RARC were elucidated by comparing them with those of LRC.

RESULTS

Robot-assisted procedures were completed in all cases without conversion to open surgery. The median time of pneumoperitoneum was 252 minutes, and the median blood loss was 340 mL. No severe complications were observed. Perioperative outcomes did not significantly differ between RARC and LRC. Although two cases of troubles in uretero-conduit anastomosis sites were observed after LRC, no patients experienced postoperative complication related to urinary diversion after RARC.

CONCLUSIONS

Our data indicate that RARC is an acceptable option even in the initial period, and it may become one of the most favorable procedures for treatment of muscle-invasive bladder cancer in the near future, although more tests and longer follow-ups are required to confirm its effectiveness and safety.

Laparoscopic versus open radical cystectomy for elderly patients over 75-year-old: a single center comparative analysis

PURPOSE

To explore the morbidity, mortality and oncological results of laparoscopic radical cystectomy (LRC) in the elderly patients over 75-year-old in contrast with open radical cystectomy (ORC).

MATERIALS AND METHODS

We analyzed 46 radical cystectomies from January 2009 to December 2013 in patients over 75-year-old in our institute, 21 patients in the LRC group and 25 in the ORC group. Demographic parameters, operative variables and perioperative outcome were retrospectively collected and analyzed between the two groups. Perioperative morbidity and mortality were categorized as early (within 90 days after surgery) or late (more than 90 days) according to the time of occurrence.

RESULTS

Patients in both groups had comparable preoperative characteristics. A significant longer operative time (418 vs. 337 min, p = 0.018) and less estimated blood loss (400 vs. 500 ml p = 0.038) were observed in LRC group compared with ORC group. Infection and ileus were the most common early complications after surgery. Patients underwent ORC suffered from significantly more postoperative ileus (28.0% vs. 4.8%, P = 0.038) and infection (40% vs. 9.5%, P = 0.019) than LRC group within 90 days after surgery. The mortality rate was 4.7% (1/21) and 4% (1/25) for LRC group and ORC group respectively. At a median follow-up of 21 months (range 2-61 months), the Kaplan-Meier survival curves and log-rank analysis demonstrate that there were no significant differences between the LRC and ORC groups in the 3-year overall, cancer-specific, or recurrence-free survival rates.

CONCLUSIONS

It is suggested that LRC should be recommended as the primary intervention to treat muscle invasive or high risk non-muscle invasive bladder cancer in elderly patients with a relative long life expectancy.

A prospective randomised controlled trial of laparoscopic vs open radical cystectomy for bladder cancer: perioperative and oncologic outcomes with 5-year follow-upT Lin et al

Background:

Laparoscopic radical cystectomy (LRC) is increasingly being used for muscle-invasive bladder cancer. However, high levels of clinical evidence comparing laparoscopic vs open radical cystectomy (ORC) are lacking.

Methods:

A prospective randomised controlled clinical trial comparing LRC vs ORC in patients undergoing radical cystectomy for bladder cancer. Thirty-five patients were eligible for final analysis in each group.

Results:

The median follow-up was 26 months (range, 4–59 months) for laparoscopic vs 32 months (range, 6–60 months) for ORC. Significant differences were noted in operative time, estimated blood loss (EBL), blood transfusion rate, analgesic requirement, and time to resumption of oral intake. No significant differences were noted in the length of hospital stay, complication rate, lymph node yield (14.1±6.3 for LRC and 15.2±5.9 for ORC), positive surgical margin rate, postoperative pathology, or recurrence rate (7 for LRC and 8 for ORC). The 5-year recurrence-free survival with laparoscopic vs ORC was 78.5% vs 70.9%, respectively (P=0.773). The overall survival with laparoscopic vs ORC was 73.8% vs 67.4%, respectively (P=0.511).

Conclusion:

Our study demonstrated that LRC is superior to ORC in perioperative outcomes, including EBL, blood transfusion rate, and analgesic requirement. We found no major difference in oncologic outcomes. The number of patients is too small to allow for a final conclusion.

Laparoscopic radical cystectomy

Objective

Laparoscopic radical cystectomy (LRC) has emerged as a minimally invasive alternative to open radical cystectomy (ORC). This review focuses on patient selection criteria, technical aspects and postoperative outcomes of LRC.

Methods

Material for the review was obtained by a PubMed search over the last 10 years, using the keywords ‘laparoscopic radical cystectomy’ and ‘laparoscopic bladder cancer’ in human subjects.

Results

Twenty-two publications selected for relevance and content were used for this review from the total search yield. The level of evidence was IIb and III. LRC results in comparable short- and intermediate-range oncological outcomes to ORC, with generally longer operative times but decreased blood loss, postoperative pain and hospital stay. Overall operative and postoperative morbidity are equivalent.

Conclusion

In experienced hands, LRC is an acceptable minimally invasive alternative to ORC in selected patients, with the main advantage of decreased blood loss and postoperative pain, as well as a shorter hospital stay and recovery.

Developing minimally invasive surgery centers within kaiser permanente: the integrated multidisciplinary experience of los angeles

Minimally invasive surgical therapies are growing in type and volume of interventions. As one of the largest health delivery organizations in the US, Kaiser Permanente staff must be aware that the proliferation of these technologies has occurred in parallel within many surgical specialties, with a large variation in level of implementation between different regions and even within regions. In Los Angeles, we have developed the Minimally Invasive Surgery Center, encompassing a multidisciplinary, integrated approach. It unites the effort and expertise of many outstanding practitioners within the organization and consolidates the achievements of many surgical specialties. It also brings together the elements needed to provide the highest level of care to our patients in a safe, efficient, cost-effective environment, with minimal morbidity and best long-term outcome.

The role of laparoscopic and robotic cystectomy in the management of muscle-invasive bladder cancer with special emphasis on cancer control and complications

CONTEXT

Minimally invasive radical cystectomy (MIRC) techniques for the treatment of muscle-invasive bladder cancer (BCa) are being increasingly applied. MIRC offers the potential benefits of a minimally invasive approach in terms of reduced blood loss and analgesic requirements whilst striving to provide similar oncologic efficacy to open radical cystectomy (ORC). Whether quicker recovery, shorter hospital stay, and a reduction in complications are routinely achieved with MIRC remains to be proved in prospective comparisons.

OBJECTIVE

To explore both laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RRC), focusing specifically on the oncologic parameters and comorbidity of the procedures. Reported complications from major centres are identified and categorised via the Clavien system. Positive margins rates, local recurrence, and both cancer-specific survival (CSS) and overall survival rates are assessed.

EVIDENCE ACQUISITION

A comprehensive electronic literature search was conducted in November 2010 using the Medline database to identify publications relating to laparoscopic, robotic, or minimally invasive radical cystectomy.

EVIDENCE SYNTHESIS

There are encouraging short- to medium-term results for both LRC and RRC in terms of postoperative morbidity and oncologic outcomes. It seems possible in experienced hands to perform a satisfactory minimally invasive lymphadenectomy regarding lymph node counts and levels of dissection. Positive soft-tissue margins are similar to large open series for T2/T3 disease but inferior for bulky T4 disease. Local recurrence rates and CSS rates seem equivalent to ORC at up to 3 yr of follow-up; however, mature outcome data still need to be presented before definitive comparisons can be made.

CONCLUSIONS

Robotic and laparoscopic cystectomy has a growing role in the management of muscle-invasive BCa. Long-term oncologic results are awaited, and there are concerns over the ability of MIRC to treat bulky and locally advanced disease, making careful patient selection vital. Forthcoming randomised trials in this area will more fully address these issues.

Will tissue-engineered urinary bladders change indications for a laparoscopic cystectomy?

Radical open cystectomy is a treatment of choice for muscle invasive urinary bladder cancer. Laparoscopic radical cystectomy (LapRC) is surgically advanced and is an extremely difficult technique but presents many advantages. Urinary diversion (conduit, pouch or neobladder) when performed during laparoscopy necessitates a conversion to open procedure. Urinary diversion using an autologous bowel is associated with longer operative times and complications. The authors have analyzed the LapRC procedure and its 2 main parts--that is, bladder resection and urinary diversion. The emphasis was on the operative time and complications related to the urinary diversion procedure. A urinary diversion created in vitro could make the LapRC totally intracorporeal, and it could be completed within an acceptable time. Tissue engineering techniques used for urinary diversion after cystectomy shorten the operative time and help avoid serious complications related to bowel surgery. LapRC with tissue-engineered urinary diversion could become a management of choice for muscle invasive bladder cancer.

Comparison of surgical stress response to laparoscopic and open radical cystectomy

OBJECTIVES

To prospectively compare stress response to laparoscopic and open radical cystectomy by the measurement of humoral mediators and the incidence of systemic inflammatory response syndrome (SIRS).

METHODS

Thirty-eight patients undergoing radical cystectomy were prospectively assessed. Blood samples were obtained from all patients before surgery, during surgery, 72 h after surgery. Serum levels of interleukin (IL)-6 and interferon (IFN)-gamma were measured using an enzyme-linked immunosorbent assay. We also investigated the incidence and duration of SIRS in the two groups.

RESULTS

The two groups had comparable perioperative variables except for less estimated blood loss in the laparoscopic group. The IL-6 levels increased during and after surgery in the two groups (P < 0.001). However, the IL-6 levels in the laparoscopic group were significantly lower than those in the open group during and after surgery (P = 0.006, P < 0.001). The incidence of SIRS was 57.1% in the laparoscopic group and 79.2% in the open group (P = 0.149). The mean duration of SIRS was 1.4 days in the laparoscopic group and 2.8 days in the open group (P = 0.032). The IFN-gamma levels decreased, but there was no difference in the two groups over the entire period assessed. Multivariate analysis demonstrated that the group (laparoscopic versus open) was the only influencing factor on the levels of IL-6 and the duration of SIRS.

CONCLUSIONS

Our study suggests that the laparoscopic group is markedly less stressful and it has a shorter duration of SIRS than the open group.

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.

Does extended lymphadenectomy preclude laparoscopic or robot-assisted radical cystectomy in advanced bladder cancer?

PURPOSE OF REVIEW

Open radical cystectomy with an appropriate bilateral lymph node dissection (LND) is currently the standard treatment for patients with muscle-invasive bladder cancer. Approximately 25% of patients with stages T1-T4 N0 M0 harbour metastatic lymph nodes at the time of radical cystectomy. Results from open high volume radical cystectomy series suggest that a more extended LND provides the best survival outcomes and the lowest local recurrence rates. Currently, there is controversy whether laparoscopic or robot-assisted extended LND at radical cystectomy is technically feasible and whether it can provide oncological control equivalent to open LND series at the time of radical cystectomy.

RECENT FINDINGS

Laparoscopic LND is technically demanding and requires prolonged operation time. Most studies to date indicate that fewer nodes are removed than with an open approach, putting a question mark to this surgical approach from an oncological point of view. Limited data on lymph node yield using a robot-assisted approach are available; however, several series found similar results as in open series.

SUMMARY

At present, there is no conclusive evidence showing that laparoscopic LND gives similar results than open LND. Robot-assisted LND is still in its learning curve and more patient series are needed.