Laparoscopic radical cystectomy with intracorporeal ileal conduit diversion: five cases with a 2-year follow-up

Comparing Bladder Neck Contracture Rate Between Robotic Intracorporeal and Extracorporeal Neobladder Construction

Robot-assisted radical cystectomy (RARC) has become more accessible to surgeons worldwide, and descriptions of intracorporeal urinary diversion techniques, such as orthotopic neobladder construction, have increased. In this study, we aim to compare the rate of bladder neck contracture (BNC) formation between RARC and two different urinary diversion techniques. We retrospectively reviewed our institutional database for patients with bladder cancer who underwent RARC with intracorporeal neobladder (ICNB) construction (n = 11) or extracorporeal neobladder (ECNB) construction (n = 11) between 2012 and 2020. BNC was defined by the need for an additional surgical procedure (e.g., dilatation, urethrotomy). Patients who underwent RARC with ICNB (n = 11) were compared to patients who underwent RARC with ECNB (n = 11) across patient characteristics and postoperative BNC formation rates. Kaplan-Meier curves were generated for freedom from BNC based on the neobladder approach and compared with the log-rank test. For patients who received an ECNB, 73% (8/11) developed a BNC; in comparison, none of the patients in the ICNB group experienced a BNC. Kaplan-Meier survival analysis demonstrates the ECNB group's median probability of freedom from BNC as 1.3 years, while the ICNB group was free of BNC over the study period (p < 0.001). RARC with ICNB creation demonstrated a significantly reduced BNC rate in contrast to RARC with ECNB construction. Longer-term follow-up is needed to assess the durability of this difference in BNC rates.

Long-term oncologic outcomes of robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD): a multi-center study

PURPOSE

To report survival outcomes after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) for recurrent/muscle-invasive non-metastatic bladder cancer.

METHODS

Prospectively maintained databases were queried for "robotic cystectomy AND ICUD". Patients treated after October 2013 and those treated without curative intent were excluded. Kaplan-Meier method was used to plot stage-specific survival outcomes, computed at 1, 2, and 5 years after surgery. Univariable and multivariable Cox analyses assessed predictors of recurrence-free (RFS), cancer-specific (CSS) and overall (OS) survival.

RESULTS

113 consecutive patients were included, mostly men (82%). Neoadjuvant chemotherapy was performed in 23% of cases, median lymph node (LN) yield was 36 (IQR 28-45) and the rate of positive surgical margins (PSM) was 8%. Orthotopic ileal neobladder was the preferred ICUD type (57%). An organ-confined disease was observed in 51% of cases and 21% were pT0 on final histology. Overall, 5-year RFS, CSS and OS probabilities were 58 ± 5%, 61 ± 5% and 54 ± 5%, respectively. At Kaplan-Meier method, tumor stage group was a significant predictor of survival probabilities (all p < 0.001) and this was confirmed at multivariable Cox regression analysis (RFS-OR 2.29; 95% CI 1.58-3.32; p < 0.001) (CSS-OR 1.82; 95% CI 1.3-2.53; p < 0.001) (OS-OR 2.14; 95% CI 1.46-3.14; p < 0.001). PSM status was associated to CSS (OR 2.54; 95% CI 1.13-5.69; p = 0.024) and OS (OR 2.82; 95% CI 1.17-6.77; p = 0.021), but did not predict RFS (p = 0.062).

CONCLUSIONS

Long-term oncologic outcomes after RARC with ICUD appear similar to recent robotic series with extracorporeal diversion and historical open experiences.

Benefits of laparoscopic prostate-sparing radical cystectomy

PURPOSE

Prostate-sparing radical cystectomy has been described in the literature and has proven to be a promising procedure owing to the continence and erectile function results without necessarily compromising the oncologic outcome in selected patients.

TECHNIQUE POINTS

A transperitoneal approach is used. Lymph node dissection is performed with frozen section, and then the ureters are ligated and biopsied. The seminal vesicles are dissected, followed by complete mobilization of the bladder. Incision of the bladder neck is performed, followed by simple prostatectomy. Finally, bowel reconstruction is carried out via a small infra-umbilical incision that also permits the extraction of the surgical specimen and the anastomosis of neobladder to the prostate capsule. A total of 25 patients have undergone this procedure, with average surgical times of 285 min and blood loss of 640 ml. The complications encountered included: one bowel incarceration, one urinary leak, one lymphocele and one port hernia. At median 9 months follow-up, no patient presented with daytime incontinence, although seven complained of nocturia. A total of 20 patients maintained their preoperative sexual potency, and four reported a postoperative decrease in their erectile function.

CONCLUSIONS

Laparoscopic prostate-sparing radical cystectomy appears to be oncologically safe, reproducible and has promising functional benefits. The authors believe this procedure presents a good option in very select patients.

Long-term experience on laparoscopic incontinent urinary diversion unrelated to cystectomy in radiated or recurrent pelvic malignancies

BACKGROUND:

There are few reports describing series of cases about development on laparoscopic urinary diversions no related to cystectomy. The aim of this paper is to show the experience of our reference institutions for treatment of pelvic malignancies when laparoscopic techniques were applied to perform only urinary diversion without cystectomy or pelvic exenteration.

MATERIALS AND METHODS:

We included retrospectively 12 cases of cutaneous ureterostomy and 21 cases with a reservoir (16 ileal conduits, 2 colonic conduits and 3 wet colostomies) treated in our institute from 2004 to 2010. It was evaluated operative time, blood loss, intraoperative complications, conversion rate, length of large incision, post operative complications, analgesic consumption, time to food intake, hospital stay, time to recovery to normal activities. Mean time to follow-up was 3(2-7) years.

RESULTS:

All procedures were completed without conversions. In the cutaneous ureterostomy group the mean surgical time.

Initial experience of robot-assisted radical cystectomy with total intracorporeal urinary diversion: comparison with extracorporeal method

PURPOSE

To report our surgical technique and initial experience with robot-assisted laparoscopic radical cystectomy (RARC) with total intracorporeal urinary diversion compared with an extracorporeal method.

SUBJECTS AND METHODS

In total, 42 patients underwent RARC by a single surgeon at our institute for clinically localized bladder cancer. Among these, 4 patients underwent RARC with complete intracorporeal urinary diversion. An ileal conduit was achieved in 3 patients, and an orthotopic neobladder was created in 1 patient. Our surgical technique is presented in detail, and the intracorporeal cases were compared with 38 previous extracorporeal diversion cases for perioperative outcome, postoperative oncologic outcome, and complications.

RESULTS

Three men and 1 woman underwent complete intracorporeal urinary diversion. In patients receiving ileal conduits the mean total operative time was 510 minutes, and the estimated blood loss was 400 mL. In the patient receiving an ileal neobladder the total operative time was 585 minutes, and the estimated blood loss was 500 mL. Mean time to flatus was 60 hours, and no intraoperative or postoperative major complications occurred. Surgical margins were negative with no positive lymph nodes. Compared with extracorporeal cases, the mean total operative time for RARC was significantly longer, but perioperative outcomes of estimated blood loss, time to flatus, and postoperative oncologic outcomes were not significantly different.

CONCLUSIONS

Our initial experience showed that RARC with complete intracorporeal urinary diversion is feasible based on perioperative data and oncologic features. However, in this small case series, we observed no definite benefits associated with intracorporeal urinary diversion over extracorporeal urinary diversion except for better cosmesis. Long-term, large-scale, prospective comparative studies will be needed to demonstrate the benefit of intracorporeal urinary diversion.

Feasibility of minimally invasive lymphadenectomy in bladder and prostate cancer surgery

With the rapid and widespread adoption of minimally invasive procedures (laparoscopic and robotic) for the treatment of prostate and bladder cancers in the last decade, concerns have been raised regarding whether the technique can emulate the time-tested gold standard open procedures. This article briefly reviews the indications for lymph node dissection for bladder and prostate cancer, and reviews the role of extended lymphadenectomy in each procedure. Much of the focus of this review is on minimally invasive approaches and the technical aspects of the procedures, the feasibility of the robotic technique, and early oncologic outcomes.

Laparoscopic radical and partial cystectomy

Radical cystectomy remains the standard treatment for muscle invasive organ confined bladder carcinoma. Laparoscopic radical cystoprostatectomy (LRC) is an advanced laparoscopic procedure that places significant demands on the patient and the surgeon alike. It is a prolonged procedure which includes several technical steps and requires highly developed laparoscopic skills including intra-corporeal suturing. Here we review the development of the technique, the indications, complications and outcomes. We also examine the potential benefits of robotic-assisted LRC and explore the indications and technique of laparoscopic partial cystectomy.

[Laparoscopic radical cystectomy with extracorporeal creation of a "Y" shaped orthotopic ileal neobladder using non-reabsorbable mechanical suture (Fontana)]

INTRODUCTION

We describe the technique and present the preliminary results of the laparoscopic radical cystectomy technique with the extracorporeal creation of a "y" shaped ileal orthotopic neobladder using non-absorbable mechanical suture (Fontana).

MATERIALS AND METHOD

We describe the technique step by step and we present a series of 15 patients that underwent this surgery between November 2005 and August 2009, with special emphasis on the duration of the surgery, urinary diversion time, intraoperative and postoperative complications, daytime and night time continence and the frequency of postoperative micturition.

RESULTS

The mean follow-up of the series was 24 months (6-32). The mean duration of surgery was 280 (range 210-345) minutes and the mean urinary diversion time was 54.5 (range 40-75) minutes. There were no intraoperative complications and the average hospitalization time was 7 (range 5-15) days. During the follow-up, there were 5 late postoperative complications, 2 cases of urinary infection with good response to antibiotic treatment and 3 uretero-neovesical anastomosis strictures, which were treated with percutaneous balloon dilation, with a good functional result. No lithiasis was found in the neobladder. Complete daytime continence was obtained in 13/14 patients (92.9%) and complete night time continence in 6/14 (42.9%). One patient (6.7%) required clean intermittent self-catheterization as the patient did not micturate spontaneously.

CONCLUSIONS

The creation of a "Y" shaped ileal orthotopic neobladder using non-absorbable mechanical suture is a feasible, fast and safe technique and it provides promising functional results. Further follow-up is required to determine its long-term results.

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

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.

Lymph node dissection for bladder cancer: the issue of extent and feasibility in the minimally invasive era

Lymph node dissection in bladder cancer is an integral part of radical cystectomy. It allows for accurate staging of the patient and will, therefore, serve to dictate additional treatment and add prognostic information. The issue of what is an adequate lymphadenectomy as to the extent and boundaries of the operation, specifically the cephalad extent, has been the focus of recent debate. Some have suggested that lymph node yield, in terms of number, could serve as a surrogate for the adequacy of the node dissection and, thus, the oncologic efficacy of the operation. It has also been suggested that it is a marker for the experience of the operating surgeon. What is meant by a limited, standard and extended lymph node dissection varies among different publications. Recent evidence suggests that an 'extended' node dissection infers oncologic efficacy. With the advent of minimally invasive and, specifically, robotic-assisted surgery, more cystectomies are approached robotically. As such, there has been recent debate as to whether a robotic-assisted procedure can emulate the open approach, satisfying the accepted boundaries and extent of dissection and ultimately leading to equivalent oncologic outcomes without increasing morbidity. In this review, we focus on the extent of lymphadenectomy in bladder cancer by reviewing the lymphatic drainage and arguments in favor of a more extended dissection. We will then address the minimally invasive techniques, focusing on robotic-assisted surgery, and review the evidence suggesting that this is a promising new technique that results in acceptable nodal yield and potentially equivalent oncologic outcomes with no added morbidity.

Creation of the Miami Pouch During Laparoscopic-Assisted Pelvic Exenteration: The Initial Experience

Purpose:

To describe the initial experience of laparoscopic hand-assisted Miami pouch in a group of patients undergoing pelvic exenterations for pelvic malignancies.

Materials and Methods:

Thirteen female patients underwent laparoscopic-assisted pelvic exenteration in our center between September 2000 and November 2007. Six of them had the Miami pouch created for urinary diversion. The continent diversion was created extracorporeally through a right iliac fossa minilaparotomy.

Results:

The mean total operative time for the laparoscopic-assisted exenteration and reconstruction was 382 minutes (range, 270-480 minutes), but specifically for the Miami pouch, it took a mean time of 106 minutes (range, 90-130 minutes). Four patients (66.7%) had postoperative urinary tract infection that resolved with antibiotics. One patient had a ureteral stenosis requiring stenting and one had a Miami pouch cutaneous fistula that required a fistulectomy. The mean follow-up was 23 months (range, 9-48 months). All patients were continent and were able to self-catheterize approximately 3 to 6 times/d.

Conclusions:

It is technically feasible to incorporate the creation of the Miami continent urinary pouch through a minilaparotomy during laparoscopic pelvic exenteration without compromising the benefits of laparoscopic surgery.

[Place of laparoscopic radical cystectomy in the treatment of invasive bladder urothelial carcinoma]

Radical cystectomy is the reference treatment for recurrent superficial or invasive bladder tumours. The most standardized incision is midline infra-umbilical laparotomy. The first laparoscopic cystectomy was performed in 1992 in a patient with neurogenic bladder and several teams have subsequently described this incision for the treatment of bladder tumours. The advantages of laparoscopy have been reported in terms of morbidity and earlier return to daily activities. The current oncological results of this incision are difficult to compare with those of conventional open surgery due to the insufficient follow-up. However, published series have not reported any significant difference in the intermediate term. Until convincing results become available, it therefore appears legitimate to allow teams skilled in laparoscopy to demonstrate the oncological efficacy of this approach. At the present time, the reference treatment for invasive bladder cancer remains open cystectomy.

Contemporary open radical cystectomy: analysis of perioperative outcomes

PURPOSE

The feasibility of laparoscopic or robotic assisted radical cystectomy has been demonstrated in several small series, but the specific advantages are uncertain and require comparisons to more recent results that incorporate refinements in open technique and perioperative management. We reviewed our contemporary radical cystectomy series to evaluate perioperative outcome measures which could be affected by surgical approach for the purpose of establishing contemporary benchmarks for future comparisons.

MATERIALS AND METHODS

The medical records of 553 consecutive patients undergoing radical cystectomy from January 2000 through June of 2005 were reviewed. Perioperative and demographic data, type of urinary diversion, hospital stay, complications and perioperative mortality were examined.

RESULTS

Median patient age was 69 years (range 22 to 94) and average American Society of Anesthesiologists classification was 2.7. Median operative time was 258 minutes (range 89 to 801). Mean operative time for ileal conduit diversion was 271 vs 312 minutes for neobladder diversion. Median blood loss was 600 ml (range 200 to 4,200). A total of 210 patients (38%) received a blood transfusion either intraoperatively or within the first 30 days of their procedure. Median length of hospital stay was 6 days (range 4 to 79). Minor and major complications occurred in 209 (38%) and 41 (7.4%) patients, respectively. Perioperative mortality was 1.7%.

CONCLUSIONS

These results demonstrate that contemporary radical cystectomy can be accomplished through an open operative approach consistently with acceptable morbidity/mortality and with a median length of stay of less than 1 week. Efforts to further reduce morbidity and improve outcomes should continue.

Open radical cystectomy with lymphadenectomy remains the treatment of choice for invasive bladder cancer

PURPOSE OF REVIEW

Radical cystectomy with an appropriate lymph node dissection and an appropriate form of urinary diversion is the standard treatment for muscle-invasive transitional cell carcinoma of the bladder. Optimal outcomes following radical cystectomy require an extended lymph node dissection, negative surgical margins, and a continent urinary diversion. There has been an increasing number of reports describing initial experiences with laparoscopic radical cystectomy.

RECENT FINDINGS

Intermediate and long-term oncologic outcomes with laparoscopic radical cystectomy remain undefined, and appropriate lymph node dissections laparoscopically have not been uniformly performed. Furthermore, the long-term functional outcomes associated with laparoscopically performed urinary diversions also remain undefined. There appears to be a recent trend toward performing the urinary diversion portion of the procedure extracorporeally, after laparoscopic removal of the bladder. Some studies suggest a decrease in postoperative analgesic requirements and quicker recovery of bowel function in those undergoing laparoscopic radical cystectomy, but these observations have not been corroborated by others.

SUMMARY

In the absence of long-term functional and oncologic outcome data, laparoscopic radical cystectomy should be considered an investigative technique, and potential candidates for this operation should be appropriately counseled.

Surgery Insight: advantages and disadvantages of laparoscopic radical cystectomy to treat invasive bladder cancer

Laparoscopic radical cystectomy (LRC) is a challenging technique, but it has been proposed as an alternative to open radical cystectomy (ORC), which is currently the gold standard treatment for muscle-invasive or high-risk superficial bladder cancer. So far, approximately 200 cases treated with LRC have been reported in the peer-reviewed literature, but follow-up has generally been short (all <48 months). A shorter hospital stay and a quicker recovery of the patient seem to be the main advantages of LRC over ORC. Functional outcomes, cancer control obtained, and safety of the technique need to be confirmed by studies with larger cohorts of patients and longer follow-up than those previously reported, but an initial analysis suggests that LRC is not equivalent to ORC. Given that the majority of patients selected for LRC had lower American Society of Anesthesiologists scores and lower pathological stages than those in ORC studies, the proportion of patients with orthotopic neobladders (47%) and the proportion of disease-free patients (80%) seem to be suboptimal and, actually, those might represent the major disadvantages of LRC.

Laparoscopic radical cystectomy with and without orthotopic bladder replacement

The successful introduction of laparoscopic radical prostatectomy at the end of the last millennium represented a quantum leap in the technical development of minimally invasive surgery in urology. Therefore it seemed a logical step that, at the beginning of this millennium, first centers reported their initial experience with laparoscopic radical cystectomy. Based on more than 2000 laparoscopic radical prostatectomies, two centers have performed this procedure in 48 patients including a variety of urinary diversion (i.e. ileal conduit, ileal neobladder, sigmoid neobladder). In this article, all important surgical steps of laparoscopic radical cystectomy are presented, including the description of the most important techniques of urinary diversion. Based on our own experience, the results of 238 cases presented in the current literature are reviewed. The operating time mainly depended on the type and technique of urinary diversion and ranged between 352 and 430 minutes for ileal conduit, and between 478 and 649 minutes for orthotopic neobladder. The complication rate ranged between 16 and 18%, and the reintervention rate was 4-6%. Long-term follow-up is not available, disease-free survival after three years in a limited number of series ranges between 50 and 67%. No port site metastases have been reported so far. Even for the experienced surgeon laparoscopic radical cystectomy with urinary diversion represents a technically challenging procedure. Nevertheless, feasibility and safety have been proved by various authors. However, larger studies with long-term clinical outcome are necessary to determine the final value of the procedure.

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.

Laparoscopic radical cystectomy with urinary diversion: what is the optimal technique?

PURPOSE OF REVIEW

Laparoscopic prostatectomy has become a standardized procedure; consequently, many urologic surgeons have mastered it. Using the knowledge gained from this procedure, some laparoscopic urologic surgeons have also been successfully performing laparoscopic radical cystectomy. We review the current literature to determine the optimal technique for laparoscopic radical cystectomy.

RECENT FINDINGS

Three techniques for the extirpative aspect of laparoscopic radical cystectomy have been described: robot-assisted, hand-assisted and pure laparoscopic surgery. Creation of the urinary bladder has been performed via both intracorporeal and extracorporeal techniques with more recent studies favoring the extracorporeal creation of the urinary diversion.

SUMMARY

Laparoscopic radical cystectomy has become a standard procedure at many laparoscopic centers worldwide. The procedure is feasible with reproducible results. It appears to offer the patient all the advantages of other minimally invasive surgeries with respect to postoperative recovery.

Open versus Laparoscopy-Assisted Radical Cystectomy: Results of a Prospective Study

BACKGROUND AND PURPOSE

Laparoscopic radical cystectomy is confined to centers where advanced laparoscopy is performed, and its role is not yet well clear. Our aim was to evaluate, through a prospective comparative study, the advantages of the laparoscopic compared with an open approach.

PATIENTS AND METHODS

From November 2002 to December 2005, all the patients in our center who were found to have muscle-invasive bladder cancer without clinical evidence of lymph-node involvement and an American Society of Anesthesiologists (ASA) score <4 were included in a prospective nonrandomized study. Group A (N = 22) underwent open radical cystectomy, whereas group B (N = 20) underwent laparoscopy-assisted radical cystectomy. The two groups were demographically comparable. We evaluated the mean age, clinical stage, ASA score, operative time, blood loss, intraoperative complications and transfusions, type of diversion, time of catheterization, analgesic consumption, start of oral nutrition, rate of postoperative complications, length of hospital stay, pathologic diagnosis of the specimen, number of lymph nodes removed, and the oncologic outcome.

RESULTS

No significant statistical difference was observed between the two groups in intraoperative and postoperative parameters except for analgesic consumption and the start of oral nutrition (P < 0.05). The mean operative time was 260 minutes (range 210-290 minutes) for group A and 284 minutes (range 260-305 minutes) for group B. The mean blood loss was 770 mL (range 450-870 mL) in group A and 520 mL (range 400-620 mL) in group B. The rate of autologous transfusion was 18% in group A and 10% in group B. Seventeen ileal diversions and five neobladder creations were performed in group A, whereas the Bricker diversion was used in 10 cases in group B, and a neobladder was chosen in the 10 other cases.

CONCLUSION

Laparoscopy-assisted radical cystectomy is a safe procedure, like open surgery, but it offers the advantage of minimal invasiveness, represented by reduced analgesic consumption and early recovery of peristalsis with rapid oral nutrition.

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.

Hand-assisted laparoscopic radical cystoprostatectomy and urethrectomy with ileal conduit construction

INTRODUCTION

Hand-assisted laparoscopy was first performed in the 1990s by inserting the surgeon's finger or hand through a small tight wound. Although leakage of gas from the incision initially limited the usefulness of the technique, the hand-assisted procedures have advanced extensively since the introduction of the hand-assisted laparoscopy port. Laparoscopic procedure has only rarely been applied to radical cystoprostatectomy. Favorable reports for laparoscopic radical prostatectomy encouraged us to attempt a cystoprostatectomy under hand-assisted laparoscopy.

PATIENT

The patient was a 70-year-old male with an invasive bladder tumor and no distant metastasis. Informed consent for undergoing hand-assisted laparoscopic radical cystoprostatectomy and ileal conduit construction was obtained.

METHODS AND RESULTS

The bladder was dissected free and extracted whole through the incision for the hand port. The bilateral ureters and a loop of small intestine were withdrawn through the same incision. An ileal segment was isolated and small intestine continuity was recovered. Each ureter was anastomosed to one extreme of the ileal segment that was then reintroduced into the abdomen. The stoma was constructed through the right side port without additional incision. No intraoperative complications were observed. Recuperation was unusually quick and painless, and few postoperative analgesics were needed.

CONCLUSIONS

Hand-assisted laparoscopic cystoprostatectomy and urinary diversion could provide the advantage of decreased postoperative morbidity without the long operation time and technical difficulty of a strictly laparoscopic procedure.

The use of robotically assisted surgery for treating urachal anomalies

OBJECTIVE

To report the management of urachal anomalies using a robotically assisted approach.

PATIENTS AND METHODS

Between January 2005 and February 2006, five patients (mean age 51 years, range 24-68) were diagnosed with urachal anomalies. Two basic robot-assisted surgical approaches were used for excising the urachal anomalies: excision of the urachal remnant via partial cystectomy, and radical cystectomy for excision of urachal adenocarcinoma.

RESULTS

All five cases were successful and the excised specimens were assessed histologically. The short-term oncological outcome in the three patients with histologically confirmed moderately differentiated adenocarcinoma showed no evidence of recurrent disease within a median interval of 8 months. Surveillance follow-up cystoscopy in the patients who had a partial cystectomy showed a well-healed bladder mucosa with no evidence of recurrence.

CONCLUSIONS

Radical excision of the urachal tract with partial cystectomy or radical cystectomy using the da Vinci robot is safe, effective and technically feasible.

Fast and Safe Closing of Urethra during Laparoscopic Radical Cystectomy

PURPOSE

To present a simple alternative technique to close the membranous urethra during laparoscopic radical cystectomy.

PATIENTS AND METHODS

A series of 18 laparoscopy-assisted cystectomies were performed in our institute from November 2002 to May 2005. In order to prevent neoplastic-cell spillage, in 14 of these patients, the membranous urethra was closed with Hem-o-lok clips after careful dissection of the urethra and withdrawal of the bladder catheter.

RESULTS

In all cases, one or two Hem-o-lok clips were easily, safely, and quickly positioned. The remaining length of the membranous urethra was sufficient for anastomosis with the neobladder if appropriate. In follow-up (mean 14 months), no local recurrence has been recorded.

CONCLUSION

The closing of the membranous urethra with Hem-o-lok clips during laparoscopy-assisted cystectomy is in our experience a simple, fast, safe, and effective alternative that should be considered when laparoscopic radical cystectomy is performed.

[Laparoscopic pelvic exenteration for cervical cancer relapse: preliminary study]

OBJECTIVES

To determine the feasibility and short and midterm results of laparoscopic pelvic exenteration for cervical cancer relapse. Materials and methods. Five patients with centro-pelvic recurrence within 3 to 13 months after combined chemo-radiation therapy (associated to surgery for two cases) for cervical cancer tumors were included in a pilot study.

RESULTS

The procedures consisted in a complete pelvic exenteration with colo-anal anastomosis and ileal-loop conduit for 2 patients, a posterior pelvic exenteration including uterus, vagina and rectum with colo-anal anastomosis for 1 patient, an anterior pelvic exenteration including bladder and vagina with an ileal-loop conduit for 1 patient and a anterior pelvic exenteration with a laparoscopic hand assisted Miami Pouch for 1 patient. The 5 procedures were successful with no conversion to laparotomy. Time of procedure ranged between 4 h 30 and 9 hours. Average blood loss was 370 cc. Three patients developed metastatic recurrences and died. The two patients with anterior exenteration are alive and free of disease 11 and 15 months after the procedure.

CONCLUSION

Laparoscopic pelvic exenteration procedures are feasible. A larger series is necessary to determine the advantages of this technique compared to laparotomy.

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.

Laparoscopic pelvic exenteration for advanced pelvic cancers: a review of 16 cases

OBJECTIVE

The aim of this study was to retrospectively evaluate, in a series of 16 consecutive patients, the technique, feasibility and oncological safety of laparoscopic anterior exenteration for locally advanced pelvic cancers.

STUDY DESIGN

Since August 2003, 16 patients with locally advanced pelvic cancer were considered. All patients were in a good general condition, in the age group of 50-60 years of which 12 had cervical carcinoma and 4 had bladder carcinoma.

RESULTS

The median operative time was 180 min. The mean number of harvested pelvic iliac nodes was 14. All margins were tumor-free. The median postoperative hospital stay was 3 days. Three patients had postoperative complications; two had subacute intestinal obstruction and one had ureteric leak. The median follow-up was 15 months.

CONCLUSIONS

Our results have demonstrated the feasibility and oncological safety of performing anterior exenteration laparoscopically in advanced pelvic cancer patients with acceptable morbidity. Intermediate-term follow-up validates the adequacy of this procedure.

Laparoscopic Nephroureterectomy with Bladder-Cuff Resection: Techniques and Outcomes

Advancements in minimally invasive instrumentation and technique have provided the impetus to performing urologic procedures with reduced perioperative morbidity, shorter hospital stays, and, most importantly, efficacious oncologic results. At multiple centers of excellence, laparoscopic nephroureterectomy (LNU) has evolved into a new standard for the management of upper-tract transitional-cell carcinoma (TCC) that is not amenable to endoscopic resection. An LNU may be performed via a transperitoneal or retroperitoneal approach together with excision of the distal ureter and a bladder cuff. Analysis of present-day studies comparing LNU with open techniques demonstrates equivalent oncologic outcomes. In addition, those patients undergoing LNU fare better than their counterparts having open surgery with respect to hospital stay, analgesic requirements, and convalescence. With multiple options for excision of a cuff of bladder, a consensus has not been established. However, LNU has emerged as the new standard of care for the treatment of upper- tract TCC. Review of the techniques and outcomes of LNU from the minimally invasive urology community are described.

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.

Laparoscopic Radical Cystoprostatectomy: Our Experience in A Consecutive Series of 10 Patients with a 3 Years Follow-Up

OBJECTIVE

Laparoscopic radical cystectomy is a feasible procedure but there is still controversy if laparoscopic treatment of transitional cell carcinoma (TCC) of the bladder is oncologically safe. We report our experience with laparoscopic radical cystectomy in a consecutive series of 10 male patients with a 3 years follow-up.

METHODS

Between June 2001 and July 2002, 10 men age 63 to 74 years (mean 68.8) underwent laparoscopic cystoprostatectomy with urinary diversion for muscle-invasive TCC or pT1 G3 TCC plus carcinoma in situ (Cis) after 2 cycles of intravesical bacille Calmette-Guerin therapy and three or more transurethral resections (delayed cystectomy).

RESULTS

Histopathology revealed 2 stage pT1N0 TCC G3 plus Cis, 1 stage pT2aN0 TCC G3 plus Cis, 1 stage pT2bN0 TCC G2, 4 stage pT2bN0 TCC G2-3, 1 stage pT2bN0 TCC G3, 1 stage pT3aN0 TCC G3. The mean follow-up is 30.4 months (range 23-36). No local recurrences, peritoneal carcinosis or trocar-site metastases occurred. Metastases presented in 4 of 10 cases (2 patients with a stage pT1N0 plus Cis and 2 patients with a stage pT2bN0 TCC) respectively after 7, 14, 16 and 28 months. These patients died respectively at 20, 18, 22 and 31 months later. One patient died for unrelated causes. Five patients are alive, free from disease.

CONCLUSIONS

Laparoscopic radical cystectomy is feasible and accomplished with low morbidity. Up to now publishing data do not support a verified negative oncological effect of the laparoscopy in the treatment of bladder TCC, but our initial results seem worst than those achieved with open surgery. The experience of other Institutions will help to provide objective evaluation of this new and controvers technique because it is not clearly demonstrated that laparoscopic radical cystectomy is an oncologically safe procedure in the management of bladder TCC. Thus in our opinion it should be still considered experimental.

Laparoscopic radical cystectomy and urinary diversion

Most of the publications regarding laparoscopic radical cystectomy (LRC) have reported the institutions' initial experience focusing on technique and perioperative results. Increasing experience from major medical centers worldwide indicates increasing interest and expertise with LRC. In this manuscript, initial laboratory experience, contemporary series, current controversies, and future directions of the procedure are discussed. Careful prospective evaluations of oncologic and functional outcomes are awaited to define the role of LRC as a viable alternative to open radical cystectomy.

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

Laparoscopic radical cystectomy is an emerging technique. It has been proposed as an alternative to open radical cystectomy, which is the gold standard treatment of muscle-invasive or high-risk superficial bladder cancer. The experience in laparoscopic radical cystectomy reported in peer-reviewed journals account for approximately 100 cases, with a median longest follow-up of 11.5 months. Safety of the technique and cancer control need to be confirmed by a larger cohort of patients; however, after an initial analysis, it seems to be equivalent to open radical cystectomy. Equivalent does not mean better. Long-term results will determine if supposed benefits of laparoscopy overweigh the true increment of cost and time.

Nerve-sparing laparoscopic cystectomy

Laparoscopic radical cystectomy has been included among the viable options for the surgical treatment of muscle-invasive bladder cancer. Even with the minimally invasive approach, it must be considered a major surgical intervention and, even in experienced hands, it can be associated with a significant percentage of complications with a negative impact on overall quality of life, especially in terms of continence and sexual potency. According to our Medline search, only two papers are available from the literature on laparoscopic and robotic versions of nerve- and seminal-sparing cystectomy and nerve-sparing cystectomy, performed respectively on three and 17 patients, showing the feasibility and preliminary results of those surgical procedures. Therefore, data seem encouraging, but further prospective studies are mandatory to correctly assess oncologic and functional results in terms of potency and continence maintenance related to these innovative techniques.

Laparoscopic radical cystectomy with continent urinary diversion

Laparoscopic radical cystectomy with urinary diversion, although challenging even for the skilled laparoscopist, has evolved rapidly throughout the past decade. These advances are attributable to a series of well-designed animal studies transitioned carefully to humans. Short-term data have shown that this is a feasible technique that respects the basic principles of surgical oncology. However, the possibility of decreased blood loss, improved visualization, shorter hospital stay, and less postoperative pain are balanced against technical difficulty, long operative times, and unproved long-term efficacy compared with the open gold standard. The goal of this review is to reflect the available literature with regard to surgical indications, the current technique in evolution, short-term morbidity, and oncologic outcomes.

Complications of laparoscopic radical cystectomy during the initial experience

AIM

Radical cystectomy is the standard of care for patients with muscle invasive bladder cancer. While open radical cystectomy is now a standard procedure, laparoscopic radical cystectomy is still in its infancy. We performed this surgery laparoscopically in 11 patients and review the procedure specific complications.

METHODS

Beginning in February 1999, 11 patients underwent laparoscopic radical cystectomy at the Department of Urology, All India Institute of Medical Sciences, New Dehli. Urinary diversion was performed by an open-hand sewn ileal conduit.

RESULTS

There were three intraoperative complications specifically related to the laparoscopic radical cystectomy. These included injury to the external iliac vein in one patient and a small rectal tear in two. All were repaired with laparoscopic free hand suturing with normal postoperative recovery. Other laparoscopy-related complications were subcutaneous emphysema in one patient and hypercarbia necessitating conversion to open surgery in a patient who, four weeks after surgery, died of multiple organ failure. One patient had margins positive and received cisplatinum-based chemotherapy. All patients had normal renal function and preserved upper tracts with no evidence of metastasis at a mean of 18.4 months follow up (range 1-48 months).

CONCLUSIONS

Though there were three complications specific to the laparoscopic radical cystectomy, none necessitated a conversion to open surgery or hampered the overall outcome. Absence of local recurrence or metastatic disease at four years of follow up suggests that the procedure is oncologically valid. Laparoscopic radical cystectomy is a new procedure and it is important to critically analyze the complications in order to reduce their occurrence and allow the development of a better technique.

Laparoscopic radical cystectomy with continent urinary diversion (rectosigmoid pouch) performed completely intracorporeally: An intermediate functional and oncologic analysis

OBJECTIVES

To present our experience with the first series of rectosigmoid pouch creation performed completely laparoscopically for continent urinary diversion after radical cystectomy to treat transitional cell carcinoma of the bladder. We evaluated the intermediate functional and oncologic outcomes.

METHODS

Between April 2000 and January 2004, 20 patients underwent laparoscopic radical cystectomy with urinary diversion for transitional cell carcinoma at the Department of Urology, Charite Hospital, Campus Mitte. Of the 20 patients, 12 received a rectosigmoid pouch for urinary diversion. The procedures were performed completely laparoscopically, including free-hand laparoscopic suturing and in situ knot tying techniques. The mobilized specimens were removed in an endoscopy bag by way of the rectum or vagina.

RESULTS

All operations were completed laparoscopically by two surgeons without conversion to open surgery. The median operating time was 485 minutes. One patient needed a blood transfusion of 2 U. All specimens had negative surgical margins. Two patients required reoperation. The median follow-up was 33 months. All patients were continent during the day, and 11 patients were continent at night. One patient developed unilateral hydronephrosis with loss of kidney function. No patient developed local recurrence, but 3 patients had systemic progression. Two of the three died of metastatic disease.

CONCLUSIONS

This is the first series of laparoscopic radical cystectomy using an intracorporeal rectosigmoid pouch. Our functional data for continence and upper urinary tract obstruction were comparable with those of open rectosigmoid pouch studies. We were able to demonstrate an oncologic outcome similar to that achieved by the open surgical approach.