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Inderbir Gill, MD, MCh

Head, Section of Laparoscopic And Minimally Invasive Surgery Glikman Urological Institute

Executive Director

The Minimally Invasive Surgery Center

The Cleveland Clinic Foundation, Cleveland, USA

Presented herein is our initial experience of laparoscopic radical cystectomy with urinary diversion in 19 patients, performed exclusively by intracorporeal techniques.

Technique

A 6-port transperitoneal technique is employed, with the patient in the supine abducted-thighs lithotomy position. The parietal peritoneum overlying the rectovesical pouch is incised horizontally, and Denonvillier’s fascia entered in the midline, to develop the place beween the prostate and rectum. Both ureters are widely mobilized and divided close to the bladder. The posterior and lateral pedicles of the bladder are defined bilaterally, and controlled by sequential firings of the Engo-GIA stapler. The urachus is divided near the umbilicus, and the anterior surface of the bladder is completely mobilized towards the space of Retzius. The endopelvic fascia is incised, and the dorsal vein complex controlled. The urethra is sectioned distal to the prostatic apex, and the few remaining pelvic attachments divided to circumferentially free the en bloc radical cystoprostatectomy specimen. Pelvic lymphadenectomy is completed.

An appropriate 15 cm ileal segment is isolated based on a generous mesentery using the Endo-GIA stapler. Side-to-side ileo-ileal stapled anastomosis is performed intracorporeally to restore intestinal continuity. The left ureter is retroperitoneally delivered to the right side of the abdomen. An end ileal stoma is created at a pre-selected port-site in the right rectus muscle. Bilateral ileoureteral anastomses are performed over a 7-Fr, 90 cm single-J ileoureteral stent. A 4-0 Vicryl suture on a RB-1 needle is employed, and laparoscopic free-hand suturing and in situ knot-tying techniques are used exclusively. During ortholopic neobladder, 60 cm of ileum are isolated, detubularized and reconfigured to create a spherical neobladder. Ileo-urethral amastomosis is performed and both ureters are connected to the Studer limb.

Results

We have performed 19 patients to date: 13 ileal conduits, 5 orthotopic ileal neobladders, and 1 extracorporeally- constructed Indiana pouch. All patients had organ-confined bladder cancer, without CT scan evidence of extravesical involvement. Operative time ranged from 6.5 – 11.5 hours with a median blood loss of 330 cc. Three patients required blood transfusions. All procedures were accomplished laparoscopically without intraoperative open conversion. Hospital stay ranged from 3 days – 5 weeks. Postoperatively, two patients developed bowel complications requiring secondary open laparotomy, one of whom died from aspiration pneumonia and ARDS.

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Additional complications included GI bleed (1), pulmonary embolus (1), prolonged ileus (4), uretero-conduit stricture managed by stenting (1). On pathology, all bladder specimens had negative surgical margins for cancer; 4 patients had lymphatic micrometastasis. Mean specimen weight was 263 gm (90-400gm). Pathologic stage ranged from pT2b to pT4 (prostate involvement).

Discussion

Although laparoscopic cystectomy has been performed previously, both for benign and malignant disease, the accompanying technically-challenging urinary diversion has to date been performed either through a mini-laparotomy incision, or by exteriorization of the bowel and ureter through an extension of a port-site. Prior to embarking upon this clinical experience, we developed and refined the laparoscopic technique in a chronic porcine model. The patients selected for this initial experience had low-volume organ-confined cancer. Our early experience suggests that all essential ablative and reconstructive maneuvers necessary during a radical cystectomy and urinary diversion can be duplicated laparoscopically with precision. The Endo-GIA stapler is an important adjunct during the ablative radical cystectmy part of the procedure. Precise mucosa-to-mucosa ileoureteral anastomoses could be performed with free-hand intracorporeal laparoscopic suturing technique, mirroring open surgical principles. Clearly, there is a significant learning curve involved herein. However, within the space of 11 patients, we were able to decrease the surgical time from 11.5 hours in the first patient to 6.5 to 8 hour range consistently in the last 5 patients. Potential advantages of the laparoscopic technique include decreased blood loss, minimizing the need for blood transfusions, decreased postoperative pain and discomfort, and early resumption of bowel activity and ambulation. More importantly, established oncologic principles are maintained, as attested to by the negative surgical margins for cancer in all 19 patients. In summary, based on this initial experience, we believe that with further experience and technical refinement, laparoscopic radical cystoprostatectomy with urinary diversion may become a viable treatment option for the selected patient with localized muscle-invasive bladder cancer.

Take home points

1. Radical cystectomy can be effectivelly performed laparoscopically. Sequential firing of the Endo-GIA stapler controls and transects the vesical pedicles adequately, minimizing blood loss.

2. The accompanying urinary diversion is technically more challenging. However, it can be performed completely intracorporeally by free-hand laparoscopic suturing.

3. This laparoscopic procedure is in its early evolution, with lengthy operative times currently. Further clinical experience, availability of absorbable endo-GIA staplers, and prospective comparison with open surgery is necessary to determine its true place.

References

1. Parra RO, Andrus CH, Jones JP, Boullier JA: Laparoscopic cystectomy; initial report on a new treatment for the retained bladder. J Urol 148 (4): 1140-4, 1992.

2. Gill IS, Fergany A, Klein EA, et al: Laparoscopic radical cystoprostatectomy with ileal conduit performed completely intracorporeally: the initial 2 cases. Urology 56:26, 2000.

3. Fergany AF, Gill, IS, Kaouk JH, Meraney AM, Hafez KS, Sung GT: Laparoscopic intracorporeally constructed ileal conduit after porcine cystoprostatectomy. J. Urol., in press.

4. Kaouk JH, Gill IS, Merany AM: Laparoscopic orthotopic ileal neobladder. J. Endourology, 15:131, 2001. 5. Gill, I.S., Kaouk, J.H., Meraney, A.M., Desai, M.M., et al: Laparoscopic radical cystectomy and continent orthotopic neobladder performed completely intracorporeally – the initial experience. J. Urol., 168:13-18, 2002. 6. Gupta, N.P., Gill, I.S., Fergany, A., Nabi, G.: Laparoscopic radical cystectomy with intracorporeal ileal conduit diversion: five cases with a 2-year follow-up. Br. J. Urol., 90:391, 2002.

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