5.2 Laparoscopic Radical Cystectomy with Orthotopic Bladder Replacement Roland F. van Velthoven, Jens Rassweiler Contents considered recently as experimental for the treatment ofbladder cancer [3]. During the last decade, the Patient Preparation 98 greatest impact shown by the laparoscopic approach Equipment 98 Trocar Placement 98 in urology was undoubtedly shown on patients with Laparoscopic Cystoprostatectomy in the Male 29 genitourinary malignancies. Although only pelvic Dissection of the Retrovesical Space 99 lymph node dissection and occasionally nephrectomy Lateral Dissection of the Bladder 99 were initially considered as oncologically feasible, sev- Anterior Dissection of the Bladder 101 eral other approaches such as laparoscopic adrenalec- Nerve Sparing Dissection of the Vesicoprostatic tomy and radical nephrectomy are today considered as Complex 102 standards ofcare, not only at centers ofexcellence but Apical Dissection 102 Laparoscopic Cystectomy in the Female 104 even in the general community. Maturing data with Laparoscopically Assisted Orthotopic laparoscopic radical prostatectomy suggest excellent Bladder Replacement 104 continence rates and equivalent oncologic results Other Technical Options of Urinary Diversion 105 based on pathological surrogates ofcure [4]. Ileal Conduit 105 The laparoscopic approach for advanced disease Rectosigmoid Neobladder 106 such as cytoreductive nephrectomy has also been Other Types of Urinary Diversion 107 found to be feasible for selected patients with meta- Postoperative Management 107 Discussion 107 static renal cell carcinoma. Other novel therapies, such The Concept of Laparoscopic Cystectomy 107 as laparoscopic radical cystectomy with urinary diver- Technical Difficulties of the Procedure 109 sion and laparoscopic retroperitoneal lymph node dis- Extracorporeal, Hand-Assisted or Intracorporeal section, hold great promise of benefit for patients with Creation of Urinary Diversion 111 urologic malignancies [5]. Involvement of Robotics in the Field Beyond initial reports on feasibility, controversy of Laparoscopic Radical Cystectomy 111 persisted regarding the risk ofcell spillage or port me- Perspectives of Laparoscopic Radical Cystectomy 111 References 112 tastases in transitional cell carcinoma; yet the strict observation ofoncological safety rules such as the re- spect ofclosed urinary cavities has increased the ac- The American Cancer Society estimates that 57,400 ceptance oflaparoscopic nephroureterectomy [5]; new cases ofbladder cancer will be diagnosed in the hence radical cystectomy should become more and United States this year, and 12,500 people will die of more accepted ifthe same rules are carefully observed the disease. Radical cystectomy remains the gold stan- [6]. Moreover, animal and clinical experimental work dard for muscle-invasive bladder cancer and high-risk has demonstrated that laparoscopy may be less immu- superficial tumors resistant to intravesical therapy [1]; nodepressant than its open counterpart [7]; this addi- moreover, open cystoprostatectomy with urinary di- tional theoretical advantage could play a positive role version remains a major procedure, which may be de- in favor of radical cystectomy made by the laparo- manding for patients. scopic approach. Although cystectomy performed through a laparo- Although laparoscopic cystectomy with different scopic approach was first described in 1992 [2], this urinary diversions has already been described and has indication remained very controversial and was still shown to provide intraoperative and postoperative ad- 98 R.F. van Velthoven, J. Rassweiler vantages vs open surgery [8±10], the laparoscopic cys- Table 1. Equipment for laparoscopic radical cystoprostatec- toprostatectomy has rarely been well codified and illu- tomy strated [11]. Having set up an experience in radical prostatectomy since 1999, our groups started to per- Standard laparoscopic equipment n High-flow insufflator form laparoscopic radical cystectomy 1 year later, in n 300 W Xe light fountain spring 2000. Since then until June 2004, 30 and 8 pa- n 3CCD camera tients were operated on in Brussels and in Heilbronn, n 10-mm 08 endoscope 1 (308 endoscope optional) respectively. Trocars As elegantly shown in another recent review [12], n 10- to 12-mm trocars 2±3 all technical steps ofan open-surgery radical cystecto- n 5-mm trocars 3 my with urinary diversion have been translated into Instruments equivalent laparoscopic maneuvers. n Laparoscopic Metzenbaum scissors 1 The potential advantages ofdoing the procedure n Laparoscopic bipolar forceps 1 laparoscopically are the smaller incisions, hence de- n Laparoscopic atraumatic prehension forceps 2 creased pain and quicker recovery time, implying a n Laparoscopic suction irrigation cannula 1 shortened hospital stay, decreased blood loss and fluid n Laparoscopy bags (optional) imbalance compared with the open technique. Iftrans- n Harmonic scalpel or Ligasure (Tyco Healthcare) 5- to 10-mm forceps fusion is usual during open surgery, it is infrequent n Surgical endoscopy 5- to 10-mm clip applicators with laparoscopy. A stepwise protocol is actually es- tablished, with minor alternative variations between centers [9, 11, 12, 38]. Trocar Placement Patient Preparation The patient is in the supine position, with the lower Preoperatively, the bowel is prepared by oral self-ad- limbs slightly (158) abducted. A 308 flexion is given to ministration of2 l ofelectrolyte lavage solution over 2 the knees, to define accordingly the value of the Tren- days before the surgical procedure. Antibiotic prophy- delenburg position. Extension ofthe hips should be laxis with a cephalosporin is performed from day 1 to avoided to prevent any backache (Fig. 1). 5 and low-molecular-weight heparin (4,000 units) is A five-port diamond or fan-shaped transperitoneal administered preoperatively and until the postopera- approach is used (Fig. 2). The first 10-mm trocar is tive day 15. Compression stockings are applied as the placed 1 cm above the umbilicus; an open technique patient is placed in the supine position with the legs through a mini-laparotomy is optional at this level. apart to allow free access to the perineal space. The This trocar is reserved for the 08 laparoscope. The re- table is set to a 308 Trendelenburg position. An 18F maining four ports are placed under endoscopic con- Foley catheter is inserted to drain the bladder and a trol after classical establishment of the pneumoperito- nasogastric tube is positioned. As the lower limbs are neum (12±14 mmHg) with or without the use ofa carefully strapped to the table without compressions, Veress needle. no shoulder pads are necessary. At the left McBurney point, a 12-mm trocar is placed; this diameter is chosen to ease the retrieval of pelvic lymph nodes after dissection. At the true Equipment McBurney point, a 10-mm trocar is placed to accept a 10-mm instrument ifnecessary. The technique is challenging, requiring considerable On the midline, a 5-mm trocar is placed, one span laparoscopic infrastructure and expertise. Using a below the umbilical trocar. A fifth 5-mm trocar is five- or six-port transperitoneal approach, the radical placed at the horizontal level ofthe navel, on the ver- cystectomy and pelvic lymph node dissection are per- tical line ofthe right lateral trocar. formed first. Standard laparoscopic surgical equip- The abdomen and pelvis are inspected; eventual ad- ment with few special instruments are required (Ta- hesions ofthe sigmoid loop in the leftfossaare re- ble 1). leased by blunt and sharp dissection. a 5.2 Laparoscopic Radical Cystectomy with Orthotopic Bladder Replacement 99 Fig. 1. Patient positioning. The patient is in the Supine position, with the lower limbs slightly (158) abducted. A 308 flex- ion is given to the knees, to define ac- cordingly the value of Trendelenburg position. Extension of the hips shouldbe avoided Laparoscopic Cystoprostatectomy fenestrated forceps held by the second assistant. A in the Male horizontal 6- to 8-cm incision is made on the perito- neum, two fingers above the bottom of the Douglas pouch (Fig. 3). Dissection of the Retrovesical Space Ampullae and seminal vesicles are exposed but not In a male patient, the operation starts by dissection of dissected from the bladder, to which they remain at- the plane behind the seminal vesicles; the dissection is tached throughout the procedure. Ifnecessary, the started at the level ofthe Douglas pouch. The posteri- posterior aspect ofDenonvilliers fasciais exposed and or wall ofthe bladder is lifted vertically by means ofa incised horizontally to open the perirectal fatty space. When started high enough, the dissection is able to leave the Denonvilliers posterior sheet covering the seminal vesicles. The dissection is continued bluntly on each side and on the anterior aspect ofthe rectum towards the apical area ofthe prostate. The vascular supplies ofthe vesicles are recognized laterally, but not divided so far. A tunnel is created between the rectum and the prostate with the vesical and prostatic fibrovascular pedicles laterally. Lateral Dissection of the Bladder The umbilical arteries are identified close to the ab- dominal inguinal ring and the peritoneum is incised just laterally to them. From the internal inguinal ring Fig. 2. Trocar placement. The first 10-mm trocar is placed1 caudally, a vertical incision ofthe peritoneum follows cm above the umbilicus, for the 08 laparoscope. At the left the medial aspect ofthe external iliac artery until the McBurney point