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 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. 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 1 The potential advantages ofdoing the procedure n Laparoscopic bipolar 1 laparoscopically are the smaller incisions, hence de- n Laparoscopic atraumatic prehension forceps 2 creased pain and quicker recovery time, implying a n Laparoscopic irrigation cannula 1 shortened hospital stay, decreased blood loss and fluid n Laparoscopy bags (optional) imbalance compared with the open technique. Iftrans- n Harmonic 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 is inserted to 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, . 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 a 12-mm trocar is placedto ease the retrie- crossing ofthe ipsilateral ureter. The vas is divided at val of pelvic lymph nodes after dissection. At the true the level ofthe inguinal ring and retracted medially to McBurney point, a 10-mm trocar is placedto accept a 10- open the space medial to the external iliac vessels mm instrument. On the midline, a 5-mm trocar is placed, one span below the umbilical trocar. A fifth 5-mm trocar is (Fig. 4). placedat the horizontal level of the navel, on the vertical The classical or extended ilio-obturator lymph node line of the right lateral trocar dissection [13, 14] can be carried out at this moment; 100 R.F. van Velthoven, J. Rassweiler

Fig. 4. Lateral dissection. The umbilical arteries (ua) are identified and the peritoneum is incised just laterally to them. A vertical incision of the peritoneum follows the me- dial aspect of the external iliac artery (ea) until the crossing of the ipsilateral ureter (ur). The vas is divided at the level of the inguinal ring andretractedmedially. The classical or extended ilio-obturator lymph node dissection is carried out at this time

ing ofiliac vessels. This makes it possible to prepare an adequate length offree ureter in view oftheir ante- rior reimplantation. Careful hemostasis of the arteri- olar supply to the iliac portion ofureters should be ensured to avoid potentially neglected bleeding. The superior vesical artery is divided at its origin. This can be accomplished by means ofa 10-mm Liga- sure (Tyco Healthcare, Mansfield, MA, USA) forceps Fig. 3. Posterior dissection. The dissection is started at the or by section between laparoscopic clips. level of the Douglas pouch. The posterior wall of the blad- der is lifted vertically by means of a fenestrated forceps The ureter is then further followed, completely dis- heldby the secondassistant. A horizontal 6- to 8-cm inci- sected and divided between clips, close to its intra- sion is made on the peritoneum, two fingers above the bot- mural portion. The last centimeter is resected and tom of the Douglas pouch. Ampullae andseminal vesicles properly oriented for frozen section to exclude dyspla- (sv) are exposed but not dissected from the bladder. The sia ofthe lower ureter. posterior aspect of Denonvilliers fascia is exposedandin- The inferior vesical artery and vesicoprostatic ar- cisedhorizontally to open the perirectal fatty space tery are then divided as described above. Their divi- sion is carried out in close vision ofthe lateral aspect ofthe seminal vesicle to which they provide arterial sampling ofthe nodes in view offrozen sections can supply (Fig. 5). The division ofthe successive pedicles be extended to external and/or internal node groups. is temporarily interrupted at the upper lateral edge of The peritoneal incision is then extended cranially, the prostate, on each side, in order to preserve tem- at the anterior aspect ofthe ureter, beyond the cross- porarily the emergence ofthe neurovascular bundles. a 5.2 Laparoscopic Radical Cystectomy with Orthotopic Bladder Replacement 101

Fig. 5. Antegrade dissection. The superior vesical artery is divided at its origin, here by means of a 10-mm Ligasure Fig. 6. Posterior dissection completed. The division of the (Tyco Healthcare). The inferior vesical artery andvesiculo- successive pedicles is temporarily interrupted at the upper prostatic artery are then divided as described above. They lateral edge of the prostate, on each side, in order to pre- are divided in close vision of the lateral aspect of the semi- serve temporarily the emergence of the neurovascular bun- nal vesicle (sv) dles. So far, the bladder remains suspended through its anterior attachments andthe Retzius space is kept closed except for its lateral aspects So far, the bladder remains suspended through its anterior attachments and the Retzius space is kept closed except for its lateral aspects (Fig. 6). umbilical ligaments are sectioned and the Retzius space is then opened. The high section ofumbilical li- Anterior Dissection of the Bladder gaments is made possible by the supraumbilical posi- tion ofthe telescope, by the working position ofthe When the antegrade dissection and division ofthe scissors in the upper right trocar and by an hemo- bladder's upper vascular elements are achieved, the static forceps working in the left lateral trocar. 102 R.F. van Velthoven, J. Rassweiler

At this point the anterior peritoneum is incised lat- eral to the umbilical arteries from the umbilicus to the inguinal ring (Fig. 7). The prevesical space is entirely opened and the bladder is dissected from the anterior abdominal wall. With a combination ofsharp and blunt dissection, the space between the lateral wall ofthe bladder and the pelvic side wall is developed until reaching the endopelvic fascia on both sides. The super- ficial dorsal vein is then divided on the anterior aspect ofthe prostate and the endopelvic fascia is opened on its line of reflexion; the lateral surface of the prostate is separated from the levator ani muscle to carefully iso- late the dorsal vein complex and the prostatic apex.

Nerve Sparing Dissection of the Vesicoprostatic Complex At this time, the lateral aspect ofthe prostate is ex- posed by the first assistant exerting a traction on the vesicoprostatic junction in the opposite direction. This maneuver exposes the superior vesicoprostatic pedicle left intact so far (Fig. 8). In the meantime, the rectum is pushed downwards with the suction cannula, in or- der to expose the medial aspect ofthe vesicoprostatic pedicle. Descending the pelvis, the visceral fascia is opened on the lateral aspect ofthe prostate and the branches ofthe ipsilateral neurovascular bundle to the prostate are divided successively towards the apex ofthe pros- tate, on each side, using a , a 5±10 Li- gasure or a bipolar forceps.

Apical Dissection At this point the vesicoprostatic complex is still attached to the pelvic floor by the deep dorsal vein complex and Fig. 7. Anterior dissection of the bladder. The umbilical liga- the urethra. The Santorini plexus is divided after liga- ments (ua) are sectionedandthe Retzius space ( rz) is then tion or by means ofthe Ligasure forceps. opened. The high section of umbilical ligaments is made The anterior aspect ofthe urethra is exposed as possible by the supraumbilical position of the telescope, by the working position of the scissors in the upper right tro- close as possible to the prostatic parenchyma in order car, using a hemostatic forceps working in the left lateral to maintain the puboprostatic ligaments intact as well trocar. The low midline trocar is visible in the upper part of as an adequate urethral stump, ifan orthotopic neo- the picture. In the back, the right iliac artery andthe poste- bladder is planned. rior dissection planes. At this point the anterior peritoneum From the points reached by the division ofthe vis- is incisedlateral to the umbilical arteries from the umbilicus ceral fascia, the lateral and posterior aspects of the ur- to the inguinal ring. The prevesical space is entirely opened ethra are then dissected with a right-angle Maryland and the bladder is dissected from the anterior abdominal wall forceps (5 or 10 mm). When free, the urethra is li- gated with an intracorporeal knot or clamped by a 10- mm Hem-o-Lok clip and divided after removal of the indwelling catheter (Fig. 9). a 5.2 Laparoscopic Radical Cystectomy with Orthotopic Bladder Replacement 103

Fig. 8. Neurovascular bundle dissection. The lateral aspect Fig. 9. Apical dissection section of urethra. The anterior as- of the prostate is exposedby the first assistant exerting a pect of the urethra is exposedas close as possible to the traction on the vesicoprostatic junction in the opposite di- prostatic parenchyma in order to maintain the pubopros- rection. This maneuver exposes the superior vesicoprostatic tatic intact ligaments as well as an adequate urethral stump pedicle left intact thus far. Descending the pelvis, the vis- if an orthotopic neobladder is planned. The lateral and pos- ceral fascia is openedon the lateral aspect of the prostate terior aspects of the urethra are then dissected with right andthe branches of the ipsilateral neurovascular bundleto angle Marylandforceps (5 or 10 mm). The urethra is ligated the prostate are divided successively towards the apex of with an intracorporeal knot or clampedby a 10-mm Hem- the prostate, on each side, using a harmonic scalpel, a 5- to o-Lok clip and divided 10-Ligasure or bipolar forceps 104 R.F. van Velthoven, J. Rassweiler

The urinary lumen is never opened by this means the bladder neck, urethra and anterior wall ofthe va- in order to avoid any cell spillage. The terminal plate gina. Opening ofthe endopelvic fascia allows the dis- and the distal insertions ofDenonvilliers fascia are in- section to be continued until the lateral aspects ofthe cised, releasing the specimen completely. urethra, which is dissected completely, secured be- Ifthe available length ofboth ureters is considered tween clips and transected. Ifan orthotopic bladder too short by the surgeon, the former dissection is replacement is planned, a maximal urethral stump is continued cranially. The left ureter is tunnelized be- then preserved in view ofthe anastomosis. Depending hind the sigmoid loop to join the right ureter in the on patient's age and expectations, cystectomy may be retroperitoneal space; a fenestrated atraumatic forceps carried out with vaginal and uterine preservation [16]. is passed through the upper right trocar, lifting the More often, according to the tumor burden and stage, posterior peritoneum caudally to the aortoiliac bifur- the uterus and part ofthe vagina may need to be cation, and bluntly dissecting the sigmoid mesentery taken with the bladder. to allow the passage ofthe leftureter to the opposite The metal is moved to the anterior vagi- side. nal bottom to enable the dissection ofthe urethrovagi- After a last overview of the main hemostatic con- nal space, which is developed in a retrograde way trols, the pneumoperitoneum is temporarily deflated; after section of the urethra. The vaginal anterior wall lateral trocars remain as they are placed. is sectioned using the retractor, giving a flat horizon- In case ofan orthotopic bladder replacement, a tal shape to the vagina; the gas leak during section of mid-line laparotomy incision is made, unifying the the vagina is prevented by packing the vagina, even- two medial trocar holes. These trocars are temporarily tually with Vaseline gauze. removed. The vagina is repaired and closed with O-woven The vesicoprostatic specimen is removed en bloc PGA sutures, after retrieval of the specimen. through the incision, its entrapment into a bag is op- tional. Laparoscopically Assisted Orthotopic Bladder Replacement Laparoscopic Cystectomy in the Female The orthotopic neobladder pouch is created by sutur- ing the opened small bowel together to form a new The posterior dissection starts at the level ofthe rec- bladder. As usual, a 55- to 60-cm segment ofileum lo- tovaginal space. cated 15 cm away from the ileocecal junction is iso- As described in laparoscopic surgery for prolapse lated and detubularized, leaving intact a proximal 10- [15], the posterior vaginal bottom is lifted by the sec- cm isoperistaltic afferent Studer limb segment. De- ond assistant with a curved metal retractor, exposing pending on the surgeon's skills or preferences, a Haut- immediately the rectovaginal space to blunt and sharp mann ileal bladder can be built as well and the bowel dissection. This dissection is extended laterally to the prepared accordingly. The continuity ofthe small ischiorectal fossae. The peritoneal incision is then bowel is restored outside the body through the inci- continued cranially at the level ofthe first peritoneal sion made for specimen retrieval; a spherical neoblad- fold to find and dissect the ureters. der is constructed extracorporeally as well. A termino- The lateral incisions ofthe parietal peritoneum are terminal ureteroileal anastomosis is then performed started at the internal inguinal ring, both ligamenta through the same incision, using the Wallace or Bricker teres are divided and retracted medially to expose the technique. medial aspect ofthe external iliac vessels. Pelvic lymph Ureters are intubated with 8F smooth tem- node dissection is done on each side, as already de- porarily attached to the posterior wall ofthe pouch with scribed in view offrozen sections. The subsequent dis- rapid adsorbable sutures (Vicryl rapid 2/0). section and antegrade division ofthe ureters and upper Both catheters are exteriorized through the anterior vesical pedicles are then carried out as in males. wall ofthe pouch, and subsequently will be passed The umbilical ligaments and urachus are divided through the abdominal wall. and the prevesical space is opened and bluntly dis- The anterior wall ofthe reservoir is closed by a sected to expose the anterior aspect ofthe bladder to running Connel-Mayo PGA 3/0 suture; the caudal part a 5.2 Laparoscopic Radical Cystectomy with Orthotopic Bladder Replacement 105

After appropriate positioning of the ileal neoblad- der in its orthotopic position, a vesicourethral anasto- mosis is started between the ileal orifice left open and the urethral stump. This technique has been described elsewhere [17]; it has now been widely adopted for the reconstructive part ofradical prostatectomy. Briefly, the suture is started at six o'clock on the ileal edge ofthe suture; two 6- to 7-in. pieces of2/0 PGA monolayer threads knotted together are used; two hemirunning sutures are then built up to twelve o'clock, where the only knot tied intracorporeally is made (Fig. 10). When this suture is completed, a Jackson-Pratt drainage is placed in the pelvis. The tube is exterior- ized through a trocar hole in the right fossa. Fascial incisions of10 mm are closed with interrupted 0 su- tures. The skin is closed with surgical staples. This stepwise protocol and its alternative options are summarized in Table 2.

Other Technical Options of Urinary Diversion

Depending on the gender and age ofthe patient as well as on the specific indications, the following types and techniques ofurinary diversion have been per- formed.

Ileal Conduit For male patients, the ileal conduit is usually made with laparoscopic assistance. The extended sub- or supraum- bilical minilaparotomy incision for retrieval of the spec- imen is used for the isolation of the 20-cm segment of the distal ileum in an open technique. The ileoileal ana- Fig. 10. Vesicourethral anastomosis. The posterior aspect of stomosis is performed by interrupted seromuscular the anastomotic suture is completed. The caudal aspect of the anterior closing suture of the ileal neobladder is left stitches, and the ileum is brought back into the abdom- open. After completion of the anterior aspects of the two inal cavity. Subsequently, the 10-mm trocar incision in hemicircle running sutures, the intracorporeal knot is made the right lower abdomen is used as ileostoma. at twelve o'clock. The anterior aspect of the bladder is then As an alternative option, the incision at this level closed can be enlarged, the rectus fascia incised to a size al- lowing for specimen retrieval and ileoileal anastomo- sis. The distal end ofthe ileal conduit is then pulled ofthis closure is leftopen in view ofthe vesicoure- through the wound and sutured to the skin, at the thral anastomosis. upper end ofthe incision. Afterplacement oftwo sin- When the pouch is ready, it is placed in the abdomen gle J-stents, the ileal segment is manipulated back into and the mini-laparotomy is closed classically. The 10- the abdominal cavity, the subumbilical or pararectal mm trocar is replaced for the lens, in an infraumbilical incision is closed and the pneumoperitoneum re-es- position and the pneumoperitoneum reinsufflated. tablished. Finally, the left ureter is transposed retro- 106 R.F. van Velthoven, J. Rassweiler

Table 2. Laparoscopic radical cystectomy ± technical steps and options

Operative Step Options Comments

Positioning of patient Deflectedsupine Lithotomy For female patients Trocar arrangement Semilunar In case of ileal conduit W-shapedOne port=urostoma Transperitoneal access None Similar to open surgery Incision of Douglas pouch andretrovesical dissection None None Pelvic lymph node dissection Standard extended Depending on surgeon Division of ureters None None Division of ovarian anduterine vessels Endo-clips For female patients Division of umbilical ligaments and pedicles Endo-GIA Depending on surgeon Hem-o-Lok Ligasure Suturing of dorsal vein None None Division of urethra Closedby catheter Dependingon technique Closedby clip Incision of anterior vagina None In female patients Division of prostate pedicles Radical Depending on indication Nerve-sparing Depending on indication Entrapment of specimen Organ bag intra-abdominally Transrectally Retrieval of specimen Mini-laparotomy Periumbilical, mid-line Transvaginal Pararectal Transrectal peritoneally behind the sigmoid and both ureters are Rectosigmoid Neobladder sutured, stented and sutured to the ileal conduit using interrupted sutures. Some authors feel that a sigmoid neobladder can be In the female patient, following transvaginal extrac- reconstructed relatively easily in a complete laparo- tion ofthe specimen, the formation ofan ileal conduit scopic manner, mainly because ofthe anatomical lo- can be carried out completely laparoscopically. For calization ofthe sigmoid in the pelvis [18, 19]. This this purpose a 20-cm ileal segment is isolated using allows for a very stepwise construction of the reser- an endoscopic stapler. The ileoileal anastomosis is voir from the back to the front of the sigmoid loop. made with antemesenteric side-to-side stapling and After its identification and proper orientation, the sig- closure ofthe remaining opening by endoscopic sutur- moid segment is incised antemesenterically and the ing. Then, the distal end ofthe ileal segment is pulled posterior wall created by a U-shape anastomosis of out via an enlarged trocar incision in the right lower the posterior wall using a continuous suturing tech- abdomen and sutured to the skin. Via the thus created nique. Now both ureters are implanted in a serous- urostoma, single J-stents can be introduced and both lined tunnel included in the posterior wall suture, ureters are stented and sutured to the ileal conduit in stitched by interrupted sutures and stented by use of a modified Wallace-type technique or individually Mono-J-catheters, which are exteriorized through the using interrupted sutures, according to Bricker's tech- rectal catheter. Finally the anterior wall is closed com- nique. pletely. a 5.2 Laparoscopic Radical Cystectomy with Orthotopic Bladder Replacement 107

Other Types of Urinary Diversion reconstructive interventions in the pelvis could be performed laparoscopically. Moreover, some studies Additionally, in the literature the formation of an showed that despite initially longer operating times, orthotopic sigmoid pouch [20], a continent ileal pouch such procedures provided significant advantages for [21], and a prostatoenterocystoplasty after prostate- the patient when compared to the open counterpart and seminal vesicle-sparing cystectomy [22, 23] has [27, 28]. been described. Therefore it seemed to be no more than a logical In the case ofa pouch with continent catheterizable step that at the beginning ofthis century the firstcen- stoma, the pouch is created outside the body, the ur- ters reported their initial experience with laparoscopic eters are connected to the pouch, then the pouch is radical cystectomy [29, 30]. Similar to radical prosta- dropped back into the abdomen, and the stoma is cre- tectomy, there were early reports in the 1990s showing ated on the skin. significant technical difficulties and therefore prevent- ing the clinical introduction [31±33]. In the meantime, Postoperative Management an increasing number ofurologists, including various In the first night, all patients are monitored in the in- international centers, published their experiences with tensive care unit for vital parameters and adequate laparoscopic radical cystectomy (Table 3). pain management. Parenteral nutrition was continued As for the radical treatment of localized prostate until complete oral feeding. The drains are removed cancer, radical cystectomy deals with an initially abla- after reduction of secretion below 50 ml. On day 10, tive procedure followed by a major reconstructive pro- the ureteral stents are removed without cystogram. cedure in cases oflaparoscopic assistance to urinary The urethral catheter ofneobladders is removed on diversion. Moreover, it also needs to be adapted to a postoperative day 18, after 48 h of intermittent - disease present in both genders, whether for malig- ing every 2 h. nant indications or not. In contrast to laparoscopic radical prostatectomy, the numbers of the different series are still limited. Discussion On the other hand, due to the disease, various techni- cal procedures have been described concerning both The Concept of Laparoscopic Cystectomy the radical cystectomy (i.e., anterior exenteration, rad- ical cystoprostatectomy, prostate-sparing cystectomy) The successful introduction of laparoscopic radical as well as the type ofurinary diversion (i.e., ileal con- prostatectomy at the end ofthe last decade pioneered duit, continent pouch, neobladder) (Table 4). by European urologists was a major step in the techni- Open radical cystectomy requires an abdominal in- cal development ofminimally invasive surgery [24± cision with prolonged retraction ofthe abdominal 26]. It was demonstrated that even complex ablative- wall. This maneuver leads to a high level ofpostopera-

Table 3. Laparoscopic radical cystectomy with ileal conduit

Year Author No. OR time Laparoscopi- Reoperation Complications Reference (hours) cally assisted 1995 Puppo 4 6±8 Yes None None [31] 1995 Sanchez 1 8 Yes None Nerve (1) [32] de Badajoz 2002 Gill 12 7±8 No 2 Ileus (1), sepsis (1) [12] 2002 Peterson 1 7 Yes None None [35] 2003 Popken 5 5±6 Yes/no None None [36] 2003 Rassweiler 4 6±7 Yes/no None Urine leak (1) [37] 2003 Hoepffner 10 6 Yes/no None Sepsis (1) [52] 2004 Van Velthoven 13 5±7 Yes None Rectum (1) [38] 2004 Sakakibara 11 7±9 Yes None Ileus (4), leak (2) [39] Total 62 2/62 (3%) 11/62 (17.7%) 108 R.F. van Velthoven, J. Rassweiler

Table 4. Laparoscopic radical cystectomy with bladder replacement

Year Author No. Operating Diversion Laparo- Reoperation Complication Refer- time (hours) type scopic ence assistance 1999 Denewer 10 8±10 Mainz II Yes NA NA [29] 2002 Abdel-Hakim 8 7±12 Ileal Yes 0 Thrombosis (1) [42] 2002 Chiu 1 8.5 Ileal Yes 0 None [43] 2002 Tçrk 11 7±8 Mainz II No 1 Pouch fistula (2) [19] 2003 Gaboardi 6 6±8 Ileal Yes 0 None [40] 2003 Gill 3 8±12 Ileal No 0 Vaginal fistula (1) [41] GI bleeding (1) 2003 Paulhac 1 7.5 Ileal Yes 0 Urine leak (1) [21] 2003 Hoepffner 25 7 Ileal Yes 1 Cutaneous fistula [52] (1) 2003 Goharderakhshan 25 NA Ileal Yes 3 Bleeding (2), sepsis [44] (3), urine leak (3) 2003 Vallancien 20 NA Ileal Yes NA NA [22] 2003 Popken 4 6±7 Ileal Yes 0 None [36] 1 7 Mainz II No 0 2003 Guazzoni 3 7±8 Ileal Yes 0 None [23] 2003 Liu 5 7 SigmoidYes 0 NA [20] 2003 van Velthoven 15 7±9 Ileal Yes/no 0 Ileus (3) [38] 2 7±8 Mainz II Yes/no Acute retention (1) 2003 Rassweiler 1 8 Ileal Yes 1 Bleeding (1) [37] 2004 3 9±11 SigmoidNo 0 UTI (1), ureteral stenosis (1) Total 144 4.1% 15.3% Perioperative complication rate: 22/144 (15.3%); reoperation (open) rate: 6/144 (4.1%) tive pain, often requiring narcotic administration for Although there have been few studies that have ad- several days. Consequently patients remain hospital- dressed the effect of age and comorbid disease on out- ized with continuous nursing needs for a long time comes after laparoscopic urological procedures, candi- and normal activity is regained only slowly. dates for the laparoscopic procedure are the same as The main apparent advantage ofthe laparoscopic for the open procedure ± patients with organ-con- radical cystectomy consists in less postoperative pain, fined, muscle-invasive bladder cancer who need cys- due in part to the smaller incisions made. No large tectomy whether or not they have a usable urethra. metal retractors are needed to keep the incision open, In major laparoscopic procedures, the only variable which contributes also to reduced pain. In the laparo- associated with increased risk ofpostoperative compli- scopic approach there is also usually less blood loss, cations in the univariate analysis was estimated blood thus minimizing the chances for blood transfusion. loss. There was a trend toward increased postoperative Subsequently, patients are encouraged to be out ofbed complications in patients with increased comorbidity, and ambulate sooner. With quicker ambulation, many but this did not reach statistical significance. patients also experience quicker return ofbowel func- At the recent World Congress ofEndourology, in tion. The diet is advanced from clear liquids to regu- arguing against widespread use ofthe minimally inva- lar diet as the patient's bowel function recovers, some- sive procedure, deVere White cited recent research times at day 2 postoperatively. Once patients can toler- suggesting that even traditional cystectomy appears to ate regular food and are walking about freely, they are be too demanding for many surgeons. A study pre- discharged home. In addition to these advantages, the sented at a recent meeting ofthe American Society of laparoscopic approach also offers a better cosmetic re- Clinical Oncology and reported in Urology Times in sult due to the small and almost negligible incisional August 2003 evaluated 268 cystectomies performed by scars over time. 106 surgeons at 109 institutions between 1987 and a 5.2 Laparoscopic Radical Cystectomy with Orthotopic Bladder Replacement 109

1998. In up to 62% ofthe cases, the surgeons removed be demonstrated that the ablative part ofthe proce- fewer than ten lymph nodes, increasing the risk for dure does not cause major problems for experienced recurrence. The study was conducted by Harry W. surgeons, on the other hand, even for centers of exper- Herr, a bladder cancer specialist at Memorial Sloan- tise, urinary diversion, particularly ifperformed intra- Kettering Cancer Center in New York. corporeally, is a challenging operation. Over the last 3 Patients face more than a fivefold increased risk that years, however, more and more urologists have re- their cancer will recur, despite cystectomy, iffewerthan ported performing laparoscopic cystectomy. ten lymph nodes are removed. When the cancer does re- A significant number of reports are only available cur, the survival rate is grim ± less than 10% ofthese as abstracts presented at the 2003 European Urology patients live 5 years. The surgeons in the study who Association, American Urological Association and did the fewest procedures had the worst track record. World Congress ofEndourology meeting (Tables 3, But even the highest-volume surgeons removed too 4). Therefore a detailed analysis remains difficult. few lymph nodes in one-third of their cases. However, most of the reports do not differ signifi- ªBased on how well even traditional cystectomy, an cantly with respect to operating time and the type operation that has been taught for 50 years, is being per- and frequency of the observed complications. In the formed, and based on the skill required to perform la- meantime, apart from the gastric pouch, all contem- paroscopic cystectomy, widespread adoption ofthe la- porary types ofurinary diversions have been realized paroscopic technique would be unwise,º deVere White either with laparoscopic assistance or even completely said. intracorporeally. It is evident that the OR time mainly With regard to such conservative concepts, the ini- depends on the type and technique ofurinary diver- tial European experience showed the feasibility and sion. We were able to collect 206 reported cases safety of the technique, including all variations of uri- worldwide. The incidence ofcomplications (15.3%± nary diversion. Our goal was to translate the technical 17.7%) as well as the reintervention rate (3.4%±4.1%) steps routinely used in our open technique and to reflect the technical difficulties of the procedure even standardize a laparoscopic protocol. At no moment in in the hands oflaparoscopically experienced surgeons. our development in laparoscopy were we ready to ac- On the other hand, it is obvious that such problems cept compromising our oncological or functional re- are largely linked to the learning curve ofthe tech- sults because of our surgical approach. Differences niques and mainly concern the reconstruction ofthe with the open access are the immediate transperito- urinary diversion (i.e., urinary leakage, urine fistula, neal approach, posterior dissection ofthe seminal ves- ileus) rather than the radical cystectomy itself, which icles, Denonvilliers fascia incision and lymphadenecto- requires usually only 2±3 h. my possibly done after the cystoprostatectomy, for The main questions raised ofcourse concern the re- staging purposes. spect ofoncological bases ofradical cystectomy and the Beyond the unavoidable learning or discovery risk oftransitional cell spillage during the procedure. curve, the mean laparoscopic operative time in our ex- Transitional cell carcinoma is much more aggres- perience is 120±180 min, including the vesicoureteral sive than, for instance, adenocarcinoma of the pros- anastomosis when performed laparoscopically; the tate, both in terms ofthe development oflocal recur- average blood loss is below 500 cc. With regards node rence and progressive metastatic disease. There have sampling, no doubt that the laparoscopic approach en- already been reports ofdisease-specificmortality after able surgeons to perform extended lymph node dis- a short-term follow-up [6, 34]. Although recent studies section yielding more than ten lymphatic nodes; this could not reveal any specific risk factors for the devel- skill is inherited not only from conventional ilio-ob- opment ofport-site metastases related to the laparo- turator dissection but also from the modified retro- scopic technique, most ofthe reported trocar metasta- peritoneal templates performed laparoscopically. ses, in the field of urology, have been observed in cases oftransitional cell carcinoma [37, 45]. Such is- Technical Difficulties of the Procedure sues require further prospective long-term studies. Moreover, there have been oral reports on unusual Although the first laparoscopic cystectomy was per- abdominal metastases observed after laparoscopic cys- formed in 1992, very few surgeons adopted the tech- tectomy. These cases exclusively concern cystectomies nique during the rest ofthat decade. Although it could associated with prostate apex preservation in view of 110 R.F. van Velthoven, J. Rassweiler performing optimal nerve-sparing laparoscopic cystec- So far, it is illustrated here that even for the experi- tomy [22]. Indeed, beyond the specific risk of inciden- enced surgeon, laparoscopic radical cystectomy with tal prostate cancer [46], this technique also implies a urinary diversion is a technically challenging proce- wide opening ofthe bladder neck in the presence of dure. We believe that this technique is here to stay yet possible residual tumor material in the bladder lumen. easily reproducible and therefore also indicated for pa- We strongly believe, as do others [11, 12], that the tients affected by clinically organ-confined invasive bladder should be removed remaining strictly closed bladder cancer, as long as we continue to carefully re- and that the urinary pathway should be divided only spect the rules ofoncologic surgery for TCC, it may after securing by clips or ligations. Moreover, with re- become a standard ofcare even in the elderly. spect to the same risk oftransitional cell spillage, the lack oftactile control and the risk ofdysplasia ofthe Extracorporeal, Hand-assisted upper tract or ofthe urethra make frozen sections of or Intracorporeal Creation these organs mandatory. of Urinary Diversion Sticking also to the rules ofclassical radical cystec- tomy [47] implies performing the procedure through a There is no doubt that the actual reported operative strict transperitoneal approach, allowing for the re- techniques require further standardization. Some moval ofthe peritoneal coverage ofthe bladder. This authors emphasize their completely intracorporeal explains our choice ofa systematic supraumbilical tro- procedure [9], whereas others focus on the advantages car on the midline for the lens as well as the relatively ofa laparoscopically assisted or even hand-assisted high position ofthe upper right trocar, at the horizon- technique [11, 35]. We feel that an entirely laparo- tal level ofthe former one. This latter position allows scopic approach should only be performed if the re- the scissors held in the surgeon's right hand to per- trieval ofthe specimen can be accomplished without form a high, juxtaumbilical section of urachus and of an additional incision (i.e., transvaginally, transrec- umbilical ligaments. This maneuver allows the open- tally) or ifthe urinary reservoir cannot be recon- ing ofthe Retzius space, avoiding an excessively long structed via a mini-incision as in case ofrectosigmoid way into the perivesical fat as well as useless maneu- pouch or ofsigmoid neobladder. vers to improve the visibility on bladder limits. Tacti- With regard to the possibility ofhand-assisted lap- cal reasons related to the size ofthe specimen delay aroscopic cystectomy, as stated by Moinzadeh et al. this anterior exposure until the moment where the [12], we believe that the presence ofthe operator's posterior dissection is completely achieved, releasing hand may actually compromise exposure during pelvic the specimen from the prerectal space and dividing surgery dealing with a large specimen in a reduced the upper pedicles and the ureters. workspace. Moreover, skilled surgeons generally have The same logical features of an antegrade proce- an extensive experience with laparoscopic prostatecto- dure explain the stepwise progression, following the my before starting cystectomy; it is therefore unlikely ureters from the crossing with the iliac vessels, per- they will require hand assistance for an easier proce- forming an extended pelvic lymph node dissection dure. and securing successively the superior, the inferior In cases ofthe ileal conduit in male patients, the vesical arteries as well as the vesicoprostatic arteries extended paraumbilical trocar incision can be used in the male [11]. Attention should nevertheless be subsequently for the retrieval of the specimen, the for- paid to avoid premature division ofthe pedicles adja- mation ofthe ileal conduit, the ileoileal anastomosis, cent to the seminal vesicles, in view ofan optimal pre- the creation ofthe ileostoma and the placement ofthe servation ofthe neurovascular bundles. This dissec- ureteral stents. Therefore any type of intracorporeal tion should be delayed until the anterior attachments technique seems to represent an unnecessary prolon- ofthe bladder are released and the endopelvic fasciae gation ofthe operating time, without true benefitto are opened on each side ofthe prostate. Lifting the the patient. Already laparoscopic radical nephrectomy entire specimen towards the upper opposite side then and living donor nephrectomy have shown that a 5- allows the antegrade dissection ofthe neurovascular to 8-cm mini-incision does not increase the access bundles with the appropriate tools. For the same rea- morbidity significantly. In case of urinary diversion, sons, the use ofblind wide diathermy or ofendo- the combined technique leads to a significant reduc- scopic staplers should be prohibited. tion in the operating time. a 5.2 Laparoscopic Radical Cystectomy with Orthotopic Bladder Replacement 111

Table 5. Laparoscopic urinary diversion ± technical steps and options

Operative Step Options Comments Transposition of ureter None Not for sigmoid-neobladder or neopouch Creation of reservoir Intracorporeally Sigmoid neobladder Sigmoidpouch Ileal conduit in females Extracorporeally Ileal conduit in males (laparoscopically assisted) Ileal neobladder Ileal pouch Ureteral anastomosis Intracorporeally Sigmoid neobladder Sigmoidpouch Ileal conduit Extracorporeally Ileal neobladder Ileal pouch Urethral anastomosis Intracorporeally All continent diversions

In cases oforthotopic bladder replacement, the ad- erative times for these radical procedures, however, re- vantages ofthe laparoscopic vesicourethral anastomo- main longer than those for open surgery. Blood loss is sis are to be considered in terms ofimmediate water- less and patients recover more quickly. tightness to increase early continence and avoid any The learning curve oflaparoscopic radical cystecto- subsequent stenoses. my may take several years to final perfection, as al- The various options available for urinary diversion ready realized with laparoscopic radical prostatectomy. are summarized in Table 5. One reason is the significantly lower incidence of the procedure. Involvement of Robotics in the Field The operating time obviously has to be reduced of Laparoscopic Radical Cystectomy significantly to minimize the associated morbidity of the procedure. On the other hand, there are no princi- Two groups recently reported their early experience ple technical obstacles and increasing experience may with the use ofDa Vinci telemanipulators in the field lead to a dramatic reduction ofoperating times in the oflaparoscopic radical cystectomy [48] followed by in- near future. New trends in this field may concern the tracorporeal creation ofan ileal bladder [49]. The role improvement ofsuturing devices or the availability of ofthe robotic arms was essentially limited to the adsorbable staples to reduce the time devoted to nerve-sparing dissection during the ablative time and building neobladders. to the vesicourethral anastomosis, in cases ofneoblad- Furthermore, patients have to be followed carefully ders. This adds to the catalogue ofurologic proce- with respect to long-term functional and oncological dures already described with robotic assistance [50, results. 51]. Further functional results are still awaited to eval- Laparoscopic cystoprostatectomy is a feasible, fast, uate the true return ofthis investment in the fieldsof safe and rather easy procedure, yet, at present, laparo- reduced operative times, improved erectile function scopic radical cystectomy is still an operation for pio- and optimal neobladder. neers, but in our opinion this procedure may be not strictly relegated to a few centers of expertise in the future. We are optimistic that laparoscopy is likely to Perspectives of Laparoscopic play a viable role in the future management of mus- Radical Cystectomy cle-invasive bladder cancer. Patients treated with this technique benefit from all Radical cystectomy remains the gold standard for the advantages associated with laparoscopic surgery, muscle-invasive bladder cancer and high-risk superfi- which are not reduced by the external reconstruction cial tumors resistant to intravesical therapy, and a lap- ofa urinary diversion performed through a mini-lapa- aroscopic approach can reproduce open surgery. Op- rotomy. 112 R.F. van Velthoven, J. Rassweiler

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