Laparoscopic radical cystectomy with and without orthotopic bladder replacement

Advances in laparoscopic surgery in urology

In the past 10 years, laparoscopy has been challenged by robotic surgery; nevertheless, laparoscopic techniques are subject to continuous change. Ultrahigh definition is the next development in video technology, it delivers fourfold more detail than full high definition resulting in improved fine detail, increased texture, and an almost photographic emulsion of smoothness of the image. New 4K ultrahigh-definition technology might remove the current need for the use of polarized glasses. New devices for laparoscopy include advanced sealing devices, instruments with six degrees of freedom, ergonomic platforms with armrests and a chest support, and camera holders. A manually manipulated robot-like device is still at the experimental stage. Robot-assisted surgery has substantially revolutionized laparoscopy, increasing its distribution; however, robot-assisted surgery is associated with considerable costs. All technical improvements of laparoscopic surgery are extremely valuable to further simplify the use of classical laparoscopy.

[Radical cystectomy - pro laparoscopic]

Although the technical feasibility of laparoscopic radical cystectomy (LRC) has been proven and the procedure has been accepted in the EAU guidelines 2011 as a valid alternative, its actual position has to be determined. On the one hand the advantages of LRC (less blood loss, lower transfusion rates, shorter analgesia time) have been proven in retrospective studies; however, the technical difficulties of purely laparoscopic urinary diversion result in very long operating times and in cases of a laparoscopic-assisted creation of a neobladder, the question of the advantage of this approach remains doubtful. Despite case reports of port metastases and peritoneal carcinosis following laparoscopic and robot-assisted radical cystectomy, there is no difference in terms of oncological long-term data (up to 10 years) between laparoscopy and open surgery performed at centres of excellence. Evidently, the curative options for the patients do not depend on the type of surgery (open versus minimally invasive) but on the efficacy of adjuvant treatment strategies (polychemotherapy). Currently it is believed that LRC should be considered for patients with low risk of progression (pT1-2). The final position of laparoscopic radical cystectomy can only be evaluated in a multicentric randomized controlled trial.

Role of laparoscopy in reconstructive surgery

PURPOSE OF REVIEW

Despite increasing laparoscopic expertise in reconstructive surgery, open procedures still represent the gold standard. Robot-assisted techniques increasingly replace laparoscopy. However, laparoscopy is also developing: by improvement of ergonomics, new instruments, and techniques further reducing access trauma. We evaluated the actual role of laparoscopy focusing on main indications of urologic reconstructive surgery.

RECENT FINDINGS

We analysed the current literature (PubMed/Medline) concerning indications, perioperative results, complications, and long-term outcome of laparoscopy for pyeloplasty, ureteral reimplantation, stone surgery, management of vesico-vaginal fistula, sacrocolpopexy (including evidence level). For all indications, laparoscopy provides the advantages of less postoperative pain, blood loss, shorter convalescence, and minimal disfigurement. However, it requires expertise with endoscopic suturing. Most experience (N > 1000) exists with laparoscopic pyeloplasty and sacrocolpopexy which can be considered as valuable options (IIB). Concerning ureteral reimplantation and repair of vesico-vaginal fistula, only a limited number of cases were reported (N < 150) (III). Laparoscopic stone surgery may gain importance particularly in developing countries. Robot-assistance will definitively increase the application of laparoscopic techniques providing optimal ergonomics, whereas the role of single-port surgery will be limited.

SUMMARY

Laparoscopy will increasingly be used for reconstructive urologic surgery. This trend will be supported by the widespread use of the DaVinci device.

Laparoskopische Beckenchirurgie

Laparoscopic radical prostatectomy has become an equivalent alternative to the open retropubic approach, offering the advantages of minimally invasive surgery. It is being applied increasingly in Germany and the rest of Europe. Whether the surgical robot da Vinci will be used for this procedure to the same extent as in the United States is unpredictable because of high investment and maintenance costs. Similarly, laparoscopic sacrocolpopexy has proven to be a viable option compared to open transabdominal or transvaginal surgery, showing a significant reduction in postoperative morbidity. The value of radical cystectomy is controversial despite proven feasability. On one hand, the technical difficulties of purely laparoscopic urinary diversion result in very long operating times, and in the case of the laparoscopically assisted creation of a neobladder, the advantage of this approach has to be questioned. On the other hand, a maximum rate of 30% of local recurrences and distant metastases indicates at least poor patient selection. In conclusion, this procedure should be limited to a few experienced centers.