Complications of laparoscopic radical cystectomy during the initial experience

Robot-assisted laparoscopic radical cystectomy with extracorporeal urinary diversion: Initial experience and outcomes

INTRODUCTION

Open radical cystectomy (ORC) is the most common surgical approach for invasive carcinoma of the urinary bladder, but robot-assisted radical cystectomy (RARC) has recently gained popularity. There is limited data from the Indian subcontinent on RARC. The aim of this study was to assess the perioperative, pathological, and oncological outcomes of RARC and follow-up in our initial 63 cases.

MATERIALS AND METHODS

A retrospective analysis of prospectively maintained data of 63 RARC procedures performed in our tertiary care institute from July 2006 to January 2016 was done. All patients underwent RARC with extracorporeal urinary diversion. We analyzed perioperative parameters, length of hospital stay, pathological and oncological outcomes, and rate of complications. Follow-up data were analyzed for disease recurrence and survival.

RESULTS

The mean age of the patients was 58 years. The mean American Society of Anesthesiologists (ASA) score was 1.66. Mean operative time was 348.6 min and mean blood loss was 868.2 ml. Mean hospital stay was 10.4 days (±5.4 days). 42.8% patients had pT2 disease, 49.2% pT3, 1.58% pT1, and 6.34% had pT4 disease. Mean lymph node yield was 12.4 (3-25). One patient had positive surgical margins. Twenty-four patients had postoperative complications of which four were major complications (Clavien-Dindo 3 or higher). At a median follow-up of 60 months (range: 3-108 months), 11 patients were lost to follow-up 10 patients developed metastasis, out of which 4 died. Four had recurrence, two died and two are receiving chemotherapy.

CONCLUSION

This study shows the feasibility and safety of RARC. The operative time, blood loss, return of bowel activity and hospital stay were higher than those reported in the literature but may reflect the learning curve.

Intraoperative laparoscopic complications for urological cancer procedures

AIM: To structure the rate of intraoperative complications that requires an intraoperative or perioperative resolution.

METHODS: We perform a literature review of Medline database. The research was focused on intraoperative laparoscopic procedures inside the field of urological oncology. General rate of perioperative complications in laparoscopic urologic surgery is described to be around 12.4%. Most of the manuscripts published do not make differences between pure intraoperative, intraoperative with postoperative consequences and postoperative complications.

RESULTS: We expose a narrative statement of complications, possible solutions and possible preventions for most frequent retroperitoneal and pelvic laparoscopic surgery. We expose the results with the following order: retroperitoneal laparoscopic surgery (radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy) and pelvic laparoscopic surgery (radical prostatectomy and radical cystectomy).

CONCLUSION: Intraoperative complications vary from different series. More scheduled reports should be done in order to better understand the real rates of complications.

Robot-assisted radical cystoprostatectomy in the post-radiation and chemotherapy patient

We report a case of successful salvage radical cystoprostatectomy (RRCP) on a patient with recurrent high-grade T2 transitional cell carcinoma following external-beam radiation and systemic chemotherapy. The effect on tissue planes and the resulting adhesions after external radiation are well-known. While RRCPs have been successfully completed in many academic centers, there have been no reports of using this approach for salvage cystectomy after radiation. The RRCP was performed without complications, and was followed by an extended bilateral pelvic lymph node dissection and creation of an ileal conduit via the midline extraction incision.

Laparoscopic radical cystectomy and extracorporeal urinary diversion: a single center experience of 48 cases with three years of follow-up

OBJECTIVES

To report our experience with laparoscopic radical cystectomy and extracorporeal urinary diversion for high-grade muscle invasive bladder cancer in a consecutive series of 48 patients with 3 years of follow-up.

METHODS

From June 1999 to April 2006, 48 patients (42 men and 6 women; mean age 59 years, range 24 to 80) with bladder cancer underwent laparoscopic radical cystectomy and bilateral pelvic lymph node dissection at our institution. Urinary diversion was done extracorporeally through the specimen extraction incision.

RESULTS

The mean operating time was 310 minutes, and the mean blood loss was 456 mL. In 1 patient, conversion to open surgery was required because of severe hypercarbia. Three major complications were observed intraoperatively (rectal injury in 2 and external iliac vein injury in 1 patient). However, all these complications were managed laparoscopically, with completion of the procedure laparoscopically. The mean hospital stay was 10.2 days (range 7 to 25). One patient died in the postoperative period of severe lower respiratory tract infection and septicemia. Histologic examination showed organ-confined tumors (Stage pT1/pT2/pT3a) in 34 patients (71%) and extravesical disease (pT3b/pT4) in 14 (29%). Of the 48 patients, 12 (25%) had lymph node involvement. The mean number of nodes removed was 14 (range 4 to 24). At a mean follow-up period of 38 months (range 10 to 72), 35 patients were alive with no evidence of disease (disease-free survival rate 73%).

CONCLUSIONS

The results of our study have shown that laparoscopic radical cystectomy is a safe, feasible, and effective alternative to open radical cystectomy. Extracorporeal urinary diversion through a small incision decreases the operating time, while maintaining the benefits of laparoscopic surgery. The 3-year oncologic efficacy was comparable to that of open radical cystectomy.

Complications in laparoscopic radical cystectomy. The South American experience with 59 cases

OBJECTIVE

In this study, we have gathered the second largest series yet published on laparoscopic radical cystectomy in order to evaluate the incidence and cause of intra and postoperative complication, conversion to open surgery, and patient mortality.

MATERIALS AND METHODS

From 1997 to 2005, 59 laparoscopic radical cystectomies were performed for the management of bladder cancer at 3 institutions in South America. Twenty nine patients received continent urinary diversion, including 25 orthotopic ileal neobladders and 4 Indiana pouches. Only one case of continent urinary diversion was performed completely intracorporeally.

RESULTS

Mean operative time was 337 minutes (150-600). Estimated intraoperative blood loss was 488 mL (50-1500) and 12 patients (20%) required blood transfusion. All 7 (12%) intraoperative complications were vascular in nature, that is, 1 epigastric vessel injury, 2 injuries to the iliac vessels (1 artery and 1 vein), and 4 bleedings that occurred during the bladder pedicles control. Eighteen (30%) postoperative complications (not counting mortalities) occurred, including 3 urinary tract infections, 1 pneumonia, 1 wound infection, 5 ileus, 2 persistent chylous drainage, 3 urinary fistulas, and 3 (5%) postoperative complications that required surgical intervention (2 hernias - one in the port site and one in the extraction incision, and 1 bowel obstruction). One case (1.7%) was electively converted to open surgery due to a larger tumor that precluded proper posterior dissection. Two mortalities (3.3%) occurred in this series, one early mortality due to uncontrolled upper gastrointestinal bleeding and one late mortality following massive pulmonary embolism.

CONCLUSIONS

Laparoscopic radical cystectomy is a safe operation with morbidity and mortality rates comparable to the open surgery.

[Radical laparoscopic cystectomy]

Radical laparoscopic cystectomy is being adopted by most groups with proven experience in laparoscopic surgery, especially by those who have already completed the learning curves in radical laparoscopic prostatectomy. It is still considered a highly complex technique, which has not yet been mastered in many Urology Units. In this article, we review the surgical technique and available literature on this approach, with special emphasis on its indications, advantages and most frequent morbidity.

Technology Insight: surgical robots--expensive toys or the future of urologic surgery?

There is an increasing demand for minimally invasive surgery, despite any controversy over whether patients benefit from minimally invasive procedures rather than undergoing open surgery. In the field of urology, the performance of more complicated procedures is still a challenge even for experienced laparoscopic surgeons. Recently, robots have been introduced to enhance operative performance, increase applicability and precision of laparoscopy, and improve the learning curve for complicated minimally invasive procedures. With the introduction of master-slave systems where the surgeon is seated remotely from the robot and uses controls to maneuver the mechanical arms placed inside the patient, a new development in robot-assisted surgery has commenced. Several authors have suggested that surgical robots similar to the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA), which have three-dimensional (3D) vision and wristed instruments thus giving a greater degree of freedom than rigid laparoscopic instruments, will facilitate the outcome of these more challenging laparoscopic procedures. Whether these features will translate into better functional and oncological results remains to be evaluated. Data published so far clearly suggest that the patient will benefit from less postoperative pain, decreased bleeding and a shorter hospital stay compared with open surgery, and that the surgeon benefits from a faster learning curve than for conventional laparoscopy. For the benefit of our patients and for the development of urology it is vital that we understand both the limitations of telerobotics and when it is appropriate to incorporate these new techniques in day-to-day urologic surgery.

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 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.

Robot-assisted radical cystectomy and urinary diversion

Radical cystectomy remains the standard for muscle-invasive, organ-confined urothelial carcinoma of the bladder. With the emergence of minimally invasive approaches for the treatment of urologic cancers, technologic advances using laparoscopy have led to the development of robotic assistance to increase the feasibility of performing this formidable operation. In this article, we describe the procedure of robotic-assisted laparoscopic radical cystectomy with urinary diversion and review the pertinent literature.

Robotic radical cystectomy and urinary diversion in the management of bladder cancer

The authors have explored the versatility of the da Vinci robot for pelvic surgery to develop the technique of robotic radical cystectomy in conjunction with the Urology and Nephrology Center in Mansoura, Egypt, a world leader in conventional (open) cystectomy. This approach, which is designed to minimize the time required for surgery, is a sandwich technique in which the cystectomy and the neobladder-urethral anastomosis are performed with robotic assistance and the urinary diversion is performed extracorporeally. This article reviews the published literature and details the authors' current technique of robotic radical cystectomy and urinary diversion.