Clinical Experience of Laparoscopic-Assisted Radical Cystectomy with Continent Ileal Reservoir

Robot-assisted laparoscopic radical cystectomy with complete intracorporeal urinary diversion

Robot-assisted radical cystectomy with intracorporeal urinary diversion (RARC-ICUD) has only recently been explored as a viable surgical option for patients with muscle-invasive bladder cancer seeking satisfactory oncologic control while benefiting from minimally invasive surgical techniques. Inspired by earlier open and laparoscopic work, initial descriptions of RARC-ICUD were published in 2003, and have since been followed by multiple larger case series which have suggested promising outcomes for our patients. However, the rate of adoption has remained relatively slow when compared to other robot-assisted procedures such as the radical prostatectomy, likely owing to longer operative times, operative complexity, costs, and uncertainty regarding oncologic efficacy. The operative technique for RARC-ICUD has evolved over the past decade and several high-volume centers have shared tips to improve efficiency and make the operation possible for a growing number of urologists. Though there are still questions regarding economic costs, effectiveness, and generalizability of outcomes reported in published data, a growing dataset has brought us ever closer to the answers. Here, we present our current operative technique for RARC-ICUD and discuss the state of the literature so that the urologist may hold an informed discussion with his or her patients.

Laparoscopic radical and partial cystectomy

Radical cystectomy remains the standard treatment for muscle invasive organ confined bladder carcinoma. Laparoscopic radical cystoprostatectomy (LRC) is an advanced laparoscopic procedure that places significant demands on the patient and the surgeon alike. It is a prolonged procedure which includes several technical steps and requires highly developed laparoscopic skills including intra-corporeal suturing. Here we review the development of the technique, the indications, complications and outcomes. We also examine the potential benefits of robotic-assisted LRC and explore the indications and technique of laparoscopic partial cystectomy.

Bladder cancer

PURPOSE OF REVIEW

This article will review the diagnosis and management of bladder cancer at each stage, from superficial to metastatic disease with an emphasis on recent developments over the last year.

RECENT FINDINGS

Bacille Calmette-Guerin is the most effective therapy for carcinoma in situ. All patients who receive intravesical therapy with bacille Calmette-Guerin should be considered for ongoing maintenance therapy. The management of muscle invasive disease in the United States centers on radical cystectomy with bilateral pelvic lymphadenectomy. Areas of research include the optimal role for bladder preservation therapy, a growing experience in centers with laparoscopy, the effect of urinary diversion on quality of life, and the optimal standard for pelvic lymphadenectomy at surgery. The role of combination chemotherapy for advanced bladder cancer continues to evolve. Many questions remain unanswered including the relative value of neoadjuvant versus adjuvant chemotherapy for locally advanced disease and optimal chemotherapy regimen.

SUMMARY

The detection of bladder cancer continues to rely on direct visualization with cystoscopy. Efforts are underway to improve the utility of urinary markers and cystoscopy through fluorescence endoscopy. The management of superficial bladder cancer is based on transurethral resection of the tumor with perioperative intravesical instillation of chemotherapy strongly suggested for most patients. Risk stratifying patients with high-risk superficial bladder cancer remain a challenge and area of future research.

Open versus Laparoscopy-Assisted Radical Cystectomy: Results of a Prospective Study

BACKGROUND AND PURPOSE

Laparoscopic radical cystectomy is confined to centers where advanced laparoscopy is performed, and its role is not yet well clear. Our aim was to evaluate, through a prospective comparative study, the advantages of the laparoscopic compared with an open approach.

PATIENTS AND METHODS

From November 2002 to December 2005, all the patients in our center who were found to have muscle-invasive bladder cancer without clinical evidence of lymph-node involvement and an American Society of Anesthesiologists (ASA) score <4 were included in a prospective nonrandomized study. Group A (N = 22) underwent open radical cystectomy, whereas group B (N = 20) underwent laparoscopy-assisted radical cystectomy. The two groups were demographically comparable. We evaluated the mean age, clinical stage, ASA score, operative time, blood loss, intraoperative complications and transfusions, type of diversion, time of catheterization, analgesic consumption, start of oral nutrition, rate of postoperative complications, length of hospital stay, pathologic diagnosis of the specimen, number of lymph nodes removed, and the oncologic outcome.

RESULTS

No significant statistical difference was observed between the two groups in intraoperative and postoperative parameters except for analgesic consumption and the start of oral nutrition (P < 0.05). The mean operative time was 260 minutes (range 210-290 minutes) for group A and 284 minutes (range 260-305 minutes) for group B. The mean blood loss was 770 mL (range 450-870 mL) in group A and 520 mL (range 400-620 mL) in group B. The rate of autologous transfusion was 18% in group A and 10% in group B. Seventeen ileal diversions and five neobladder creations were performed in group A, whereas the Bricker diversion was used in 10 cases in group B, and a neobladder was chosen in the 10 other cases.

CONCLUSION

Laparoscopy-assisted radical cystectomy is a safe procedure, like open surgery, but it offers the advantage of minimal invasiveness, represented by reduced analgesic consumption and early recovery of peristalsis with rapid oral nutrition.

Laparoscopic Cystectomy with Extracorporeal-Assisted Urinary Diversion: Experience with 34 Patients

OBJECTIVES

Open radical cystectomy remains the gold standard for nonmetastatic muscle invasive bladder cancer. Laparoscopic cystectomy has been described as a feasible procedure and is still being evaluated. We describe our initial experience with this laparoscopic surgical approach in 34 patients.

METHODS

From February 2002 to October 2004, 18 men and 16 women underwent laparoscopic cystectomy with extracorporeal-assisted urinary diversion for transitional cell carcinoma of the bladder (n=27), invasive cervical carcinoma (n=4), and atrophic bladder (n=3). We report here on specific technical details and present initial results of our series.

RESULTS

The mean operating time was 244 min, the mean blood loss 325 ml, and the transfusion rate 5.9%. All procedures were completed laparascopically without conversion to open techniques. No major complications occurred during or after the operation. In case of urothelial malignancy (n=27), the histopathologic analysis of the removed specimen revealed organ-confined transitional cell carcinoma of the bladder in 66.7% (pT1:14.8%; pT2: 51.9%) and locally advanced disease in 33.3% (pT3: 25.9%; pT4: 7.4%). In two cases final histology proved positive surgical margins. Extended lymphadenectomy detected lymph node metastasis in two patients.

CONCLUSIONS

We demonstrate that the combination of laparoscopic cystectomy and extracorporeal urinary diversion is possible and remains a safe, feasible, and repeatable surgical technique. To determine the oncologic outcome long-time follow-up will be necessary.

Perioperative complications of radical cystectomy in a contemporary series

OBJECTIVES

Radical cystectomy is the preferred standard treatment for patients with muscle-invasive bladder cancer. With improvements in intra- and perioperative care lower complication rates have been reported. We retrospectively evaluated our series of patients who underwent radical cystectomy for advanced bladder cancer for perioperative complications as well as operative time, postoperative hospital stay and transfusion rates.

PATIENTS AND METHODS

Between April 1993 and August 2005, 516 radical cystectomies were performed for muscle infiltrating transitional cell carcinoma and other types of neoplastic diseases of the bladder at our institution. The average age was 66.3 yr (31-89).

RESULTS

The perioperative mortality rate was 0.8%. A total of 141 patients (27.3%) developed at least one perioperative complication. The most frequent medical complications were subileus in 20 (3.9%) patients, deep venous thrombosis in 24 (4.7%), and enterocolitis in 10 (1.9%). Surgical complications included pelvic lymphoceles in 42 (8.1%) patients, wound dehiscence in 46 (8.9%), pelvic hematoma in 4 (0.8%), peritonitis in 4 (0.8%) and small bowel obstruction in 4 (0.8%). The total early reoperation rate was 6.2%. Operative time, postoperative hospital stay and average number of blood units transfused decreased over the period 1993-2005.

CONCLUSIONS

Radical cystectomy today is a procedure with an acceptable rate of perioperative morbidity and mortality. Improvements in surgical technique and anaesthesia as well as increased quality of perioperative care in recent years have resulted in reduced morbidity and shorter hospital stay.