Apical Dissection

The bladder is pulled cephalad; the dorsal venous complex is incised in a tangential fashion to avoid iatrogenic incision into the prostate at the apex. Gradually an avascu-lar plane of dissection situated between the dorsal venous complex and the urethra is developed. Alternatively, if a nonorthotopic diversion is planned, one can use the Endo-GIA staplers to control the dorsal venous complex. The proximal aspect of the urethra

FIGURE 7 ■ Schematic illustrating the peritoneal incision prior to entry into the prevesical space. The incision is carried anteriorly to include the urachus.
FIGURE 8 ■ Lateral pedicle transection with Endo-GIA. Contralateral traction is provided to help delineate the space.

is either clipped or sutured to prevent tumor spillage and the urethra is divided (Fig. 9), freeing the surgical specimen, which will be placed in a laparoscopy bag. The empty pelvis is now prepared for a lymphadenectomy (Fig. 10).

LAPAROSCOPIC RADICAL CYSTECTOMY IN THE FEMALE PATIENT

In women, the procedure is very similar to a laparoscopic-assisted vaginal hysterectomy, which our gynecologic colleagues have been performing for some time. Posteriorly, the peritoneum is incised at the level of the rectovesical cul-de-sac and the posterior vaginal wall is mobilized off the rectum. After control and division of the vesical vascular pedicle and the broad ligaments, a sponge stick is inserted in the posterior vaginal cul-de-sac to expose the area of vaginotomy and to help delineate the plane of excision of the anterior vaginal wall. Once freed, the surgical specimen is retrieved through the vaginal vault.

FIGURE9 ■ Transection of posterior urethra and rectourethralis after securing bladder neck.

FIGURE 10 ■ View of empty pelvis after cystectomy and prior to pelvic lymphadenectomy.

FIGURE9 ■ Transection of posterior urethra and rectourethralis after securing bladder neck.

FIGURE 10 ■ View of empty pelvis after cystectomy and prior to pelvic lymphadenectomy.

ROBOT-ASSISTED LAPAROSCOPIC RADICAL CYSTECTOMY

The advent of the robotic technology has allowed many surgeons to translate standard surgical movements to the laparoscopic arena. After initial application in an animal study (12), robot-assisted radical cystectomy has been reported in the clinical setting (13-16). By allowing additional degrees of freedom of movement and a comfortable working position, the robotic assistance provides novice laparoscopy surgeons ease in suturing and knot tying. The general approach to the procedure, however, is the same.

URINARY DIVERSIONS

The urinary diversion may be an ileal conduit, an Indiana pouch, a Camey II performed extracorporally, an orthotopic ileal neobladder with Studer limb, or a rectal sigmoid pouch performed intracorporeally (4,5). These techniques are expertly described elsewhere in the text.

CONCLUSION

The small number of patients in current reported series and the short follow-up precludes any definitive morbidity or oncologic outcome analysis. The feasibility of the procedure has certainly been established. Only detailed analysis and follow-up will determine whether the short-term benefits become greater as more laparoscopic radical cystectomies are performed, and whether they attain the same oncologic efficacy as standard methods.

REFERENCES

1. Kaouk JH, Gill IS, Desai MM, et al. Laparoscopic orthotopic ileal neobladder. J Endourol 2001; 15:131.

2. Fergany AF, Gill IS, Kaouk JH, Meraney AM, Hafez KS, Sung GT. Laparoscopic intracorporeally constructed ileal conduit after porcine cystoprostatectomy. J Urol 2001; 166:285.

3. Abdel-Hakim AM, Bassiouny F, Abdel Azim MS, et al. Laparoscopic radical cystectomy with orthotopic neobladder. J Endourol 2002; 16:377.

4. Gill IS, Kaouk JH, Meraney AM, et al. Laparoscopic radical cystectomy and continent orthotopic ileal neobladder performed completely intracorporeally: the initial experience. J Urol 2002; 168:13.

5. Turk I, Deger S, Winkelmann B, Schonberger B, Loening SA. Laparoscopic radical cystectomy with continent urinary diversion (rectal sigmoid pouch) performed completely intracorporeally: the initial 5 cases. J Urol 2001; 165:1863.

6. Herr HW. Superiority of ratio based lymph node staging for bladder cancer. J Urol 2003; 169:943.

7. Herr HW. Extent of surgery and pathology evaluation has an impact on bladder cancer outcomes after radical cystectomy. Urology 2003; 61:105.

8. Herr H, Lee C, Chang S, Lerner S. Standardization of radical cystectomy and pelvic lymph node dissection for bladder cancer: a collaborative group report. J Urol 2004; 171:1823.

9. Herr HW, Faulkner JR, Grossman HB, Natal C RB, devere White R, Sarosdy MF, Crawford ED. Surgical factors influence bladder cancer outcomes: a cooperative group report. J Clin Oncol 2004; 22(14):2781-2789.

10. Simonato A, Gregori A, Lissiani A, Bozzola A, Galli S, Gaboardi F. Laparoscopic radical cysto-prostatectomy: a technique illustrated step by step. Eur Urol 2003; 44:132.

11. Sorcini A, Tuerk I. Laparoscopic radical cystectomy with ileal conduit urinary diversion. Urol Oncol 2004; 22:149.

12. Gill IS, Sung GT, Hsu TH, Meraney AM. Robotic remote laparoscopic nephrectomy and adrenalectomy: the initial experience. J Urol 2000; 164:2082.

13. Menon M, Hemal AK, Tewari A, et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int 2003; 92:232.

14. Menon M, Hemal AK, Tewari A, et al. Robot-assisted radical cystectomy and urinary diversion in female patients: technique with preservation of the uterus and vagina. J Am Coll Surg 2004; 198:386.

15. Beecken WD, Wolfram M, Engl T, et al. Robotic-assisted laparoscopic radical cystectomy and intraabdominal formation of an orthotopic ileal neobladder. Eur Urol 2003; 44:337.

16. Rimington P, Dasgupta P. Laparoscopic and robotic radical cystectomy. BJU Int 2004; 93:460.

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