Indications And Contraindications

Following radical cystectomy, and in certain cases for benign conditions, the flow of urine is directed either through a conduit, the so-called noncontinent diversion, or a continent reservoir. The latter includes continent reservoirs with catheterizable stomas in which a low-pressure reservoir is fashioned from a detubularized bowel segment. When the urethra is not involved with cancer, appropriate patients may have a reservoir attached to their native urethra as an orthotopic neobladder. The latter is the goldstandard urinary diversion for patients undergoing radical cystectomy for muscle invasive bladder cancer.

General guidelines for choosing the type of laparoscopic urinary diversion best suited to each patient do not differ from their open surgical indications.

There are technical advantages specific to certain laparoscopic procedures, however, particularly in regards to bowel fixation and ease of suturing. The choice of bowel segment is made with careful consideration of expected metabolic disturbances as they interact with existing medical conditions, as with open surgery.

At all times, sound oncologic principles and the creation of an appropriate urinary diversion suited to the individual patient take precedence. If the surgeon is unable to perform the desired diversion by laparoscopic techniques, open surgery should be employed.

In cases of locally advanced pelvic malignancy, urinary diversion may be indicated without cystectomy. The remainder of patients include those with neurogenic bladder with chronic catheterization, refractory hemorrhagic cystitis, or other conditions in which the bladder may be left in situ while urinary flow is diverted.

Complex reconstructive laparoscopic surgery begins with careful patient selection. In cases where urinary diversion is required following radical cystectomy, exclusion criteria for the cystectomy portion of the procedure will generally dominate the decision process. Common exclusion criteria for laparoscopic surgery in general will apply. Multiple prior abdominal surgeries portend extensive adhesions and usually preclude laparoscopic access; however, on an individual basis, prior surgery is only a relative contraindication. Obesity must also be evaluated in each individual case. For instance, the exact distribution of subcutaneous abdominal fat differs amongst individuals. In cases where the fat is heavily distributed in the lower abdominal and suprapubic regions, excessive traction on trocars to obtain optimal instrument angles may be a limiting factor. As in open surgery, significant obesity may prevent adequate creation of an everted stoma without excessive mesenteric tension. Prior abdominal or pelvic radiation therapy is also a relative contraindication to laparoscopic urinary diversion but may influence the choice of bowel segment.

Case

Male/

Urinary

Specimen

Complete

Operative

No. of

LOS

Year

Author

profile

n

female

diversion

retrieval

intracorporeal?

time (hrs)

ports

(day)

Firsts

1992

Kozminski, Partamlan

No cystectomy

1

M

Ileal conduit

n/a

No

6.3

5

7

First lap ileal conduit

1995

Bajadoz

TCC

1

F

Ileal conduit

R flank mini-lap

No (right/ left extended port sites)

8.0

5

Not specified

First lap radical cystectomy and ileal conduit

1995

Puppo

TCC

5

F

Cutaneous ureterostomy (1), Ileal conduit (4)

Transvaginal (4), midline lap (1)

No (mini-lap at stoma site)

6-9

5

7-18

1999

Denewer

TCC (5), SCC (2), verrucous (2), anaplastic (1)

10

M (9), F (1)

Sigmoid pouch

Infraumblllcal midline

No (Infraumbilical midline)

2.6 for laparoscopic portion, 55 minutes for pouch

4

10-13

2000

Gill

TCC

2

M

Ileal conduit

Extended port site

Yes

10-11.5

6

6

First LRC Ileal conduit completely Intracorporeally

2000

Potter

Neurogenic bladder

1

M

Ileal conduit

n/a

Yes

4.5

5

Not specified

2001

Tuerk

TCC

5

M (3), F (2)

Sigma rectum (Mainz II)

None (transrectal)

Yes

7.4

6

10

First LRC with Intracorporeal continent urinary diversion

2002

Abdel-Hakim

TCC (8), SCC (1)

9

M (8), F (1)

Ileal orthotopic neobladder (modified Carney II)

Abdominal incision

No

8.3 mean

5-6

Not specified

2002

Gaboardi

TCC

1

M

Ileal orthotopic neobladder

Supraumblllcal incision

No

7.5

5

7

2002

Gill

TCC

3

M (2), F (1)

Studer orthotopic neobladder (2), Indiana pouch (1)

Extended port site

Yes (orthotopic neobladder); no (Indiana Pouch)

7-10.5

6-7

5-12

First complete intracorporeal LRC with orthotopic neobladder

2002

Peterson

TCC

1

M

Ileal conduit

Hand port

No (hand port)

7.0

4 + hand

7

Only report of hand-assisted LRC with Ileal conduit

2003

Bal aj i

Radiation cystitis (2), TCC(1)

3

M (2), F (1)

Ileal conduit

Extended port site

Yes

11.5 mean for all three,10.4 for diversion In 2 patients undergoing diversion alone

5 (robotic)

5-10

First complete intracorporeal robotic LRC

2003

Hemal

TCC (9), SCC (1)

10

M (9), F (1)

Ileal conduit

Infraumbilical midline

No (Infraumbilical midline)

6.48 mean

5-6

10.8 mean

2003

Menon

TCC

17

M (14), F (3)

Ileal conduit (3), W-pouch (10), double chimney (2),T-pouch (2)

Suprapubic Incision

No

2.3 robotic radical cystectomy, 2 Ileal conduit, 2.8 orthotopic neobladder

6 (robotic)

Not specified

2004

Menon

TCC

3

F

Ileal conduit (1), W-pouch (1), T-pouch (1)

Infraumbilical midline

No

3 robotic radical cystectomy, 2.16 Ileal conduit, 3 orthotopic neobladder

5

5-8

Abbreviations: Lap, laparoscope LRC, laparoscopic radical cysectomy.

Kozminski and Partamian performed the first laparoscopic-assisted ileal conduit diversion in 1992. Their procedure did not include a cystectomy.

Sanchez de Badajoz et al. reported the first laparoscopic combined radical cystectomy and laparoscopic-assisted ileal conduit in 1995 in a 64-year-old woman with high-grade muscle invasive transitional cell carcinoma.

Currently, laparoscopic radical cystectomy, bilateral pelvic lymphadenectomy, and ileal conduit can be performed using a mini-lap technique with operative times comparable to open surgery.

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