International Registry And Future Direction

There is no current universally established approach for the reconstructive component of this surgery. Indication for choosing the type of laparoscopic urinary diversion that is best suited to a patient is not different from that of open surgery.

To define the laparoscopic radical cystectomy can be a viable alternative to standard open radical cystectomy, careful prospective and long-term evaluation of oncologic and functional outcomes will be necessary. Recently created International Registry for Laparoscopic Radical Cystectomy has been established by Gill and coworkers to facili-

The author reported significant difference was observed only in the mean postoperative parenteral analgesia administration; handassisted, 31 mg versus open, 149 mg (p = 0.01); however, no statistical differences in others, including (i) operative time; hand-assisted, 403 minutes versus open, 420 minutes (p = 0.7), (ii) blood loss; hand-assisted, 637 mL versus open, 957 mL (p = 0.2), (iii) hospital stay; hand-assisted, 6.4 days versus open,

9.8 days (p = 0.06), (iv) regular diet; hand-assisted, 4.5 days versus

Cathelineau et al. reported the largest experience with laparoscopic radical cystectomy in 84 patients, including cystoprostatectomy in 31, and prostate-sparing cystectomy in 40.

At an average follow up of 18 months (range 1-44 months), all 84 patients were alive at last follow up, and 83% were disease-free without any evidence of trocar or extraction site seeding. Eight patients developed metastatic disease, and five developed local recurrence.

To define the laparoscopic radical cys-tectomy can be a viable alternative to standard open radical cystectomy, careful prospective and long-term evaluation of oncologic and functional outcomes will be necessary. Recently created International Registry for Laparoscopic Radical Cystectomy has been established by Gill and coworkers to facilitate development of this emerging field in a cohesive manner by optimizing operative techniques, establishing standardized critical care postoperative pathways, and prospectively collecting oncologic, functional, and quality-of-life outcomes data.

Complications were reported intraoperatively in 25 (8%), postoperatively in 75 (24%), and in a delayed fashion in 49 (16%). Positive surgical margins were in 11 patients (4%). In mean follow-up of 18 months (range 0.5-68) among 292 patients (95%) with available information, the overall and cancer-specific survival was 80% and 94%, respectively. There were local recurrences in 20 patients (7%), systemic recurrences in 20 patients (7%), and no port site recurrences.

In the future, laparoscopic radical cystectomy will evolve into a technically optimal combination, with intracorpo-real performance of the radical cystec-tomy, including extended pelvic lymphadenectomy, ureteral mobilization, and selection of the appropriate bowel segment. Majority of the reconstructive procedures, creation of the bowel reservoir, and ureterointestinal anastomoses are likely to be performed extracorporeally through a minilaparo-tomy. In patients undergoing ortho-topic reconstruction, the urethroenteric anastomosis will then be completed intracorporeally.

tate development of this emerging field in a cohesive manner by optimizing operative techniques, establishing standardized critical care postoperative pathways, and prospectively collecting oncologic, functional, and quality-of-life outcomes data (3).

The International Registry database involved nine international centers with published experience in laparoscopic radical cystectomy of at least 10 cases. From December 1999 to July 2005, 308 patients underwent laparoscopic radical cystectomy in 244 males and 64 females with a mean age of 65 years old. Preoperatively, concomitant carcinoma in situ was in 18%, and preoperative computed tomography indicated pelvic lymphadenopathy in 3% and perivesical fat involvement in 8%. Laparoscopic radical cystectomy procedures included cystoprostatectomy (69%), prostate-sparing cystec-tomy (11%), female anterior pelvic exenteration (14%), and female radical cystectomy (6%). Pelvic lymphadenectomy was performed in 91% of the patients (the mean number of lymph nodes nine, ranged 2-36), revealing nodal involvement on pathology in 52 patients (17%). The types of urinary diversion included orthotopic neobladder (56%) and ileal conduit (38%), which were reconstructed extracorporeally in 89% and intra-corporeally in 11%. Mean operating room time was 6.3 hours {1.6-13.8}, and blood loss was 660 cc {50-5000} with 10 patients electively converted to open surgery because of extensive tumor.

Complications were reported intraoperatively in 25 (8%), postoperatively in 75 (24%), and in a delayed fashion in 49 (16%). Positive surgical margins were in 11 patients (4%). In mean follow-up of 18 months (range 0.5-68) among 292 patients (95%) with available information, the overall and cancer-specific survival was 80% and 94%, respectively. There were local recurrences in 20 patients (7%), systemic recurrences in 20 patients (7%), and no port site recurrences.

Because the most technically challenging of laparoscopic radical cystectomy is the reconstructive urinary diversion, the majority of centers preferably perform the urinary diversion extracorporeally through a minilaparotomy incision. Published literatures reported that perioperative outcomes of extracorporeal versus intracorporeal reconstruction of urinary diversion are likely very similar, albeit with shorter operative times and less requirement of advanced laparoscopic skills in the extracorporeal technique.

In the future, laparoscopic radical cystectomy will evolve into a technically optimal combination, with intracorporeal performance of the radical cystectomy, including extended pelvic lymphadenectomy, ureteral mobilization, and selection of the appropriate bowel segment. Majority of the reconstructive procedures, creation of the bowel reservoir, and ureterointestinal anastomoses are likely to be performed extracorporeally through a minilaparotomy. In patients undergoing orthotopic reconstruction, the ure-throenteric anastomosis will then be completed intracorporeally.

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