Introduction

As recent growing experiences were published from the major medical centers throughout the world, minimally invasive surgery for bladder carcinoma and urinary diversion reconstruction is gaining acceptance. During the initial part of the learning curve, laparoscopic radical cystectomy should be reserved for nonobese patients with organ-confined, nonbulky bladder cancer without preoperative radiographic and clinical findings of concomitant pelvic lymphadenopathy.

Radical cystectomy is the established, standard treatment for patients with organ-confined, muscle-invasive, or recurrent high-grade bladder cancer. The optimal goals of the therapy for bladder cancer can include achieving excellent long-term oncologic outcomes as well as improved quality of life, coupled with the evolved urinary diversion.

The potential advantages of laparoscopic surgery are decreased blood loss, avoidance of certain laparotomy, less postoperative pain, less morbidity, early return to full activity, and better cosmesis. Following recent establishment of laparoscopic upper urinary tract and prostate surgery with a noteworthy decrease in patients' morbidity, a natural progression has been made to applying the laparoscopic technique to bladder surgery. Although the most challenging aspect of laparoscopic surgery for bladder carcinoma is reconstructive procedures, Gill et al. reported initial laparoscopic radical cystectomy with either ileal conduit or orthotopic urinary diversion (Studer pouch), with entire procedure being performed purely intracorporeally, in 2000 and 2001, respectively (1,2). Achieved decrease of blood loss in laparoscopic radical cystectomy (~ 300-400 cc) is considered to be due to clear visualization and delicate hemostatic handling of the bladder pedicles using linear stapling devices, with the tamponade effect afforded by the CO2 pneumoperitoneum pressure.

Open radical cystectomy with urinary diversion provides accepted oncologic outcomes (Table 1) (3); however, it is a major demanding surgery for patients, involving long postoperative recovery. In the outcomes of the recent largest series in 1054 patients undergoing open radical cystectomy and urinary diversion of conduit (n = 267, 25%), ureterosigmoidostomy (n = 17, 2%), continent cutaneous (n = 372, 35%), or orthotopic (n = 398, 38%), with a median follow-up of 10.2 years, there were 27 (3%) perioperative deaths, with a total of 292 (28%) early complications (4). Distant recurrence was reported in 234 patients (22%) and local recurrence in 77 patients (7%). Overall recurrence-free survival at 5 and 10 years was 68% and 66%, respectively. Patients with fewer than five positive lymph nodes, undergoing their proposed extended pelvic iliac lymph node dissection approach, had significantly better survival rates than those with five or more lymph nodes involved (p = 0.003) (4).

The laparoscopic radical cystectomy with urinary diversion is a recently emerged surgery, requiring advanced laparoscopic training. As recent growing experiences were published from the major medical centers throughout the world, minimally invasive surgery for bladder carcinoma and urinary diversion reconstruction is gaining acceptance. During the initial part of the learning curve, laparoscopic radical cystectomy should be reserved for nonobese patients with organ-confined, nonbulky bladder cancer without preoperative radiographic and clinical findings of concomitant pelvic lymphadenopathy (1).

TABLE 1 ■ Laparoscopic Radical Cystectomy and Lymphadenectomy: Oncologic Outcomes

No. of

Technique

Lymphadenectomy

Mean (range) months

N

Author (yr)

patients

(reconstruction)

Margins

(n node, range)

at stated follow-up

Overall survival

Puppo(1995)

5

Lap (extra)

Not stated

Limited (not stated)

10.8 (6-18)

5

Denewer (1999)

10

Lap (extra)

Not stated

Limited (not stated)

Not stated

9

Turk (2001)

5

Lap (purely intra)

5/5 negative

Limited (not stated)

Not stated

5

Abdel-Hakim (2002)

9

Lap (extra)

9/9 negative

Limited (n = 2-4)

Not stated

9

Simonato (2003)

10

Lap (extra)

10/10 negative

Limited (not stated)

12.3 (5-18)

10

Menon (2003)

17

Robot (extra)

17/17 negative

Limited (n = 4-27)

(2-11)

17

Hemal (2004)

11

Lap (extra)

10/11 negative

Limited (not stated)

18.4 (1-48)

10

Basillotte (2004)

13

Lap (extra)

12/13 negative

Limited (not stated)

Not stated

13

Taylor (2004)

5

HAL (extra)

4/5 negative

Extended (not stated)

Not stated

5

Gill (2004)

22

Lap (purely intra)

21/22 negative

11/22 extended

11 (2-43)

18

(n = 21,6-30)

All (83% disease-free)

Cathelineau (2005)

84

Lap (extra)

All negative

Not stated

18 (1-44)

Source: From Ref. 3.

Although the above reports established laparoscopic feasibility of certain portions of laparoscopic cystectomy or urinary diversion, it was not until 2000 that entire laparoscopic radical cystec-tomy and completely intracorporeal ileal conduit urinary diversion was employed clinically in two male patients with bladder cancer, following a successful pilot study in 10 pigs by Cleveland Clinic. Similarly, in author's institution, the completely intracorporeal orthotopic ileal neobladder was initially developed successfully in animal study using 12 pigs, followed by clinical application of orthotopic urinary diversion in one man and in one woman, and an Indiana pouch in one man.

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