Laparoscopic Assisted Laparoscopic Radical Cystectomy

In 2002, Gaboardi et al. (16) introduced the laparoscopic-assisted technique of laparoscopic radical cystectomy with ileal neobladder, in which extracorporeal restoring of intestinal

TABLE2 m Operative Outcomes of Reconstructive Urinary Diversion

Puppo

Denewer

Turk

Abdel-Hakim

Simonato

Menon

Hemal

Basillotte

Taylor

Gill

Author (yr)

(1995)

(1999)

(2001)

(2002)

(2003)

(2003)

(2004)

(2004)

(2004)

(2004)

Number of

5

10

5

9

10

17

11

13

8

22

patients

Technique

Transvaginal

Laparoscopic-

Purely

Laparoscopic-

Laparoscopic-

Robot-

Laparoscopic-

Laparoscopic-

Hand-

Purely

and laparoscopic-

assisted

intracorporeal

assisted

assisted

assisted

assisted

assisted

assisted

intracorporeal

assisted (extra)

(extra)

laparoscopic

(extra)

(extra)

(extra)

(extra)

(extra)

(extra)

laparoscopic

Type of

Ileal

Sigmoid-pouch,

Rectal-sigmoid-

Orthotopic,

Orthotopic,

Orthotopic,

Ileal conduit,

Orthotopic,

Ileal conduit,

Ileal conduit, 14

urinary

conduit 4

10 (extra)

pouch, 5

9 (extra)

6 sigmoid-

14 Ileal

11 (extra)

13 (extra)

8 (extra)

orthotopic,

diversion

Cutaneous, 1

(Purely intra)

ureterostomy,

conduit,

6 (intra) Indiana,

2 cutaneous-

3 (extra)

2 (extra)

ureterostomy,

2 (extra)

Mean (range)

7.2 (6-9)

3.6(3.3-4.1)

7.4(6.9-7.9)

8.3 (6.5-12)

Orthotopic,

Orthotopic,

6.1 (4.3-8)

8.0 hrs

6.7(5.5-7.7)

8.6

operative

7.1 sigmoid,

5.1 Ileal

(±77 min)

duration (hr)

ureterostomy,

conduit, 4.3

5.8 cutaneous-

ureterostomy, A 7

Blood loss (mL),

3 pts transfused

Transfused

310

<150

530

1000 ± 414

637 (400-1000),

490

transfusion

2-6 units

mean 2.2 unit,

(190-300)

(220-440)

(300-900)

transfused

range 2-3

in 2 pts

Ileus (day)

2.6 (2-4)

Not stated

Not stated

Not stated

3.3(1-5)

Not stated

Not stated

Not stated

1 prolonged

6 prolonged ileus,

3 bowel obstruction

Length of

10.6(7-18)

10-13

10 (in all 5)

Not stated

Orthotopic,

Not stated

10.5

5.1 ± 1.2

6.4 (3-10)

Not stated

stay (day)

8.1 sigmoid-,

ureterostomy,

8 cutaneous-,

ureterostomy, 5

Time to oral

2-4

Not stated

Liquid 3

3

3-6

Not stated

Not stated

Liquid 2.8,

4.5 (3-8)

8

intake (day)

solid 4.1

Time to return

Not stated

Not stated

Not stated

Not stated

Not stated

Not stated

26

11.0 ± 1.9

21-28

Not stated

to work (day)

Functional

4/5 discharged

All continence,

All 5 with

No complications 2 bilateral

13 bilharziasis

All had normal

1 ureteral

1 upper

1 ureteroileal leak,

outcomes

with no post

1 ureterosig-

continent and

in pouchgram

hydronephrosis

with periureteric,

renal function

obstruction, 1

gastrointestinal

1 urethrovaginal

operative compli

moid urine

no obstruction

on 10th post

and metabolic

perivesicular;

and preserved

bladder neck

bleed, 1 rectal

fistula

cations, 1

leak, 1

of upper urinary

operative day

acidosis, 1

and perivesical

upper urinary

contracture, 1

injury and ileus

discharged after

pyelonephritis

tract in urogram

monolateral

scarring

tracts

obturator nerve

18 days due to

on 10th post

hydronephrosis

paresis

obesity and diabetic problems operative day o> lo tfl a «

obesity and diabetic problems operative day

Source: From Ref. 3.

In their six cases experience of laparoscopic-assisted laparoscopic radical cystectomy with orthotopic ileal neobladder, operative time was reported, 360 to 510 minutes (mean, 425); estimated blood loss, 220 to 440 mL (mean, 311); ileus day, three to five days (mean, 3.7); and hospital stay, seven to nine days (mean, 8.1). All six patients were alive during follow-up of 5 to 15 months (mean, 9.3), however, despite negative surgical margins two (33%) patients (T1N0G3+Cis and T2aN0G2-3) had metastatic diseases at six months after surgery.

The authors concluded that laparoscopic-assisted approach contributes to decreased postoperative pain and quicker recovery with similar complication rate to open approach. It should be noted that in this study, the reconstructive portion was performed through a 15-cm low Pfannenstiel incision.

In the initial experiences of 11 patients who underwent laparoscopic radical cystectomy and an open-hand sewn ileal conduit from 1999 to 2002, Hemal et al. reported one (9%) case with positive margin and other five (45%) cases of procedure-specific complications.

In 2003, the first case report of daVinci-assisted laparoscopic cystectomy with intracorporeally created ileal neobladder (Hautmann) was described by Beecken et al., resulting in operative time of 8.5 hours.

continuity and partial construction of the posterior plate of ileal neobladder with 25-cm loop was performed through a 5-cm supraumbilical incision that is necessary to remove the surgical specimen. Following closing the supraumbilical incision and recreation of pneu-moperitoneum, the urethra-neobladder anastomosis, ureteral anastomosis, and closing of the remained anterior neobladder wall were completed intracorporeally. The authors discussed extracorporeally detubularization of the ileal loop may prevent fecal contamination of the abdominal cavity, and open-assisted ileal-to-ileal anastomosis of the posterior plate with reapproximation of mesenteric margin may prevent intestinal mechanical obstruction.

In their six cases experience of laparoscopic-assisted laparoscopic radical cystec-tomy with orthotopic ileal neobladder, operative time was reported, 360 to 510 minutes (mean, 425); estimated blood loss, 220 to 440 mL (mean, 311); ileus day, three to five days (mean, 3.7); and hospital stay, seven to nine days (mean, 8.1). All six patients were alive during follow-up of 5 to 15 months (mean, 9.3), however, despite negative surgical margins two (33%) patients (T1N0G3+Cis and T2aN0G2-3) had metastatic diseases at six months after surgery (17).

The authors concluded that laparoscopic-assisted approach contributes to decreased postoperative pain and quicker recovery with similar complication rate to open approach. It should be noted that in this study, the reconstructive portion was performed through a 15-cm low Pfannenstiel incision.

Among total 10 cases of their laparoscopic radical cystectomy series with different urinary diversions, two cases of completely intracorporeally created sigmoid ureterostomy were noted with an operative time of 300 to 390 minutes (Table 2) (3).

In the initial experiences of 11 patients who underwent laparoscopic radical cys-tectomy and an open-hand sewn ileal conduit from 1999 to 2002, Hemal et al. reported one (9%) case with positive margin and other five (45%) cases of procedure-specific complications (18).

The authors described three intraoperative complications including injury to the external iliac vein (n = 1) and a small rectal tear (n = 2), all repaired by laparoscopic freehand suturing. Other laparoscopic surgical complications were subcutaneous emphysema (n = 1), and hypercarbia (n = 1) necessitating conversion to open surgery. The authors discussed that laparoscopic radical cystectomy was associated with complications similar to those seen with other laparoscopic and open surgery procedures, especially during the initial experience.

In 2004, Basillote et al. retrospectively compared perioperative outcomes of radical cystectomy with ileal neobladder between 11 men who underwent open approach and 13 men who underwent laparoscopic-assisted approach (19). The authors suggested laparoscopic approach provided significant decrease in postoperative pain, represented by parenteral morphine equivalent use (mg); open, 144 versus laparoscopy, 61, p = 0.04, as well as provided significant quicker recovery, represented by (i) start of oral liquids (days); open, 5 versus laparoscopy, 2.8, p = 0.004, (ii) start of oral solids (days); open, 6.1 versus laparoscopy, 4.1, p = 0.002, (iii) hospital stay (days); open, 8.4 versus laparoscopy, 5.1, p = 0.0004, (iv) lights work back (days); open, 19 versus laparoscopy, 11, p = 0.0001, without a significant increase in operative time (open, 7.2 hours vs. laparoscopy 8 hours, p = 0.5) and with similar complication rate (open, one major and five minor vs. laparoscopy, four major and two minor).

In the initial experiences of 11 patients who underwent laparoscopic radical cys-tectomy and an open-hand sewn ileal conduit from 1999 to 2002, Hemal et al. reported one (9%) case with positive margin and other five (45%) cases of procedure-specific complications (18).

As such, an ileal loop or orthotopic neobladder could be completed purely laparo-scopically or in an open fashion through an enlarged extraction incision. Proponents of the open-assisted approach refer its decreased operative time for performing the neoblad-der when compared to the purely intracorporeal procedure. Retrospective or prospective data comparing between intracorporeal and open-assisted approach are not yet available.

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