Patient Selection

Bladder cancer is a potentially lethal disease; the patient's prognosis is partially dictated by the quality of the cystectomy and extent of the lymphadenectomy (6-9). The introduction of the laparoscopic approach with its potential low morbidity profile is, in part, an effort to preserve high quality of care while minimizing the often debilitating effects of cystectomy and permitting more patients the opportunity to undergo this potentially lifesaving procedure. This approach should by no means compromise the oncologic quality of radical cystectomy. Laparoscopic radical cystectomy is still in its early stages, and its long-term advantages and disadvantages are poorly defined. Therefore, patient selection is paramount to a successful laparoscopic radical cystectomy program.

Patients with bulky and locally advanced primary disease are not good candidates for laparoscopic radical cystectomy. Prior pelvic radiation therapy, prior prostate surgery, extensive transperitoneal surgery, and/or low ability to tolerate prolonged pneumoperitoneum (i.e., chronic obstructive pulmonary disease) constitute relative contraindications to laparoscopic radical cystectomy at this time. The laparoscopic approach for the treatment of invasive bladder cancer is promising, and with the accumulated experience its indications will continue to safely expand.

PREOPERATIVE PATIENT PREPARATION

Preoperatively patients receive a mechanical bowel preparation, identical to that for open surgery. Thromboprophylaxis is ensured by sequential compressive devices on both lower extremities and low-molecular-weight heparin administered prior to surgery, then daily afterwards until discharge from the hospital. Thromboprophylaxis is essential given the multiple risk factors, including oncologic surgery, pelvic surgery, laparoscopy, and prolonged operative time. Patients also receive antibiotic prophylaxis.

SURGICAL TECHNIQUE Patient Positioning

The patient is positioned in a low lithotomy position or a supine position with the lower extremities apart on spreader bars to allow access to the perineum. Both arms are set alongside the body and the patient is secured to the operating table with surgical tape. A right-handed surgeon stands on the patient's left with the assistant on the opposite side; the monitor is placed between the patient's legs, at the surgeon's eye level and as close as necessary (Fig. 1). The operating table is placed in a steep Trendelenburg position during surgery.

Port Placement

The pneumoperitoneum is obtained through a Veress needle and set at a pressure of 12 mmHg. A five to six-port fan-shaped transperitoneal approach is used. First a 12 mm port is inserted supraumbilically and used for the laparoscope. The peritoneal contents are examined for trocar injury and evidence of metastasis, and then the remaining four to five ports are placed under visual control (Fig. 2).

A bilateral pelvic lymphadenectomy is performed either initially or after the cys-tectomy is completed. The authors' preference is to perform the lymphadenectomy after the cystectomy, prior to specimen extraction in the male, and following specimen extraction in the female (Fig. 3). The lymphadenectomy is often extended to at least the common iliac bifurcation and often to the aortic bifurcation. Laparoscopic bilateral pelvic lym-phadenectomy is described elsewhere in this book and will not be covered here Table 1.

LAPAROSCOPIC RADICAL CYSTECTOMY IN THE MALE PATIENT (Table 1) Posterior Peritoneal Incision (Pouch of Douglas to Ureters)

The sigmoid colon is retracted gently by the assistant, moving any redundant rectum cephalad. In rare cases, a redundant sigmoid colon can be retracted cephalad using a silk

FIGURE 1 ■ Operating room setup demonstrating patient in lithotomy with position of robotic arm camera holder.

FIGURE2 ■ Schematic of port placement and port size for laparoscopic radical cystectomy.

TABLE 1 ■ Surgical Steps of Laparoscopic Radical Cystectomy

Technical steps

First step

Posterior peritoneal incision to access through the cul-de-sac of Douglas

Second step

Dissection of the ureters

Third step

Control of the posterior vesical pedicle

Fourth step

Anterior approach and development of the Retzius space

Fifth step

Transection of the lateral vesical and prostatic vascular pedicles

Sixth step

Apical dissection, transection, and specimen entrapment

Seventh step

Bilateral pelvic lymph node dissection

FIGURE3 ■ Pelvis after cystectomy, showing completed right-side pelvic lymphadenectomy and dissection for left-sided pelvic lymphadenectomy.

FIGURE4 ■ Initial posterior peritoneal incision to access posterior cul-de-sac. The dotted line illustrates planned continued incision of posterior peritoneum overlying the ureter and lateral pedicle.

retraction suture placed through the tenia coli and brought through the skin with a suture passer. The surgeon incises the posterior vesical peritoneum transversally approximately 2 cm above the recess of the pouch of Douglas. This dissection should follow the inferior peritoneal flap; it exposes the outlines of the vesicular complex formed by the vasa defer-entia and seminal vesicles. The incision is carried proximally near the lateral pelvic sidewall and to the pelvic brim in order to expose the ureters (Fig. 4).

The seminal vesicular complex is seen through Denonvilliers' fascia. Unlike laparoscopic radical prostatectomy, the vesicular complex is not mobilized but left en-bloc with the bladder. Denonvilliers fascia should be respected at this level and opened lower and closer to the prostate. At that location, Denonvilliers fascia is incised medially and horizontally, bringing into view the prerectal fatty tissue. Dissection is then taken in the plane between the posterior aspect of the prostate and the anterior rectal wall as far as the prostatic apex. This dissection separates the rectum from the posterior and lateral vascular pedicles of the bladder and prostate.

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