Purely Laparoscopically Completed Orthotopic Ileal Neobladder or Ileal Loop Cleveland Clinic Experience

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Gill et al. reported completely intracorporeal techniques in a manner duplicating open surgical principles can be performed for laparoscopic radical cystectomy with ileal conduit as well as with orthotopic continent urinary diversion (Studer pouch), in 2000 and 2002, respectively (1,2). Specifically, laparoscopic radical cystectomy respects established oncologic principles of wide margin resection in open radical cystectomy, and we have obtained negative margins in all but one of total 33 laparoscopic radical cystectomy performed to date. Mean estimated blood loss was 490 mL. There were no intraoperative complications

Oncologic outcomes of the initial 22 patients with mean follow-up of 11 months (range 2-43) were that 21 (95%) had negative margin, six (27%) had positive lymph nodes, three (14%) died of distant recurrence, and one local recurrence (4.5%) in case with pT4N2 with lung metastasis (alive, undergoing chemotherapy) was noted.

The median number (n = 21) of nodes retrieved in the author's series and anatomical boundaries of the surgical procedure (bilaterally skeletonizing the genitofemoral nerve, external iliac artery, external iliac vein, obturator nerve, hypogastric artery, common iliac artery, and pubic bone) were commensurate with those of current recommendation for open surgery. No patient developed port site or no local recurrence over the short follow-up of 11 months (range, 2-43 months).

The complications of the initial 22 cases of laparoscopic radical cystectomy, all with intracorporeally created urinary diversion, were summarized in six major (27%) and nine minor (41%) complications.

All had negative surgical margins, and an average of 10 lymph nodes (range, 5-16) were removed, resulting in positive lymph nodes in three patients (25%). No patients developed local recurrence. Three (25%) developed systematic disease (two in bone and one in liver and lung) at a median follow-up of 33 months (median time to progression), 22 months; and two (17%,pT3aG3 and pT3aG3N1) of the three patients died of the metastatic disease 15 and 24 months after surgery.

necessary to convert to open. Laparoscopic-magnified image provides excellent mucosa-to-mucosa precision during creation of an orthotopic neobladder, and during urethraileal and ureteroileal anastomosis. Although our initial operative times were around 10 hours, current operative time decreased to 8.5 hours with additional 1.5 hours by extended laparoscopic lymphadenectomy. The cystectomy part of the procedure now comprises approximately two hours.

Oncologic outcomes of the initial 22 patients with mean follow-up of 11 months (range, 2-43) were that 21 (95%) had negative margin, six (27%) had positive lymph nodes, three (14%) died of distant recurrence, and one local recurrence (4.5%) in case with pT4N2 with lung metastasis (alive, undergoing chemotherapy) was noted.

Importantly, radical cystectomy can provide not only an accurate pathological evaluation of the primary bladder cancer but also the assessment of regional lymph nodes involvement. There is increasing evidence to support extensive and meticulous dissection to enhance nodal yield, and oncologic outcomes. Herr et al. (12) reported regarding the impact of numbers of lymph nodes retrieved on outcomes of open radical cystectomy; patients with positive lymph nodes had significantly better survival when greater than 11 lymph nodes were retrieved for examination, and patients with negative lymph nodes had better survival when eight or greater lymph nodes were evaluated. Technique and initial outcomes of laparoscopic extended lymphadenectomy for bladder cancer was reported recently from Cleveland Clinic (13).

The median number (n = 21) of nodes retrieved in the author's series and anatomical boundaries of the surgical procedure (bilaterally skeletonizing the genitofemoral nerve, external iliac artery, external iliac vein, obturator nerve, hypogastric artery, common iliac artery, and pubic bone) were commensurate with those of current recommendation for open surgery. No patient developed port site or no local recurrence over the short follow-up of 11 months (range, 2-43 months) (13).

Laparoscopic radical cystectomy is a complex procedure and requires advanced laparoscopic expertise; as such, a critical appraisal of the attendant complications is essential.

The complications of the initial 22 cases of laparoscopic radical cystectomy, all with intracorporeally created urinary diversion, were summarized in six major (27%) and nine minor (41%) complications (13,14).

The major complications, all of which required reoperation, were small bowel obstruction (n = 3, 14%), ureteroileal anastomotic leak (n = 1, 4.5%), urethrovaginal fistula (n = 1, 4.5%), and bowel perforation with delayed death (n = 1, 4.5%). Minor complications were mainly related to prolonged ileus (n = 6, 28%), all of which were conservatively managed, deep venous thrombosis (n = 2, 9%) that was managed by thrombolytics administration, and postoperative bleed (n = 1, 4.5%) that was laparoscopically suture repaired.

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