Step 15 Drains and Foley Catheter Placement

Finally, two suction drains are left in the pelvic cavity and the pouch of Douglas. The Foley catheter is left in the urethra for nine days.

DESCRIPTION OF TECHNICAL MODIFICATIONS

At our center, we modified the surgical technique previously described to render this technique easier to reproduce. Two major modifications include the type of simple

FIGURE5 ■ Lower urinary tract reconstruction with the "Z" ileal neobladder.

3 cm

FIGURE5 ■ Lower urinary tract reconstruction with the "Z" ileal neobladder.

3 cm

TABLE 3 ■ European Groups that Perform Open or Laparoscopic Prostate-Sparing Cystectomy

Center

No. of

Continence Erections

patients

(%)

(%)

Montsouris

132

100

84

Colombo

41

100

100

Horenblas

39

70

70

Sèbe

34

90

88

Coulange

25

93

86

Meinhardt

24

96

83

Ghanem

4

100

75

prostatectomy, and the approach for the anastomosis during the lower urinary reconstruction.

In the beginning of our experience we performed a transurethral resection of the prostate extending from the bladder neck to the verumontanum at the beginning of the surgery. Specimens of the prostatic urethra and transition zone were sent in separate containers for frozen section examination before proceeding with the cystectomy. However, currently we have noted that performing a simple prostatectomy after the bladder dissection offers the benefit of the complete prostatic urothelium for histopathologic analysis, and can be done without compromising the surgical results and not increasing significantly the surgical time. However, both options are feasible and the surgeon should select either, according to preference.

The second variation of the technique is the option, after the neobladder construction, of performing the neobladder prostate capsule anastomoses and ureter-neobladder anastomosis laparoscopically by closing the midline incision. We have performed these anastomoses by open and laparoscopic approaches, and have seen that the laparoscopic technique at this stage of the operation does not modify significantly the results and could result in a longer surgical time and a difficult procedure, especially concerning the neobladder-prostate capsule anastomosis (4).

Guazzoni et al. have recently described the laparoscopic approach for a nerve-and seminal-sparing cystectomy, doing one week before the surgery a transurethral resection of the prostate and transectioning the bladder vascular pedicles with Endo-GIA. In our experience, this stapler is not necessary as described in our technique, due to its cost and risk of malfunction, and because we deem bipolar diathermy sufficient (10).

There are no other laparoscopic prostate-sparing techniques described in the literature; however, there have been some techniques applied through an open approach that propose some variations concerning the prostate-sparing dissection planes. These modifications will be described briefly because they are performed by an open technique; however, they could eventually be performed laparoscopi-cally also.

Colombo et al. have reported a similar technique to ours, except for the fact that they perform cystectomy extraperitoneally. After the completion of cystectomy, they open the peritoneum and perform the ileal bladder reconstruction and anastomosis with two semicircular running sutures (11).

Meinhardt and Horenblas have performed a technique in which the prostate and seminal vesicles are preserved allowing the neobladder to be anastomosed to the lateral edge of the prostate; however, they do not specify any further details (12).

Ghanem has proposed ligating the anterior prostatic veins and incising the prostate capsule transversely 0.5 cm below the bladder neck, as in retropubic prostatectomy to allow a dissection of the prostatic adenoma attached to the bladder, and continuing a circumferential incision from the anterior transverse incision of the pro-static capsule, to complete the cysto-prostatic-adenomectomy (Table 3) (13).

Spitz et al. described a technique for nonurothelial tumors, and mentioned the variation of an incision of the endopelvic fascia adjacent to the prostate and ligation of the anterior and lateral aspects of the prostate proximal to the puboprostatic ligaments, controlling the dorsal venous complex and the incision of the prostatic stroma at the level of the urethra. This prostate transection is continued posteriorly without compromising the ejaculatory ducts (14).

All of these open technique variations can be easily applied to the laparoscopic approach; however, the choice of technique depends on the surgeon's personal experience.

TECHNICAL TIPS

■ When opening the Retzius space, it is not necessary to open the endopelvic fascia, because the prostate capsule is not manipulated in this technique. Avoiding the incision of the endopelvic fascia ensures that the neurovascular bundles of the prostate are left undisturbed, as well as the surrounding tissues, which being intact serve as support for the prostate.

■ During the incision of the bladder vascular pedicle with bipolar diathermy, it is important to take adequate time to ensure that no postoperative bleeding occurs from these vessels.

■ The bladder neck can be identified by mild traction on the Foley catheter, which makes evident the prostatovesical junction anteriorly. Another option is to visualize the perivesical fat, which does not extend into the prostate and makes a subtle bladder neck delineation. Finally, if neither of the above is useful, a Benique dilator can be introduced and visualized inside the bladder; however, we must keep in mind that the bladder neck is higher than the tip of the metal dilator.

■ To perform the bladder neck incision, it is done along the prostatic adenoma, 10 mm below the bladder neck, ensuring that a complete resection of the bladder neck is performed, thereby diminishing the risk positive margins along the lower portion of the surgical specimen.

■ After the bladder is completely liberated, the bladder neck closure must be performed immediately after completing the bladder neck dissection, and introduced into an extraction bag without any excessive pressure on the bladder. All this is done to avoid any possible tumor cell spillage, although the risk is low considering that the bladder has been completely emptied of any remaining urine with the Foley catheter and the ureters have been long since ligated and transected.

■ When performing the simple prostatectomy, the distal portion of the incision along the prostatic urethra must not be beyond the verumontanum, in order to avoid any damage to the sphincter.

SPECIFIC MEASURES TAKEN TO AVOID COMPLICATIONS

Complications involved in laparoscopic surgery of the lower urinary tract are mainly the same as those involved with open surgery (15). We describe the transoperative (divided according to the different surgical steps) and postoperative complications.

Perioperative Complications

Perioperative complications are associated with the patient position (such as compartment syndromes and neurologic sequelae secondary to prolonged compression), insufflations (vascular or intestinal injuries), and those associated with intestinal displacement during the laparoscopic stage. These complications can be prevented by carefully positioning the patient with enough cushioning of the dependent areas, by avoiding excessive pressure on the abdominal wall when introducing the insufflation needle, and finally by managing the gastrointestinal tract with blunt instruments and carefully.

Postoperative Complications

Postoperative complications are associated with the different stages of the surgery, and include hematomas resulting from inadequate use of diathermy during dissection, and lymphocele, which is usually rare because the operation is performed transperitoneally and, as such, is reabsorbed by the peritoneum. Wound infections are not due to the intestinal content and should not influence this complication. Neobladder stenosis is rare but can be the result of an incision too low along the prostate or an inadequate anastomosis. Urine leak is due to damage of the tissues in the anastomosis or an inefficient suture, which can be verified transoperatively by filling the neobladder with saline solution. Intestinal fistulae can occur if the entero-entero anastomosis is not carefully performed or there is an ischemic lesion on the ileal wall.

POSTOPERATIVE EVALUATION

The follow-up protocol that we routinely use includes a complete physical exam with digital rectal exam, complete blood analysis with a special interest in urine analysis, serum creatinine, total prostate-specific antigen and free prostate-specific antigen, chest X-rays and computed tomography scan of the abdomen every six months for the first three years, and yearly afterwards. Continence is evaluated using a mailed questionnaire, evaluating their use of protection pads. We define erectile function according to their ability to perform intercourse.

Continence and potency are assessed by the patients (16,17), using mailed questionnaires. Patients are considered continent only when they do not use any pads. They are strictly instructed during the first postoperative year to empty the bladder once or twice at night in order to achieve adequate nighttime continence. Potency is strictly defined as the ability to maintain an unassisted erection sufficient for intercourse. Partial potency is defined as the ability to achieve but not maintain erection long enough for satisfactory intercourse without the use of any device or medications. Patients unable to achieve an erection, as well as those using medications or devices to stimulate erection, are considered as impotent.

RESULTS

In our experience, the oncologic and functional results of our laparoscopic series are comparable to that of the open approach series, with the added benefit of a diminished bleeding and less need of postoperative analgesics.

TABLE4 ■ Patient Characteristics, Clinical Tumor Stage, and Tumor Grade of Initial Experience Performing Laparoscopic Prostate-Sparing Cystectomy

Laparoscopic

No. of patients

25

Age

59.8 (range, 43-77)

Date of surgery

03/02-03/04

Follow-up

9.7 m (range, 3-27)

Smoking habit

Positive in 20

Stage

T0

2

Ta

2

CIS

2

T1

2

T2a

6

T2b

2

T3a

8

T3b

-

T4 (prostate)

1

Grade

G1

-

G2

6

G3

19

Abbreviation: CIS, carcinoma-in-situ.

During the last 12 years 132 patients have undergone a prostate-sparing cystectomy in our department (4). The first 107 procedures were performed with open approach, and the last 25 using laparoscopic-assisted technique. In our experience, the oncologic and functional results of our laparoscopic series are comparable to that of the open approach series, with the added benefit of a diminished bleeding and less need of postoperative analgesics.

From March 2002 to March 2004, we employed the laparoscopic prostate-sparing technique in 25 patients. The average age was 60 (range, 43-77 years), 20/25 of the patients had a history of smoking as a risk factor. The different pathologic postoperative stages were pTl = 8, pT2 = 8, pT3 = 8, pT4 = 1 involving the prostate neck (N0, M0). They all had negative surgical margins and no lymph nodes with metastasis. The histopathologic grade was moderate in 6 and high grade in 19. Mean operating time including the neobladder reconstruction was 4.75 hours (range, 3.3-6.3 hours) and mean intraoperative blood loss was 640 cc (range, 200-1500 cc) with transfusion required in six patients. The surgery was successfully completed as described with the laparoscopic and open stages in all of the patients, without any transoperative complications or conversions (Table 4). After performing the neoblad-der anastomosis laparoscopically in five patients, we did not observe any significant advantage for the surgical technique, and decided to continue performing the neobladder-prostatic anastomosis through the infraumbilical incision by an open technique. Overall, this offers the advantage of preventing any traction on the abdominal wall and hence minimizes postoperative pain. All of our patients were followed up for the first 24 hours in the intensive care unit according to hospital policy without any complications, except for a sinus tachycardia, which resolved without any sequelae. In all, the laparoscopic approach offered diminished bleeding and less postoperative pain.

Among the postoperative complications there was one intestinal suboclusion, one urinary fistula and one pelvic lymphocele. The average follow-up of these patients was 9.7 months (range, 3-27 months). There have been two metastatic progressions (at five and eight months) and one local recurrence (six months after the surgery); the three patients have been submitted to chemotherapy following a methotrexate, vinblastine, adriamycin and cisplatin scheme with good results. All of the patients are alive except for a T3a patient who died seven months after the surgery due to cancer progression. Interestingly, this same patient in the final pathology analysis was reported with a small prostatic adenocarcinoma with a Gleason 3+3 in the resected prostatic adenoma, which was not diagnosed during the frozen section study; he was managed with hormone therapy. Concerning renal function, creatinine levels have been maintained and have not varied significantly (average of 97mmol/L before and 102 mmol/L after the surgery). This figure also applies to the prostate specific antigen, although a slight decrease was detected after the surgery (from 2 ng/mL before to 0.6 ng/mL after the surgery), which was mainly due to the simple adenomectomy. Finally, concerning functional results, all our patients achieved satisfactory daytime and nighttime continence, without using any pad after surgery. Nighttime continence is complete; however, seven patients developed nocturia between one and three per night. No patient has presented with urinary retention, 21 patients (84%) maintained their preoperative sexual potency, and four alluded to a decrease in their erectile function postoperatively. All of our patients have retrograde ejaculation after surgery, which is related to the simple prostatectomy.

Laparoscopic prostate-sparing cystec-tomy is associated with the potential risk of developing prostate cancer, carcinoma in situ of the prostatic urethra, transitional cell cancer of the prostatic ducts or glands, and prostatic invasion by bladder cancer, which as a group might influence the oncologic control obtained with this procedure.

DISCUSSION

The current standard of care for muscle invasive and refractory superficial high-grade organ-confined bladder cancer is radical cystoprostatectomy (18). This procedure removes the bladder, prostate, seminal vesicles and vas deferens, and involves a deep pelvic dissection with a significant risk of damage to the pelvic nerves as well as extensive manipulation of the external sphincter (19). This explains why it is associated with a considerable degree of incontinence (5-18%) when a neobladder is constructed and erectile dysfunction (75-80%) (20-22). These functional results explain why more conservative techniques are constantly being explored. The goal is to preserve the urethral sphincter and neurovascular bundles, which will impact on the functional results for these patients (23).

With the above in mind, the laparoscopic prostate-sparing cystectomy was developed at our Institute.

Laparoscopic prostate-sparing cystectomy is associated with the potential risk of developing prostate cancer, carcinoma in situ of the prostatic urethra, transitional cell cancer of the prostatic ducts or glands, and prostatic invasion by bladder cancer, which as a group might influence the oncologic control obtained with this procedure (24).

Risk of Prostate Cancer

Kabalin et al. (25) reported a 38% incidence of occult prostate cancer in cystoprostatec-tomy specimens but only 1.9% of these had tumors exceeding 0.1 cc in volume. Moreover, their study was performed before the prostate specific antigen era and patients were excluded from their analysis if they had an abnormal digital rectal exam. Our patients were assessed carefully preoperatively to exclude the risk of prostate cancer (26). Patients with an abnormal digital rectal examination, total prostate specific antigen > 3ng/mL, or percent free prostate specific antigen <12% underwent prostatic biopsies. Preoperatively, frozen sections of the transitional zone were routinely done. These frozen sections were initially of the transurethral resection chips, before the laparoscopic procedure was started; afterwards in our experience, the complete transitional zone was analyzed after the simple prostatectomy in the laparoscopic approach. In our series, two cases were not completed because they had positive frozen section for prostate cancer, and the procedure was completed with a radical cystoprostatectomy. The simple prostatectomy that we currently perform laparoscopically (27) allows complete removal of the transitional zone, improving the reliability of pathologic analysis, which with our strict follow-up protocol of digital rectal examination, and total and free prostate specific antigen every six months, leads to an early detection of any de novo prostate cancer, giving enough time for the patient to be treated successfully with either of the different modalities (external beam radiotherapy, transrectal focused ultrasound, brachytherapy or hormonal treatment). In our experience, two de novo prostate cancers have been diagnosed at three and five years after the prostate-sparing procedure and have been treated successfully, one with external beam radiation and the other by transrectal high intensity energy ultrasound.

0 0

Post a comment