Laparoscopic Radical Cystoprostatectomy: ATechnique Illustrated Step by Step

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1 European Urology European Urology 44 (2003) Laparoscopic Radical Cystoprostatectomy: ATechnique Illustrated Step by Step Alchiede Simonato *, Andrea Gregori, Andrea Lissiani, Andrea Bozzola, Stefano Galli, Franco Gaboardi Department of Surgery, Division of Urology, Luigi Sacco Hospital, Milan, Italy Accepted 18 April 2003 Abstract Objectives: Laparoscopic surgery is expanding among urologists as a minimally invasive treatment and may now be applied to treat neoplasms of the pelvic organs. Laparoscopic cystoprostatectomy has still not been well codified and illustrated. We describe a technique of laparoscopic radical cystoprostatectomy that we have developed in 10 patients after practicing in laparoscopic radical prostatectomy. Methods: Between June 2001 and July 2002, 10 men with bladder cancer underwent laparoscopic cystoprostatectomy with urinary diversion. This report details step by step our 5-port transperitoneal technique with primary access to the seminal vesicles and Denonvillier s fascia, ureters detection after umbilical arteries incision, endopelvic fascia incision and dorsal vein complex control before division of the vesical and prostatic fibrovascular pedicles with a harmonic scalpel. Results: We performed 6 orthotopic ileal s, 2 sigmoid ureterostomies and 2 cutaneous ureterostomies. In all cases no conversion to open surgery was necessary. The mean time to perform the laparoscopic radical cystoprostatectomy, including the lymph node dissection, was 166 minutes (range ). Mean estimated blood loss was 310 ml (range ). Mean hospital stay was 8.1 days (range 7 9) for ileal orthotopic, 8 days (range 7 9) for sigmoid and 5 days for cutaneous. The mean follow up is 12.3 months (range 5 18). Two patients respectively with stage T2bN0 G2 3 and stage pt1n0 (plus carcinoma in situ) G3 transitional cell carcinoma and surgical margins tumor free had diffusive metastatic after 6 months. The other 8 patients are free from. Conclusions: Laparoscopic radical cystectomy is still an operation for pioneers but this procedure may be not strictly relegated to a few academic centers. In our opinion laparoscopic cystoprostatectomy is a feasible, fast, safe and easy procedure and urinary diversion may be performed with a laparoscopic, open or combined approach without reducing the advantages of laparoscopy. # 2003 Elsevier Science B.V. All rights reserved. Keywords: Bladder neoplasms; Cystoprostatectomy; Laparoscopy 1. Introduction Radical cystectomy remains the gold standard for muscle invasive bladder cancer and high risk superficial tumors resistant to intravesical therapy [1]. Open cystoprostatectomy with urinary diversion is a major * Corresponding author. Tel. þ ; Fax: þ address: alchiedesimonato@libero.it (A. Simonato). procedure which may be demanding for patients. Laparoscopic surgery is expanding among urologists as a minimally invasive treatment and may be now applied to treat neoplasms of the pelvic organs [2 4]. Laparoscopic cystectomy with different urinary diversions has already been described and has been shown to provide many intraoperative and postoperative advantages versus open surgery [5 12]. Nevertheless, the laparoscopic cystoprostatectomy has still not been well codified and illustrated. We describe a technique of /03/$ see front matter # 2003 Elsevier Science B.V. All rights reserved. doi: /s (03)

2 A. Simonato et al. / European Urology 44 (2003) laparoscopic radical cystoprostatectomy that we have developed in 10 patients after practicing in laparoscopic radical prostatectomy. 2. Material and methods Between June 2001 and July 2002, 10 men age 63 to 74 years (mean 68.8) with bladder cancer who were candidates for radical surgery underwent laparoscopic cystoprostatectomy with urinary diversion. After transurethral resection of the primary tumor, all patients were evaluated with a chest radiograph, abdominal-pelvic CT scan, bone scan and liver function tests to rule out distant metastasis. Three out of 10 patients had previous abdominal surgery: appendicectomy in 2 cases and appendicectomy plus cholecystectomy in 1 case Patient preparation Preoperatively, the bowel is prepared by oral self-administration of 2 liters of electrolyte lavage solution the afternoon before of the surgical procedure. Antibiotic prophylaxis with a cephalosporin and low molecular weight heparin (4000 units) are administered preoperatively and until the postoperative day 15. Compression stockings are applied and the patient is placed in the supine position with the legs apart to allow free access to the perinal space. The table is set in the Trendelemburg position. An 18Fr Foley Table 1 Equipment for laparoscopic radical cystoprostatectomy mm trocars 2 5 mm trocars 1 10 mm 308 endoscope 1 Laparoscopic Metzembaum scissors 2 Laparoscopic bipolar forceps 1 Laparoscopic atraumatic prehension forceps 1 Laparoscopic suction irrigation canula 3 Laparoscopy bags 1 Harmonic scalpel Surgical endoscopy clips catheter is inserted to drain the bladder and a nasogastric tube is positioned Equipment Standard laparoscopic surgical equipment with few special instruments are required (Table 1) Laparoscopic access A 5-port fan-shaped transperitoneal approach is used (Fig. 1). The first 12-mm trocar is placed with open technique through a mini-laparotomy 1 cm below the umbilicus. This trocar is reserved for the laparoscope. The remaining 4 ports are placed under endoscopic control after establishment of the pneumoperitoneum. The abdomen and pelvis are inspectioned Dissection of the seminal vesicles and Denonvilliers fascia incision The first step in our approach is the bilateral incision of the peritoneum at the level of the abdominal inguinal ring. Fig. 1. Five-port fan-shaped placement. The 308 laparoscope is inserted through the 10 mm. umbilical port. The figure also shows the 5 cm. supraumbilical incision (arrowhead) used both for the extraction of the specimen and for the external reconstruction time when an orthotopic resevoir is applied. Fig. 2. Aspect of the pelvis and lines of incision. Dotted line: first incision of the peritoneum at the level of the deep inguinal ring down to the second peritoneal arch at the inferiorposterior aspect of the bladder. Interrupted line: laterally to the umbilical arteries, the incision is prolonged bilaterally both upward to the umbilicus and downward to the deep iliac arteries.

3 134 A. Simonato et al. / European Urology 44 (2003) Vasa deferentia are dissected up to the second peritoneal arch at the inferoposterior aspect of the bladder in the Douglas pouch (Fig. 2). The seminal vesicles are easily reached and isolated but manteined en bloc with the bladder specimen. The ampullae of the vasa deferentia and the seminal vesicles are retracted in order to expose the Denonvilliers fascia. The Denonvilliers fascia is incised horizontally, exposing the prerectal fat. The anterior surface of the rectum is then dissected up to the prostatic apex. A tunnel between the rectum and the prostate with the vesical and prostatic fibrovascular pedicles laterally is created Ureters dissection The umbilical arteries are identified close to the abdominal inguinal ring and the peritoneum is incised just laterally to them. The umbilical arteries are then isolated up to the deep iliac artery. At this step the ureters are easily detected just medially to the origin of the umbilical arteries (Fig. 3). The umbilical arteries are clamped where they emerge from the internal iliac arteries between surgical endoscopy clips and cut. The ureters are isolated as distally as possible, clamped between surgical endoscopy clips and cut. The distal ureteral margins are sent for frozen section evaluation Endopelvic fascia incision and dorsal vein complex control At this point the anterior peritoneum is incised lateral to the umbilical arteries up to the umbilicus (Fig. 2). The umbilical arteries and the uracus are divided in the midline. The prevesical space is entirely opened and the bladder is dissected from the anterior abdominal wall. With a combination of sharp and blunt dissection, the space between the lateral wall of the bladder and pelvic side wall is developed until reaching the endopelvic fascia on both side. The endopelvic fascia is incised on its line of reflection and the lateral surface of the prostate is separated from the levator ani muscle to carefully isolate the dorsal vein complex and the prostatic apex. A number zero absorbable stitch is passed and the dorsal vein complex is ligated to guarantee good hemostasis Vesical and prostatic fibrovascular pedicles incision At this time the first assistant pulls the bladder upward and towards the right side of the pelvis by using a grasper with the left hand while in the meantime with the right hand he pushes with the suction canula downward the rectum in order to expose the left vesico-prostatic pedicle. Using a harmonic scalpel and bipolar forceps the vesical and prostatic fibrovascular pedicles are progressively coagulated and divided (Fig. 4). Then, the bladder is pulled by the surgeon on the left side while the suction canula continues to push downward the rectum in order to expose the right vascular pedicle, progressively coagulated and divided Apex incision At this point the vesico-prostatic complex is still fixed to the pelvic floor by the deep dorsal vein complex and the urethra. The dorsal vein complex is then divided and the anterior urethral wall is incised, close to the prostatic parenchyma in order to mantain intact the puboprostatic ligaments and an adequate urethral stump, if an orthotopic is planned. The distal end of the catheter is ligated, transected and pulled into the abdominal cavity, maintaining the balloon inflated in the bladder to avoid intra-abdominal urine contamination. The posterior wall of the urethra is divided. The rectourethralis muscle and the distal insertions of Denonvilliers fascia are incised, totally releasing the specimen. The specimen is immediately entrapped in an endoscopy bag Lymphadenectomy and speciment extraction A bilateral pelvic lymphadenectomy is then performed. The boundaries of dissection are laterally to the external iliac artery, Fig. 3. The left vasa deferent (LVD) is first isolated and transected at its emerging from the deep inguinal ring. Then, following downward the umbilical artery (UA) to its origin, the left ureter (LU) is detected just medially to it in close contact to the deep iliac artery. At this time with a careful blunt dissection, the superior vesical artery (SVA) and the inferior vesical artery (IVA) are also found and isolated. Fig. 4. While the suction device pulls up the vesico-prostatic complex, the vesico-prostatic pedicles are dissected by the use of a harmonic scalpel. The picture illustrates that at this moment the vesico-prostatic complex is fixed to the pelvis by just the urethra anteriorly and the pedicles laterally and no other vascular structures are present in between. Also shown are the umbilical arteries that had been transected at their proximal and distal ends and lie upon the bladder covered by a flap of peritoneum.

4 A. Simonato et al. / European Urology 44 (2003) posteriorly to the hypogastric artery, distally to the inguinal ligament and proximally to the common iliac artery. Once lymphadenectomy is completed, lymph nodes are secured inside an endoscopic bag. A 5 cm midline skin incision of the abdominal wall starting 1 cm above the umbilicus is then made to extract the specimen, leaving in place the five trocars to perform later the urinary diversion (Fig. 1). 3. Results Our results are summarized in Table 2. We performed 6 orthotopic ileal s with a combined technique [12], 2 sigmoid ureterostomies performed completely intracorporeally after specimen extraction and 2 cutaneous ureterostomies. In all cases no conversion to open surgery was necessary and previous abdominal surgery had no influence on the surgical procedure. We did not observe intraoperative and early postoperative complications. The mean time of the overall procedure was 425 minutes for the orthotopic ileal, 345 minutes for the sigmoid and 280 minutes for the cutaneous. The mean time to perform the laparoscopic radical cystoprostatectomy, including the lymph node dissection, was 166 minutes (range ). Mean estimated blood loss was 310 ml (range ). Postoperatively pain required intramuscolar morphine during the first postoperative night and just minor analgesics for next 2 3 days. The patients were ambulant between the 1st and the 3rd postoperative day and recovered bowel activity during the 2nd and the 4th postoperative day. They began food intake 1 2 days later. The drains were removed on days 2 and 6. The ureteral stents were removed on day 7 8, after follow up radiography. The patients with orthotopic s were discharged with an indwelling catheter, which was removed 7 days later. Mean hospital stay was 8.1 days (range 7 to 9) for ileal orthotopic, 8 days (range 7 to 9) for sigmoid and 5 days for cutaneous. Histopathology revealed 2 pt1n0 G3 plus carcinoma in situ, 1 pt2an0 G3 plus carcinoma in situ, 1 pt2bn0 G2, 4 pt2bn0 G2 3,1pT2bN0G3,1 pt3an0 G3 with surgical margins tumor free. The mean follow up is 12.3 months (range 5 to 18) Biochemical tests, including creatinine, blood urea nitrogen, electrolytes, blood gas analyses, urinalysis and urine culture, performed after 3 and 6 months showed no metabolic alterations, renal failure or infection in 8 patients. Urography revealed grade 2 bilateral hydronephrosis and grade 1 monolateral hydronephrosis respectively in 2 patients with orthotopic s. Grade 3 bilateral hydronephrosis was revealed in a patient after sigmoid. The two patients with bilateral hydronephrosis had metabolic acidosis well controlled by oral sodium bicarbonate administration. Two patients respectively with stage T2bN0 G2 3 and stage pt1n0 (plus carcinoma in situ) G3 transitional cell carcinoma and surgical margins tumor free are alive with diffusive Table 2 Results of present series Patient (No.) Age (years) Urinary diversion ptnm Grading Overall operative time (minutes) Cystoprostatectomy operative time (minutes) Estimated blood loss (ml) Ileus (days) Hospital stay (days) Follow up (months) Status 1 74 Cutaneous 2 63 Sigmoid 3 72 Cutaneous 4 68 Sigmoid 5 68 Orthotopic ileal 6 70 Orthotopic ileal 7 68 Orthotopic ileal 8 66 Orthotopic ileal 9 72 Orthotopic ileal Orthotopic ileal T2bN0 G Alive, free from T2bN0 G Alive, free from T3aN0 G Alive, free from T1N0 G Alive, free þ Cis from T1N0 G Alive, metastatic þ Cis T2bNo G Alive, free from T2bNo G Alive, free from T2bN0 G Alive, metastatic T2aN0 G Alive, free from þ Cis T2bN0 G Alive, free from

5 136 A. Simonato et al. / European Urology 44 (2003) metastatic after 6 months. The other 8 patients are alive and free from. 4. Discussion Open radical cystectomy requires an abdominal incision with prolonged retraction of the abdominal wall. This maneuver leads to a high level of postoperative pain, often requiring narcotic administration for several days. Consequently patients remain hospitalized with continuous nursing needs for a long time and normal activity is regained only slowly. Several authors [5 9] have demonstrated that laparoscopic cystectomy is feasible with lower morbidity and shorter hospital stay than the open procedure. Laparoscopic surgery has been shown to have many intraoperative and postoperative advantages over open surgery [2 4]. Some authors have reported a lower incidence of postoperative ileus after the laparoscopic approach compared with the open surgery approach, principally because the bowel is manipulated less and fewer narcotics are necessary to control pain postoperatively [12,13]. Laparoscopic surgery is also associated with better preservation of the immune system than open surgery which results in a decreased incidence of infectious complications [14]. Moreover, magnification offered by the optical instrumentation can enable more precise dissection with less blood loss and better preservation of anatomical structures [15]. Laparoscopic cystectomy with different urinary diversions has been reported by multiple investigators [5 12,16,18]. In these reports are especially shown in detail the urinary diversions with less emphasis for the cystectomy s steps. The various published papers [7 12,16] report small series and are comprehensive of radical cystectomies performed in males and females. With our data, laparoscopic radical cystoprostatectomies were performed on 38 patients (Table 3). All authors utilize a transperitoneal approach with 4 [7], 5 [8,10 12,16,18] or 6 [9] ports. Lymphadenectomy was performed before the cystectomy by some authors [7,9], after the cystectomy by others [8,10,12,16,18] or in the middle of the procedure by other investigators [11]. The ureters are isolated without transecting the umbilical arteries by many authors [7 11,16,18]. In our opinion the incision of the umbilical arteries at the origin from to the deep iliac artery creates a better operative space because the bladder is mobilized and is very useful to detect the distal ureter [12,17]. Moreover, the vesical and prostatic fibrovascular pedicles become shorter because the superior vesical artery is a branch of the umbilical artery. At this point, the Fig. 5. Schematic rappresentation of the arterial supply of the bladder: SVA ¼ superior vesical artery that arises from the proximal portion of the umbilical artery and gives branches to the antero-lateral wall of the bladder and to the seminal vesicles; IVA ¼ inferior vesical artery which supplies the lower part of the ureter, the bladder base and seminal vesicles; VPA ¼ vesico-prostatic artery which supplies both the prostate and the seminal vesicles; MRA ¼ middle rectal artery which gives two anterior branches, an ascending branch to the bladder and a descending branch to the prostate; IPA ¼ internal pudendal artery. fibrovascular pedicles are no more than 3 5 cm long and include the inferior vesical arteries, branches of the hypogastric arteries and the posterior vesical arteries, branches of the middle rectal arteries (Fig. 5). The lateral and posterior vascular pedicles of the bladder and prostate are controlled with sequential firings of the Endo-GIA stapler by many authors [7 11,16,18]. Other authors use the harmonic scalpel routinely [12] or sometimes [11]. Sequential firings of the Endo-GIA stapler, in our opinion, result in less precise dissection with improving of costs linked to the procedure and with no substantial reduction in operative time. In our experience the harmonic scalpel with the help of bipolar forceps provided a precise dissection and a perfect control of vascular pedicles. In some reported series [8,10,11,16,18] the vesical and prostatic fibrovascular pedicles are controlled with sequential firings of the Endo-GIA stapler without previous incision of the endopelvic fascia and ligature of dorsal vein complex. In our opinion previous incision of the endopelvic fascia and ligature of dorsal vein complex [9,12] is mandatory to provide adequate space for the fibrovascular pedicles control and so that the remainder of the procedure can be performed in a bloodless field. Some authors [7,8,10,11,16,18] distend the bladder with ml of saline or formalin to allow better access to the prevesical space limiting the risk of a bladder injury with local tumor spillage. In our opinion this maneuver is unnecessary. Moreover, formalin may

6 Table 3 Results of laparoscopic radical cystoprostatectomy Authors Denewer et al. [7] Mansoura, Egypt Gill et al. [8] Cleveland, Ohio Turk et al. [9] Berlin, Germany Gupta et al. [16] New Delhi, India Gill et al. [10] Cleveland, Ohio Abdel-Hakim et al. [11] Cairo, Egypt Present series No. patients Urinary diversion Sigmoid pouch Ileal conduit Sigmoid pouch Ileal conduit 1 Indiana pouch; Orthotopic ileal 2 cutaneous ; 1 orthotopic ileal 2 Sigmoid ; 6 orthotopic ileal Overall operative time (minutes) Mean 160 plus 55 for diversion Cystoprostatectomy plus Not stated Not stated Not stated Not stated lymphadenectomy operative time (minutes) Estimated blood Not stated loss (ml) Ambulation (days) Not stated 2 Not stated Not stated 1 3 Ileus (days) Not stated Hospital stay (days) Not stated 5 9 Complications 1 external iliac artery injury; 1 Gastrointestinal 2 bilateral hydronephrosis; 1 death (disseminated intravascular coagulation); bleeding 1 monolateral hydronephrosis 1 urinary leakage; 1 deep venous thrombosis; 1 pelvic collection plus upper urinary tract infection Note 7/9 men underwent salvage cystectomy after radiotherapy 1 death for metastatic? (not stated follow up and gender) 2 metastatic s after 6 months A. Simonato et al. / European Urology 44 (2003)

7 138 A. Simonato et al. / European Urology 44 (2003) be dangerous in case of urine spillage. Equipment for laparoscopic radical cystoprostatectomy requires few instruments, listed in Table 1. Our technique provides an anatomic approach, familiar to most urologists and anatomical landmarks are easy to follow. Our goal was to transfer the technical steps that we usually use in our open technique. Differences with the open access are the immediate transperitoneal approach, dissection of the seminal vesicles, Denonvilliers fascia incision and lymphadenectomy after the cystoprostatectomy. Patients treated with our technique benefit of all the advantages associated with laparoscopic surgery. The advantages of the laparoscopic approach are not reduced by the external reconstruction of a urinary diversion performed through a mini-laparotomy [11,12]. We believe that this technique is easily reproducible and indicated for patients affected by clinically organ-confined invasive bladder cancer. The indications and contraindications for this operation are those for abdominal laparoscopy [19]. We believe that specific contraindications are a large volume neoplasms and a high volume benign prostatic hyperplasia. In these cases operating space is reduced and laparoscopic maneuvers are more difficult. Moreover, the vesical and prostatic fibrovascular pedicles are less clearly visualized so that the procedure could be completed only by a demanding retrograde approach. 5. Conclusions Radical cystectomy remains the gold standard for muscle invasive bladder cancer and high risk superficial tumors resistant to intravesical therapy and a laparoscopic approach can reproduce open surgery. Laparoscopic cystoprostatectomy with our technique is a feasible, fast, safe and easy procedure. Laparoscopic radical cystectomy is still an operation for pioneers but in our opinion this procedure may be not strictly relegated to a few academic centers. Urinary diversion may be performed with a laparoscopic, open or combined approach: in our opinion, the advantages of laparoscopic cystoprostatectomy are not reduced by an open or a combined approach for the urinary diversion. The initial reports are encouraging but additonal work and a strict follow up are necessary to compare critically the oncological outcome with open surgery and to make final conclusions. References [1] Dalbagni G, Genega E, Hashibe M, Zhang ZF, Russo P, Herr H, et al. Cystectomy for bladder cancer: a contemporary series. J Urol 2001;165(4): [2] Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris experience. J Urol 2000;163(2): [3] Breda G, Nakada SY, Rassweiler JJ. Future developments and perspectives in laparoscopy. Eur Urol 2001;40(1): [4] Schulam PG. Editorial: new laparoscopic approaches. J Urol 2001;165(6 Pt 1):1967. [5] Puppo P, Perachino M, Ricciotti G, Bozzo W, Gallucci M, Carmignani G. Laparoscopically assisted transvaginal radical cystectomy. Eur Urol 1995;27(1):80 4. [6] Sanchez de Badajoz E, Gallego Perales JL, Reche Rosado A, Gutierrez de la Cruz JM, Jimenez Garrido A. Laparoscopic cystectomy and ileal conduit: case report. J Endourol 1995;9(1): [7] Denewer A, Kotb S, Hussein O, El-Maadawy M. Laparoscopic assisted cystectomy and lymphadenectomy for bladder cancer: initial experience. World J Surg 1999;23(6): [8] Gill IS, Fergany A, Klein EA, Kaouk JH, Sung GT, Meraney AM, et al. Laparoscopic radical cystoprostatectomy with ileal conduit performed completely intracorporeally: the initial 2 cases. Urology 2000;56(1):26 9. [9] Turk I, Deger S, Winkelmann B, Schonberger B, Loening SA. Laparoscopic radical cystectomy with continent urinary diversion (rectal sigmoid pouch) performed completely intracorporeally: the initial 5 cases. J Urol 2001;165(6 Pt 1): [10] Gill IS, Kaouk JH, Meraney AM, Desai MM, Ulchaker JC, Klein EA, et al. Laparoscopic radical cystectomy and continent orthotopic ileal performed completely intracorporeally: the initial experience. J Urol 2002;168(1):13 8. [11] Abdel-Hakim AM, Bassiouny F, Abdel Azim MS, Rady I, Mohey T, Habib I, et al. Laparoscopic radical cystectomy with orthotopic. J Endourol 2002;16(6): [12] Gaboardi F, Simonato A, Galli S, Lissiani A, Gregori A, Bozzola A. Minimally invasive laparoscopic. J Urol 2002;168(3): [13] Maxwell-Armstrong CA, Robinson MH, Scholefield JH. Laparoscopic colorectal cancer surgery. Am J Surg 2000;179(6): [14] Targarona EM, Balague C, Knook MM, Trias M. Laparoscopic surgery and surgical infection. Br J Surg 2000;87(5): [15] Steinberg AP, Gill IS. Laparoscopic radical prostatectomy: progress, problems, and promise. Contemporary Urology 2002;5: [16] Gupta NP, Gill IS, Fergany A, Nabi G. Laparoscopic radical cystectomy with intracorporeal ileal conduit diversion: five cases with a 2-year follow-up. BJU Int 2002;90(4): [17] Wood DP. Editorial comment: Laparoscopic radical cystectomy with urinary diversion: completely intracorporeal technique. J Endourol 2002;16(6):341. [18] Matin SF, Gill IS. Laparoscopic radical cystectomy with urinary diversion: completely intracorporeal technique. J Endourol 2002; 16(6): [19] Peters CA, Kavoussi LR. Laparoscopy in children and adults. In Walsh PC, Retik AB, Vaughan Jr ED, editors. Campbell s Urology. Philadelphia: W.B. Saunders Company; 1998, p