Presentation on theme: "Laparoscopic Radical Cystectomy in Catholic University Experience"— Presentation transcript:
1 Laparoscopic Radical Cystectomy in Catholic University Experience Department of Urology, Kangnam St. Mary’s HospitalThe Catholic University of Korea, College of MedicineYoo Shin Ha
2 Encourage to explore the role of IntroductionRadical cystectomy :the gold standard for M. invasive or high risk bladder cancerLaparoscopic surgery :expandingnow applied to treat neoplasm of the pelvic organExcellent perioperative & long-term results in RCC, Prostate ca..Encourage to explore the role oflaparoscopy in bladder ca..
3 To define the role of laparoscopic radical cystectomy ? The main problems to solveTechnical difficultyUrinary diversion methodintracorporeally ? or extracorporeally ?Oncologic risk , replicating the outcome of open surgery ?.To overcoming these problems, We would like to shareour experience with LRC in 36 cases, since june 2003,.
4 The steps of operations PathogenesisThe steps of operationsPort placementCamera portMarking incision sitefor specimen removal5-port fan-shapedtransperitoneal approach
5 Mobilization & division of the ureters Important landmarksMedial umbilical lig.VasRectovesical pouchIliac vesselsIncision of Peritoneumdissection down to theUVJisolation of ureteras distally as possibleFrozen biopsy..
6 Posterior dissection Transverse peritoneotomy at arch of douglas pouch Developing plane BetweenSV, prostate and the rectumDenonvilliers’ fasciaPrerectal fat.Incision of the peritoneum at the arch of the douglas pouch and dissecting down to the S.VThe S.V & Vas are easily reached andWith S.V & Vas retracted the plane between S.V Prostate and rectum are developed and expose expose the denovillier’s fasciaThe Denonvilliers’ fascia is incised horizontally, exposing the prerectal fat.The anterior surface of the rectum is then dissected up to the prostatic apex.
7 Anterior dissection Bladder is filled with saline . . starting lateral to medialumbilical lig.divide urachusthe prevesical space is opened..
8 Endopelvic fascia incision & DVD control Exposure of endopelvic fasciaIncision on line of reflectionSeparation from the levator ani M.Suture of DVC (3-0 PDS).The space of Retzius is developed behind the pubic bone. Loose areolar tissue is dissected away to expose the anterior surface of the prostate and the endopelvic fascia on each side. The endopelvic fascia is incised on its line of reflection and the lateral surface of the prostate was separated from the levator ani muscle, and down to the region of the dorsal venous complex (DVC).The DVC is suture ligated to guarantee good hemostatis.
9 Lateral dissection Retracting bladder medially . . away to the ext. iliac VDivide the vesical & prostaticfibrovascular pediclesSono-surg and Hem-o-lok clip..
10 Apex dissection divide the DVC & expose urethra . . To prevent contamination ,occlude the urethradivide the urethra & posteriorattachment..
11 Extended PLND Ant. to Ext. iliac artery and . . medial to genitofemoral N.along the Ext. iliac veinand the medial side ofpelvic wallObturator N.Along the common iliac A.up to the aortic bifurcation..
12 Extracorporeal urinary diversion through incision for speciemenremovalGIA stapplerileal conduit or ileal neobladderis made in the usual manner4th port expanded for stoma..
14 Result LRC : 36 patients Male 32, Female 4 June 2003 – MAY 2008LRC : 36 patientsMale 32, Female 4Mean age (SD) : (± 10.1)Mean BMI (SD) : 23.2 (± 2.4) Between June 2003 and May 2008, Total 36 patients including 4 womaunderwent laparoscopic radical cystectomy with urinary diversion. mean age is 67 years.
15 Perioperative characteristics Mean total operative time (SD) : (± 108.0)Ileal conduit group : (± 98.9)Neobladder group : (± 104.3)Mean estimated blood loss (SD) : (± 496.1)Days to ambulation : 4.1 days (3-5)Days to oral intake : 4.5 days (2-6)Post-op hospital stay : 12.8 days (7-26)Urethrectomy : 17 casesMean operating time was 570 min. the operating time of neobladder group was longer than ileal conduit group.Mean estimated blood loss was about 700 mL (range 400–1050).Mean days to ambulation and oral intak was 4.1 days and 4.5 days, respectively.Mean hospital stay was 12.8 days (range 7–28).In 17 cases urethrectomy was
16 Perioperative complications Cystectomy and PLND could be completed laparoscopicallywithout conversion & complicationsno rectal injuryno major vessel injuryEarly complications (<30 days)Patients (n)IleusIntestinal obstructionStoma site strictureUrine leakageWx. Problem61 (small intestine segmentectomy)21 (W-neobladder)3Late complications (> 30 days)Ureterointestinal strictureLymphocele1All schedulled patients underwent cystectomy and PLND laparoscopic assisted, without open conversion and intraoperative complication including rectal injury and maor vessel injury,Early complications (earlier than 1 month) were observed in 13 patients; most common Cx. Was ileus and intestine obstruction was 1 patient, who was managed surgicallyLate complications (longer than 1 month) were observed in 3 patiets, stricture of ureterointestinal anastomosis site was developed in 2 patients,
17 Constructed extracorporeally through the same incision Urinary diversionConstructed extracorporeally through the same incisionDiversion : Ileal conduit 32 patientsW-neobladder 3 (open conversion 2)Y-neobladdr 1 (open conversion 1)Ileal conduitW-neobladderY-neobladdercaudalcranialIn all patients who underwent radical cystectomy, the urinary diversion have been constructred extracorporeally.Through the same incision for speciemen removal, ileum was extracted and selected for diversionWe performed 32 ileal conduits and 4 orthotopic neobladdersBut 3 of orthotopic neobladder cases were converted to open anastomosis because of technical difficulty in urethroneovesical anastomosisopeningopening
18 Campbell-Walsh urology 9th ed. UrethrectomyIndications : carcinomatous involvement of the urethra,typically prostatic urethraHigh risk of urethral recurrenceCampbell-Walsh urology 9th ed.involvement of the prostatic urethramultifocal diseasethe presence of carcinoma in situ (CIS)involvement of the bladder neckupper tract TCCUrol Clin North Am 2005;32:
19 Urethrectomy in catholic experience Of total 36 patients, 17 cases of total urethrectomy was doneIn 17 casesPositive margin of urethra : 4 casesinvolvement of the bladder neck : 9 casesthe presence of carcinoma in situ (CIS) : 1 casesinvolvement of the prostatic urethra : 3 cases
21 Standard PLND vs Extended PLND lymphatic tissue ofcommon iliac V andup to aortic bifurcationMore accurate stagingTherapeutic benefitExtended PLND remove the lymphatic tissue of common iliac vessel, added to the boundary of standard PLND.In addition to accurate staging, Recent reports suggest the therapeutic benefit of the extended PLNDUrol Steven K, Poulsen AL J Urol 2007Mills et al ; Surg Oncol Clin N Am 2007
22 Extended PLND in catholic experience after 25th case No.StageHarvested L/NPositive L/NStandardExtended125thT2bN0M014-226thTaN0M018327thT4N1M020Ext. iliac &obturator, RtPresacral429th26Obturator, Lt.Common iliac, Rt.533th12634thT3N0M0735thT1N0M0+ CIS836thT2N0M013Standard PLND – 12.8 (4 - 22)Extended PLND – 16.9 ( )
23 Dis. Specific survival (%) Recur-free survival (%) Oncological outcomesnF/U period (month)Overall survival (%)Dis. Specific survival (%)Recur-free survival (%)commentStein1054606668Open cystectomyCathelineau8418 (1-44)10083Hemal4838 (10-72)733 yr f/uGill3731 (1-66)63925 yr f/uCatholic2129 (3-51)718676Over 2 yr f/uLong term f/u data after ORC are well documented, but long term oncologic data of LRC are not yet available, and under survey.Only short and intermediate oncologic follow up results are available, which were very small enrolled casesRecently, the only one oncologic result of 5 yr f/u after LRC was reported by gill’ group, and this data suggest that LRC provides oncological outcomes comparable to open RCIn catholic cases, Of 20 patients who had follow up exceeding 2 yrs, the oveall survival and recurrence free survival rate is over 70 %In catholic experienceoncological efficacy comparable to other reports of LRCpossible to replicate oncologic results of ORCLong term (over 5 yrs) oncologic surveyLarge scale survey
24 The main problems to define the role LRC CONCLUSION ;The main problems to define the role LRCTechnical difficultyUrinary diversion methodLaparoscopic radical cystectomy is technically feasible.Extracorporeal urinary diversion with small incisionmaintains the benefits of laparoscopysafe and effective methodproviding comparable perioperative and functional outcomesas open suregeryOncologic risk , replicating the outcome of open surgery ?.Need for technical advance for orthotopic neobladder !!
25 Oncologic risk , replicating the outcome of open surgery ? Not yet !!Oncological outcomes from several centers’ experiencesincluding catholic university may suggest the possiblity ofreplicating oncological outcomes of ORCLarge number and long-term oncologic data is required todocument long term cancer control with LRC..