1. Laparoscopic Radical Cystectomy in Catholic University Experience
Department of Urology, Kangnam St. Mary’s Hospital
The Catholic University of Korea, College of Medicine
Yoo Shin Ha

2. Encourage to explore the role of
Introduction
Radical cystectomy :
the gold standard for M. invasive or high risk bladder cancer
Laparoscopic surgery :
expanding
now applied to treat neoplasm of the pelvic organ
Excellent perioperative & long-term results in RCC, Prostate ca. .
Encourage to explore the role of
laparoscopy in bladder ca. .

3. To define the role of laparoscopic radical cystectomy ?
The main problems to solve
Technical difficulty
Urinary diversion method
intracorporeally ? or extracorporeally ?
Oncologic risk , replicating the outcome of open surgery ? .
To overcoming these problems, We would like to share
our experience with LRC in 36 cases, since june 2003, .

4. The steps of operations
Pathogenesis
The steps of operations
Port placement
Camera port
Marking incision site
for specimen removal
5-port fan-shaped
transperitoneal approach

5. Mobilization & division of the ureters
Important landmarks
Medial umbilical lig.
Vas
Rectovesical pouch
Iliac vessels
Incision of Peritoneum
dissection down to the
UVJ
isolation of ureter
as distally as possible
Frozen biopsy . .

6. Posterior dissection Transverse peritoneotomy at arch of douglas pouch
Developing plane Between
SV, prostate and the rectum
Denonvilliers’ fascia
Prerectal fat .
Incision of the peritoneum at the arch of the douglas pouch and dissecting down to the S.V
The S.V & Vas are easily reached and
With S.V & Vas retracted the plane between S.V Prostate and rectum are developed and expose expose the denovillier’s 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 .

7. Anterior dissection Bladder is filled with saline . .
starting lateral to medial
umbilical lig.
divide urachus
the prevesical space is opened . .

8. Endopelvic fascia incision & DVD control
Exposure of endopelvic fascia
Incision on line of reflection
Separation 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 V
Divide the vesical & prostatic
fibrovascular pedicles
Sono-surg and Hem-o-lok clip . .

10. Apex dissection divide the DVC & expose urethra . .
To prevent contamination ,
occlude the urethra
divide the urethra & posterior
attachment . .

11. Extended PLND Ant. to Ext. iliac artery and . .
medial to genitofemoral N.
along the Ext. iliac vein
and the medial side of
pelvic wall
Obturator N.
Along the common iliac A.
up to the aortic bifurcation . .

12. Extracorporeal urinary diversion
through incision for speciemen
removal
GIA stappler
ileal conduit or ileal neobladder
is made in the usual manner
4th port expanded for stoma . .

14. Result LRC : 36 patients Male 32, Female 4
June 2003 – MAY 2008
LRC : 36 patients
Male 32, Female 4
Mean 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 cases
Mean 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 laparoscopically
without conversion & complications
no rectal injury
no major vessel injury
Early complications (<30 days)
Patients (n)
Ileus
Intestinal obstruction
Stoma site stricture
Urine leakage
Wx. Problem 6
1 (small intestine segmentectomy) 2
1 (W-neobladder) 3
Late complications (> 30 days)
Ureterointestinal stricture
Lymphocele 1
All 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 surgically
Late 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 diversion
Constructed extracorporeally through the same incision
Diversion : Ileal conduit 32 patients
W-neobladder 3 (open conversion 2)
Y-neobladdr 1 (open conversion 1)
Ileal conduit
W-neobladder
Y-neobladder
caudal
cranial
In 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 diversion
We performed 32 ileal conduits and 4 orthotopic neobladders
But 3 of orthotopic neobladder cases were converted to open anastomosis because of technical difficulty in urethroneovesical anastomosis
opening
opening

18. Campbell-Walsh urology 9th ed.
Urethrectomy
Indications : carcinomatous involvement of the urethra,
typically prostatic urethra
High risk of urethral recurrence
Campbell-Walsh urology 9th ed.
involvement of the prostatic urethra
multifocal disease
the presence of carcinoma in situ (CIS)
involvement of the bladder neck
upper tract TCC
Urol Clin North Am 2005;32:

19. Urethrectomy in catholic experience
Of total 36 patients, 17 cases of total urethrectomy was done
In 17 cases
Positive margin of urethra : 4 cases
involvement of the bladder neck : 9 cases
the presence of carcinoma in situ (CIS) : 1 cases
involvement of the prostatic urethra : 3 cases

20. Pathological outcomes
Histopathological stage
variables
pTa
pT1
pT2
pT3a
pT3b
pT4 3 8 12 7 2 4
pN classification
pN0
pN+ 29
Positive surgical margins
Among total 36 cases, distant metastasis - 7 cases
Local recurrence – 2 cases

21. Standard PLND vs Extended PLND
lymphatic tissue of
common iliac V and
up to aortic bifurcation
More accurate staging
Therapeutic benefit
Extended 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 PLND
Urol Steven K, Poulsen AL J Urol 2007
Mills et al ; Surg Oncol Clin N Am 2007

22. Extended PLND in catholic experience after 25th case
No.
Stage
Harvested L/N
Positive L/N
Standard
Extended 1
25th
T2bN0M0 14 - 2
26th
TaN0M0 18 3
27th
T4N1M0 20
Ext. iliac &
obturator, Rt
Presacral 4
29th 26
Obturator, Lt.
Common iliac, Rt. 5
33th 12 6
34th
T3N0M0 7
35th
T1N0M0
+ CIS 8
36th
T2N0M0 13
Standard PLND – 12.8 (4 - 22)
Extended PLND – 16.9 ( )

23. Dis. Specific survival (%) Recur-free survival (%)
Oncological outcomes n
F/U period (month)
Overall survival (%)
Dis. Specific survival (%)
Recur-free survival (%)
comment
Stein
1054 60 66 68
Open cystectomy
Cathelineau 84
18 (1-44)
100 83
Hemal 48
38 (10-72) 73
3 yr f/u
Gill 37
31 (1-66) 63 92
5 yr f/u
Catholic 21
29 (3-51) 71 86 76
Over 2 yr f/u
Long 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 cases
Recently, 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 RC
In 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 experience
oncological efficacy comparable to other reports of LRC
possible to replicate oncologic results of ORC
Long term (over 5 yrs) oncologic survey
Large scale survey

24. The main problems to define the role LRC
CONCLUSION ;
The main problems to define the role LRC
Technical difficulty
Urinary diversion method
Laparoscopic radical cystectomy is technically feasible .
Extracorporeal urinary diversion with small incision
maintains the benefits of laparoscopy
safe and effective method
providing comparable perioperative and functional outcomes
as open suregery
Oncologic 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’ experiences
including catholic university may suggest the possiblity of
replicating oncological outcomes of ORC
Large number and long-term oncologic data is required to
document long term cancer control with LRC . .

26. Thanks for your attention. .