Presentation on theme: "Department of Urology, Kangnam St. Mary’s Hospital The Catholic University of Korea, College of Medicine Yoo Shin Ha Laparoscopic Radical Cystectomy in."— Presentation transcript:
Department of Urology, Kangnam St. Mary’s Hospital The Catholic University of Korea, College of Medicine Yoo Shin Ha Laparoscopic Radical Cystectomy in Catholic University Experience
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. Introduction Encourage to explore the role of laparoscopy in bladder ca.
The main problems to solve 1.Technical difficulty 2.Urinary diversion method intracorporeally ? or extracorporeally ? 3.Oncologic risk, replicating the outcome of open surgery ?.. To define the role of laparoscopic radical cystectomy ? To overcoming these problems, We would like to share our experience with LRC in 36 cases, since june 2003,
Pathogenesis The steps of operations P ort placement 5-port fan-shaped transperitoneal approach Marking incision site for specimen removal Camera port
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 Mobilization & division of the ureters
Transverse peritoneotomy at arch of douglas pouch Developing plane Between SV, prostate and the rectum Denonvilliers’ fascia Prerectal fat.. Posterior dissection
.. Anterior dissection Bladder is filled with saline starting lateral to medial umbilical lig. divide urachus the prevesical space is opened
.. 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)
.. Lateral dissection Retracting bladder medially away to the ext. iliac V Divide the vesical & prostatic fibrovascular pedicles Sono-surg and Hem-o-lok clip
.. Apex dissection divide the DVC & expose urethra To prevent contamination, occlude the urethra divide the urethra & posterior attachment
.. 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
.. Extracorporeal urinary diversion through incision for speciemen removal GIA stappler ileal conduit or ileal neobladder is made in the usual manner 4 th port expanded for stoma
June 2003 – MAY 2008 LRC : 36 patients Male 32, Female 4 Mean age (SD) : (± 10.1) Mean BMI (SD) : 23.2 (± 2.4 ) Result
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
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 2 1
opening Ileal conduitW-neobladderY-neobladder caudal cranial Diversion : Ileal conduit 32 patients W-neobladder 3 (open conversion 2) Y-neobladdr 1 (open conversion 1) Urinary diversion Constructed extracorporeally through the same incision
Urethrectomy Indications : carcinomatous involvement of the urethra, typically prostatic urethra High risk of urethral recurrence Campbell-Walsh urology 9 th ed. 1. involvement of the prostatic urethra 2. multifocal disease 3. the presence of carcinoma in situ (CIS) 4. involvement of the bladder neck 5. upper tract TCC Urol Clin North Am 2005;32:
Urethrectomy in catholic experience Of total 36 patients, 17 cases of total urethrectomy was done In 17 cases 1. Positive margin of urethra : 4 cases 2. involvement of the bladder neck : 9 cases 3. the presence of carcinoma in situ (CIS) : 1 cases 4. involvement of the prostatic urethra : 3 cases
Standard PLND vs Extended PLND Urol Steven K, Poulsen AL J Urol 2007 Mills et al ; Surg Oncol Clin N Am 2007 lymphatic tissue of common iliac V and up to aortic bifurcation More accurate staging Therapeutic benefit
Extended PLND in catholic experience after 25th case Extended PLND in catholic experience after 25 th case No.Stage Harvested L/N Positive L/N StandardExtended 125 th T2bN0M th TaN0M th T4N1M0 20 Ext. iliac & obturator, Rt Presacral 429 th T4N1M0 26Obturator, Lt.Common iliac, Rt. 533 th T4N1M th T3N0M th T1N0M0 + CIS th T2N0M Standard PLND – 12.8 (4 - 22) Extended PLND – 16.9 ( )
Oncological outcomes n F/U period (month) Overall survival (%) Dis. Specific survival (%) Recur-free survival (%) comment Stein Open cystectomy Cathelineau 8418 (1-44) Hemal 4838 (10-72)73 3 yr f/u Gill 3731 (1-66) yr f/u Catholic 2129 (3-51)718676Over 2 yr f/u 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
.. 1.Technical difficulty 2.Urinary diversion method Laparoscopic radical cystectomy is technically feasible 3.Oncologic risk, replicating the outcome of open surgery ? CONCLUSION ; The main problems to define the role LRC CONCLUSION ; The main problems to define the role LRC Extracorporeal urinary diversion with small incision maintains the benefits of laparoscopy safe and effective method providing comparable perioperative and functional outcomes as open suregery Need for technical advance for orthotopic neobladder !!
.. 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 3.Oncologic risk, replicating the outcome of open surgery ? Not yet !!