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Laparoscopic Radical Cystectomy in Catholic University Experience

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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 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
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