Department of Urology, Kangnam St. Mary

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

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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.

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Encourage to explore the role of laparoscopy in
bladder ca.
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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 ?

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To overcoming these problems, We would like to
share our experience with LRC in 36 cases, since
june 2003,
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Pathogenesis
The steps of operations
Port placement


Camera port
Marking incision site for specimen removal
5-port fan-shaped transperitoneal approach
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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

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Posterior dissection

• Transverse peritoneotomy
• at arch of douglas pouch
• Developing plane Between
• SV, prostate and the rectum
• Denonvilliers fascia
• Prerectal fat

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Anterior dissection

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

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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)

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Lateral dissection

• Retracting bladder medially
• away to the ext. iliac V
• Divide the vesical prostatic
• fibrovascular pedicles
• Sono-surg and Hem-o-lok clip

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Apex dissection

• divide the DVC expose urethra
• To prevent contamination ,
• occlude the urethra
• divide the urethra posterior
• attachment

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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

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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

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Result

• June 2003 MAY 2008
• LRC 36 patients
• Male 32, Female 4
• Mean age (SD) 67.35 ( 10.1)
• Mean BMI (SD) 23.2 ( 2.4)

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Perioperative characteristics

• Mean total operative time (SD) 573.9 (
  108.0)

• Ileal conduit group 557.7 ( 98.9)
• Neobladder group 698.8 ( 104.3)

• Mean estimated blood loss (SD) 709.5 (
  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

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Perioperative complications
Early complications (lt30 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 (gt 30 days)
Ureterointestinal stricture Lymphocele 2 1
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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)
opening
opening
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Urethrectomy

• Indications carcinomatous involvement of the
  urethra,
• typically prostatic
  urethra
• High risk of urethral recurrence

Campbell-Walsh urology 9th 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 200532199-206
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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

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Pathological outcomes
Histopathological stage variables
pTa pT1 pT2 pT3a pT3b pT4 3 8 12 7 2 4
pN classification
pN0 pN 29 7
Positive surgical margins 0
Among total 36 cases, distant metastasis - 7
cases
Local recurrence 2 cases
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Standard PLND vs Extended PLND

• lymphatic tissue of
• common iliac V and
• up to aortic bifurcation
• More accurate staging
• Therapeutic benefit

Urol Steven K, Poulsen AL J Urol 2007 Mills et al
Surg Oncol Clin N Am 2007
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Extended PLND in catholic experienceafter 25th
case
No. Stage Harvested L/N Positive L/N Positive L/N
No. Stage Harvested L/N Standard Extended
1 25th T2bN0M0 14 - -
2 26th TaN0M0 18 - -
3 27th T4N1M0 20 Ext. iliac obturator, Rt Presacral
4 29th T4N1M0 26 Obturator, Lt. Common iliac, Rt.
5 33th T4N1M0 12 - -
6 34th T3N0M0 14 - -
7 35th T1N0M0 CIS 20 - -
8 36th T2N0M0 13 - -
Standard PLND 12.8 (4 - 22) Extended PLND
16.9 (12 - 26)
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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) 100 100 83
Hemal 48 38 (10-72) 73 73 3 yr f/u
Gill 37 31 (1-66) 63 92 92 5 yr f/u
Catholic 21 29 (3-51) 71 86 76 Over 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
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CONCLUSION The main problems to define the
role LRC

• Technical difficulty
• Urinary diversion method

Laparoscopic radical cystectomy is technically
feasible
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• Extracorporeal urinary diversion with small
  incision
• maintains the benefits of laparoscopy
• safe and effective method
• providing comparable perioperative and
  functional outcomes
• as open suregery

1. Oncologic risk , replicating the outcome of open
   surgery ?

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Need for technical advance for orthotopic
neobladder !!
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1. 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

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Thanks for your attention
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