Department of Urology, Kangnam St. Mary’s Hospital Department of Urology, Kangnam St. Mary’s Hospital

The Catholic University of Korea, College of MedicineThe Catholic University of Korea, College of Medicine

Yoo Shin HaYoo Shin Ha

Laparoscopic Radical Cystectomy in Catholic University Experience

Radical cystectomy : the gold standard for M. invasive or high risk bladder cancer

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Laparoscopic surgery :

expanding

now applied to treat neoplasm of the pelvic organ

Excellent perioperative & long-term results in RCC, Prostate ca.

IntroductionIntroduction

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 ? .

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To define the role of laparoscopic radical cystectomy ?To define the role of laparoscopic radical cystectomy ?To define the role of laparoscopic radical cystectomy ?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 operationsThe steps of operations Port placement Port 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.

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• Incision of Peritoneum

• dissection down to the

UVJ

• isolation of ureter

as distally as possible

• Frozen biopsy

Mobilization & division of the uretersMobilization & division of the uretersMobilization & division of the uretersMobilization & division of the ureters

• Transverse peritoneotomy

at arch of douglas pouch

• Developing plane Between

SV, prostate and the rectum

• Denonvilliers’ fascia

• Prerectal fat

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Posterior dissectionPosterior dissectionPosterior dissectionPosterior dissection

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Anterior dissectionAnterior dissectionAnterior dissectionAnterior 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 controlEndopelvic fascia incision & DVD controlEndopelvic fascia incision & DVD controlEndopelvic 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 dissectionLateral dissectionLateral dissectionLateral 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 dissectionApex dissectionApex dissectionApex dissection

• divide the DVC & expose urethra

• To prevent contamination ,

occlude the urethra

• divide the urethra & posterior

attachment

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Extended PLNDExtended PLNDExtended PLNDExtended 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 Extracorporeal urinary diversion Extracorporeal urinary diversion 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

• 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)

Result Result

Perioperative characteristicsPerioperative characteristicsPerioperative characteristicsPerioperative 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

Perioperative complicationsPerioperative complicationsPerioperative complicationsPerioperative 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 opening

Ileal conduit W-neobladder

Y-neobladder

caudal cranial

Diversion : Ileal conduit 32 patients

W-neobladder 3 (open conversion 2)

Y-neobladdr 1 (open conversion 1)

Urinary diversionUrinary diversionUrinary diversionUrinary diversion

Constructed extracorporeally through the same incision

UrethrectomyUrethrectomy Indications : carcinomatous involvement of

the urethra, typically prostatic urethra

High risk of urethral recurrence

Campbell-Walsh urology 9th ed.

1. involvement of the prostatic urethra2. multifocal disease3. the presence of carcinoma in situ (CIS) 4. involvement of the bladder neck

5. upper tract TCC Urol Clin North Am 2005;32:199-206

Urethrectomy in catholic Urethrectomy in catholic experience experience

Of total 36 patients, 17 cases of total urethrectomy was done

In 17 cases

1. Positive margin of urethra : 4 cases2. involvement of the bladder neck : 9 cases3. the presence of carcinoma in situ (CIS) : 1

cases4. involvement of the prostatic urethra : 3

cases

Pathological outcomesPathological outcomesPathological outcomesPathological outcomes

Histopathological stage variables

pTapT1pT2

pT3apT3bpT4

38

12724

pN classification

pN0 pN+

297

Positive surgical margins 0

Among total 36 cases, distant metastasis - 7 cases Local recurrence – 2 cases

Standard PLND vs Extended Standard PLND vs Extended PLNDPLND

Urol Steven K, Poulsen AL J Urol 2007Mills 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 Extended PLND in catholic experienceexperience

after 25after 25thth case caseNo.

StageHarveste

d L/N

Positive L/N

Standard Extended

1 25th T2bN0M0 14 - -

2 26th TaN0M0 18 - -

3 27th T4N1M0 20Ext. iliac &

obturator, RtPresacral

4 29th T4N1M0 26Obturator,

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)

Oncological outcomesOncological outcomesOncological outcomesOncological outcomes

nF/U period

(month)

Overall survival

(%)

Dis. Specific survival (%)

Recur-free survival (%)

comment

Stein 1054 60 66 68Open

cystectomy

Cathelineau 84 18 (1-44) 100 100 83

Hemal 4838 (10-

72)73 73 3 yr f/u

Gill 37 31 (1-66) 63 92 92 5 yr f/u

Catholic 2129 (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 surveyLarge scale survey

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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 !!

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• 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 !!

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Thanks for your attention