Laparoscopy and Robotics Laparoscopic Radical Cystectomy With Intracorporeal Orthotopic Ileal Neobladder: Technique and Clinical Outcomes Pengfei Shao, Pu Li, Xiaobing Ju, Chao Qin, Jie Li, Qiang Lv, Xiaoxin Meng, and Changjun Yin OBJECTIVE




To study the feasibility and safety of laparoscopic radical cystectomy with intracorporeal orthotopic ileal neobladder and to evaluate the role of endoscopic stapling in neobladder construction. Fifty-five patients with bladder cancer who underwent laparoscopic radical cystectomy were retrospectively examined. Extended pelvic lymph node dissection was performed before cystectomy. An ileal segment of 50 cm was harvested to construct a U-shaped reservoir. The bottom of the reservoir was anastomosed with the posterior urethra. Twenty-five patients underwent neobladder construction by manual suturing and 30 patients by endoscopic stapler suturing. The mean operative time was 346 minutes, and mean neobladder construction time was 230 minutes. The median estimated blood loss was 500 mL, and 17 patients received intraoperative transfusion. Postoperative complications included 2 cases of urine leakage, 7 cases of pyelonephritis, 4 cases of incomplete bowel obstruction, 1 case of anastomotic stricture, and 1 case of death. Endoscopic stapler suturing for neobladder construction took significantly less time than manual suturing. However, neobladder stones were found in 2 patients who underwent operation using endoscopic suturing, and the stones were removed cystoscopically. The functional outcomes of the 2 constructive methods were comparable. Laparoscopic radical cystectomy with intracorporeal orthotopic neobladder is safe and feasible for experienced laparoscopic surgeons. Application of endoscopic stapler simplifies the surgical procedure while increasing the risk of neobladder stone formation. UROLOGY 85: 368e374, 2015.  2015 Elsevier Inc.


pen radical cystectomy (ORC) is the goldstandard treatment for patients with invasive bladder cancer.1,2 This procedure has 3 steps, namely, cystectomy, standard or extended pelvic lymph node dissection (PLND), and urinary diversion. For the former 2 steps, laparoscopic or robotic-assisted surgeries have been applied extensively instead of ORC and have achieved comparable surgical outcomes with ORC.1,3,4 Currently, most urinary diversions are performed extracorporeally because the procedure is complex and time consuming. With improvements in minimally invasive techniques, increasing attention has been focused on

Pengfei Shao and Pu Li have contributed equally to this study. Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China Address correspondence to: Changjun Yin, Ph.D., Department of Urology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China. E-mail: [email protected] Submitted: July 14, 2014, accepted (with revisions): September 29, 2014


ª 2015 Elsevier Inc. All Rights Reserved

intracorporeal urinary diversions, such as ileal conduits and orthotopic ileal neobladder. Orthotopic ileal neobladder is a widely used diversion for localized muscleinvasive bladder cancer; it is advantageous for urinary continence and has good compliance and a large reservoir volume, all of which contribute to better quality of life compared with ileal conduits or cutaneous ureterostomy.5,6 The robotic-assisted laparoscopic approach is most commonly used in intracorporeal neobladder construction, whereas the purely laparoscopic approach has seldom been reported since the first 2 cases presented by Gill et al.7 Therefore, it would be interesting to explore whether this complex procedure can be duplicated in a purely laparoscopic manner. In the present study, we examined the feasibility and safety of the pure laparoscopic procedure for neobladder construction and evaluated the role of endoscopic staplers in this procedure. Here, we present our experience of laparoscopic radical cystectomy (LRC) with intracorporeal orthotopic ileal neobladder construction. 0090-4295/15

MATERIALS AND METHODS From April 2011 to December 2013, 55 patients with bladder cancer underwent LRC with intracorporeal orthotopic ileal neobladders at our department. All patients underwent pelvic magnetic resonance or enhanced computed tomography examination before the operation. Diagnostic transurethral resection of the bladder tumors was performed in 23 patients. Radical cystectomy was indicated in cases of muscle-invasive tumors, recurrent bladder cancer, or high-grade superficial bladder cancer. Orthotopic ileal neobladder was considered after comprehensive evaluation of the patient’s intention, general condition, and tumor status. The exclusion criteria were clinical tumor stage of T4, tumors involving the prostatic urethra, urethral stenosis, decompensated renal function, history of intestinal or colonic surgery, severe cardiopulmonary disease, and advanced age (>75 years). For LRC, the patients were administered general anesthesia and placed in the supine position with the head tiled down to angle of 30 . Five laparoscopic ports were introduced: the first port for the lens was placed 3 cm above the umbilicus, and pneumoperitoneum was created with a pressure of 15 mm Hg. A 12-mm port was placed at the left lateral rectus line 1 cm above the umbilicus, and a 5-mm port was placed at the left McBurney point. Two 5-mm ports were placed at symmetric positions on the right abdominal wall for assistance. The pelvic peritoneum was incised and extended PLND was performed before cystectomy. The proximal boundaries of the extended PLND reached the inferior mesentery artery or aortic bifurcation. The ureter was bilaterally transected during dissection. For pathologic examination, the nodes were separately extracted from the different points. Cystectomy was then performed using the same technique as that reported previously,8 after which the patients were tilted back to the supine position level. Before urinary diversion, a 50-cm ileal segment 15 cm proximal to the ileocecum was harvested. This ileal segment and the ileal mesentery were transected using a 60-mm laparoscopic intestinal stapler (Echelon 60; Ethicon Endo-Surgery, Inc.). The continuity of the ileum was then restored using side-to-side staples. The incised mesentery was closed to prevent hernia. The harvested segment was symmetrically folded into a U shape with identical arm lengths. An opening was made at the bottom of the reservoir for vesicourethral anastomosis. The margin of the opening was circumferentially sutured to prevent anastomotic laceration. Then, the posterior urethra was anastomosed with the reservoir using 1-needle running sutures from the 8-o’ clock position in the counter clockwise direction. Two methods were used to construct orthotopic ileal neobladders: autosuturing using endoscopic staplers was used in 30 patients, and manual suturing using 3-0 Vicryl was used in 25 patients (Fig. 1). Most patients selected for manual suturing underwent surgeries in the former phase, and most patients selected for autosuturing underwent surgeries in the latter phase. In the autosuturing group, 2 aligned 20-cm arms were detubularized and reanastomosed using endoscopic staples, leaving 2 limbs of 5 cm at each end for ureteroileal anastomosis. Two stapler jaws were separately inserted into the ileal lumen and fired twice or thrice to extend the intraluminal anastomosis distally (Fig. 1). The left 2-3 cm of the unincised bottom segment was incised and sutured manually to complete the construction. The ureters were spatulated for about 1.5 cm and then end-to-side anastomosed with the 2 ileal limbs. In the manual suturing group, 2 aligned 20-cm ileal segments were

UROLOGY 85 (2), 2015

incised at the antimesenteric border, and the posterior wall of the reservoir was reconstructed using 3-0 Vicryl continuous sutures. Before the anterior reservoir wall was closed, the ureter was bilaterally anastomosed with the 2 ileal limbs. Two ureteric stents were introduced through the anterior reservoir wall and brought out of the body from a low abdominal incision. Data regarding operative time, estimated blood loss (EBL), bowel recovery time, hospitalization stay, pathologic results, and intraoperative or postoperative complications were collected. After surgeries, abdominal computed tomography scans were performed every 6 months to evaluate the oncologic outcomes. Neobladder function was studied at 6 months postoperatively. Daytime or night-time continence referred to the requirement of

Laparoscopic radical cystectomy with intracorporeal orthotopic ileal neobladder: technique and clinical outcomes.

To study the feasibility and safety of laparoscopic radical cystectomy with intracorporeal orthotopic ileal neobladder and to evaluate the role of end...
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