Laparoscopic cystoprostatectomy for bladder cancer in a male patient

Radical cystectomy remains the gold standard for muscle invasive bladder cancer and high-risk superficial tumors resistant to intravesical treatment. Nevertheless, the laparoscopic cystoprostatectomy has rarely been well codified and illustrated. Please click here to watch the video of the procedure.

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Laparoscopic   cystoprostatectomy   for   bladder   cancer   in   a   male   patient

Authors
R Van Velthoven
Abstract
Radical cystectomy remains the gold standard for muscle invasive bladder cancer and high-risk superficial tumors resistant to intravesical treatment. Nevertheless, the laparoscopic cystoprostatectomy has rarely been well codified and illustrated.
Please click here to watch the video of the procedure.
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2008-02
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E-publication
WeBSurg.com, Feb 2008;8(02).
URL: http://www.websurg.com/doi-ot02en311.htm

Laparoscopic   cystoprostatectomy   for   bladder   cancer   in   a   male   patient

1. Introduction
Radical cystectomy remains the gold standard for muscle invasive bladder cancer and high-risk superficial tumors resistant to intravesical treatment (Dalbagni et al., 2001); moreover, open cystoprostatectomy with urinary diversion remains a major procedure, which may be demanding for patients.
Although cystectomy performed through a laparoscopic approach was firstly described in 1992 (Parra et al.), this indication remained very controversial and was still considered recently as experimental for the treatment of bladder cancer (Breda et al., 2001). During the last decade, the greatest impact of the laparoscopic approach in urology was undoubtedly shown on patients with genitourinary malignancies. When only pelvic lymph node dissection and occasionally nephrectomies were initially considered as oncologically feasible, presently, several other approaches such as laparoscopic adrenalectomy and radical nephrectomy are today considered as standards of care, not only at centers of excellence but even in the general community. Maturing data with laparoscopic radical prostatectomy suggest excellent continence rates and equivalent oncologic results based on pathological surrogates of cure (Guillonneau and Valancien, 2000).
Laparoscopic approach for advanced disease such as cytoreductive nephrectomy has also been found to be feasible for selected patients with metastatic renal cell carcinoma. Other novel therapies, such as laparoscopic radical cystectomy with urinary diversion and laparoscopic retroperitoneal lymph node dissection, hold great promise of benefit for patients with urologic malignancies (Matin, 2003).
Beyond initial reports on feasibility, controversy persisted regarding the risk of cell spillage or port metastases in transitional cell carcinoma; yet the strict observation of oncological safety rules as the respect of closed urinary cavities has increased the acceptance of laparoscopic nephro-ureterectomy (Matin, 2003); hence, radical cystectomy should become increasingly accepted if the same rules are carefully observed (Tsivian and Sidi, 2003). Moreover, animal and clinical experimental work has demonstrated that laparoscopy may be less immunodepressant than its open counterpart (Miyake et al., 2002); this additional theoretical advantage could play a positive role in favor of radical cystectomy performed laparoscopically.
Although laparoscopic cystectomy with different urinary diversions has already been described, it has shown to provide intraoperative and postoperative advantages when compared to open surgery (Paz et al., 2003; Matin and Gill, 2002; Wood, 2002). Nevertheless, the laparoscopic cystoprostatectomy has rarely been well codified and illustrated (Simonato et al., 2003). Having set up an experience in radical prostatectomy since 1999, our groups started to perform laparoscopic radical cystectomy one year later, in spring 2000; from then and until June 2004, 30 patients were operated in Brussels and 8 in Heilbronn.
As elegantly shown in another recent review (Moinzadeh and Gill, 2004), all technical steps of an open surgical radical cystectomy with urinary diversion have been translated into equivalent laparoscopic maneuvers.
The potential advantages of doing the procedure laparoscopically are the smaller incisions, hence decreased pain and quicker recovery time implying shortened hospital stay, decreased blood loss and fluids imbalance compared with the open technique. If transfusion is usual during open surgery, it is uncommon with laparoscopy. A stepwise protocol is actually established, with minor alternative variations between centers (Matin and Gill, 2002; Simonato et al., 2003; Moinzadeh and Gill, 2004; van Velthoven et al., 2003).
2. Anatomy
• Anatomical relations
The anatomical relationships of the prostate and the bladder are complex. Situated deep at the base of the pelvis, it is in contact with the following:
- muscular and aponeurotic structures (levator ani muscles, endopelvic fascia, Denonvilliers' fascia/rectoprostatic fascia);
- visceral structures (rectum);
- vascular structures (prostatic venous plexus);
- neurovascular structures (neurovascular bundles leading to ischiocavernous muscle);
- lower urinary apparatus (bladder neck, striated urethral sphincter).
The prostate is joined to the bladder. They are removed en bloc.
• Vascular supply
Blood supply to the bladder largely depends on the anterior branches of the hypogastric artery: the superior vesical artery, the inferior vesical artery, and the vesicoprostatic artery.
The branches are encountered successively at the root of the hypogastric artery. The superior vesical artery runs under the peritoneal cover of the superior lateral aspect of the bladder; it gives two to five branches to the bladder and generally the funicular artery of the ductus deferens.
The inferior vesical artery runs medially to reach the bladder base, supplying the bladder, the prostate and the ampulla of the ductus deferens.
The vesicoprostatic arteries generally originate from the inferior vesical artery and supply the seminal vesicle and the prostate.
3. Indications/Contraindications
Radical cystectomy is the gold standard treatment for:
- muscle-invasive (>= pT2a) bladder cancer;
- high-risk (pT1G3, pTis) disease resistant to conservative treatment.
4. Preoperative management
Preoperatively, the bowel is prepared by oral self-administration of 2 liters of electrolyte lavage solution during two days before the surgical procedure. Prophylaxis with a cephalosporin antibiotic is performed from day 1 to 5 and low-molecular-weight heparin (4000 Units) is administered preoperatively and until postoperative day 15. Compression stockings are applied as the patient is placed in the supine position with the legs apart to allow free access to the perineal space. The table is set to a 30° Trendelenburg position. A Foley catheter (18 French) is inserted to drain the bladder and a nasogastric tube is positioned. As the lower limbs are carefully strapped to the table without compressions, no shoulder pads are necessary.
5. Operating room set-up
• Patient
The technique is challenging, requiring considerable laparoscopic infrastructure and expertise. Using a five- or six-port transperitoneal approach, the radical cystectomy and pelvic lymph node dissection are performed first. Standard laparoscopic surgical equipment with few special instruments is required. The patient is placed in a supine position with the legs apart for easy access to the perineal space.
The table is set to a Trendelenburg position (30° tilt).
The patient’s lower limbs are carefully strapped to the table.
• Team
1. The surgeon is on the patient’s left side, if right-handed.
2. The assistant is on the patient’s right side.
3. A second assistant stands next to the first assistant and can help pass the instruments and can also handle one of the trocars.
• Equipment
1. The laparoscopic unit and the monitor are placed at the patient’s feet, between the legs.
2. The operating table must permit a 30° Trendelenburg position.
6. Trocar placement
The patient is in a supine position, with the lower limbs slightly abducted (15°). A 30° flexion is given to the knees to define the value of Trendelenburg position accordingly. Extension of the hips should be avoided to prevent any backache.
A 5-port diamond or fan-shaped transperitoneal approach is used. The first 10 mm trocar is placed 1 cm above the umbilicus; an open technique through a mini-laparotomy is optional at this level. This trocar is reserved for the 0° laparoscope. The remaining 4 ports are placed under endoscopic control after classical establishment of the pneumoperitoneum (12-14 mm Hg) with or without the use of a Veress needle.
At the left McBurney’s point, a 12 mm trocar is placed; this diameter is chosen to ease the retrieval of pelvic lymph nodes after dissection. At the true McBurney’s point, a 10 mm trocar is placed to accommodate a 10 mm instrument if necessary.
On the midline, a 5 mm trocar is placed, one span below the umbilical trocar. A fifth 5 mm trocar is placed horizontally to the umbilicus, on the vertical line of the right lateral trocar.
The abdomen and pelvis are inspected; adhesions of the sigmoid loop in the left fossa, when present are released by blunt and sharp dissection.
7. Instruments
The basic instrumentation is common to all laparoscopic procedures:
1. 0° laparoscope
2. Fine dissecting scissors
3. Ultrasonic dissectors (optional)
4. Fine grasping forceps
5. 2 fenestrated grasping forceps
6. Bipolar cauterizing grasper
7. Needle holder
8. Suction-irrigation device
9. 5 mm clip applier
10. Retrieval bag
- urinary catheter
- 2.0 braided suture, 26 mm needle
- 3.0 absorbable monofilament suture, 26 mm needle
8. Operative protocol
1. Dissection of prerectal space (seminal vesicles left intact)
2. High peritoneal incision from along the ureters until internal inguinal ring
3. Division of ductus deferens, using a medial retractor
4. Extended pelvic lymph node dissection (ilio-obturator, internal iliac/medial external iliac): both the extent of node dissection and the number of lymph nodes removed has a direct impact on survival for both negative and positive node patients)
5. Division of ureter (once clamped)
6. Merging of peritoneal incisions; division of superior, inferior vesical artery, vesicular arteries
7. Late division of urachus and umbilical ligaments
8. Dissection of Retzius’ space
9. Complete dissection of the endopelvic fascia
10. Dissection along the prostate for preservation of neurovascular bundles (intrafascial: Aphrodite’s veil)
11. Complete dissection of urethra
12. Retrieval of the closed specimen “en bloc”
Laparoscopic anastomosis to the urethra in orthotopic bladder replacement
9. Dissection/retrovesical space
The procedure begins with dissection of the plane posterior to the seminal vesicles. Dissection is started at the level of the rectovesical pouch (Douglas’ pouch). The posterior wall of the bladder is lifted vertically using a fenestrated forceps held by the second assistant. A horizontal 6-8 cm incision is carried out on the peritoneum two fingerbreadths above the bottom of the Douglas’ pouch.
Ampullae and seminal vesicles are exposed but not dissected from the bladder to which they remain attached throughout the procedure. If necessary, the posterior aspect of Denonvilliers’ fascia is exposed and incised horizontally to open the perirectal fatty space. When started high enough, the dissection is able to leave the Denonvilliers’ posterior sheet covering the seminal vesicles.
The dissection is continued bluntly on each side and on the anterior aspect of the rectum towards the apical area of the prostate.
The vascular supplies of the vesicles are identified laterally, but not divided so far.
A tunnel between the rectum and the prostate with the vesical and prostatic fibrovascular pedicles is created laterally.
10. Lateral dissection of bladder
• Division of ductus deferens
The umbilical arteries are identified close to the abdominal inguinal ring and the peritoneum is incised just laterally to them. From the internal inguinal ring caudally, a vertical incision of the peritoneum follows the medial aspect of the external iliac artery until the crossing of the ipsilateral ureter. The ductus deferens is divided at the level of the inguinal ring and retracted medially to open the space medial to the external iliac vessels.
• Lymph node dissection
The classical or extended ilio-obturator lymph node dissection (Stone et al., 1997; Lieskowsky and Skinner, 1984) may be carried out at this moment; sampling of the nodes in view of frozen sections can be extended to external and/or internal node groups.
• Division of ureter
The peritoneal incision is then extended cranially, at the anterior aspect of the ureter, beyond the crossing of iliac vessels; this allows preparation of an adequate length of free ureter in view of their ulterior re-implantation. Careful hemostasis of the arteriolar supply to the iliac portion of ureters should be ensured to avoid potentially neglected bleedings.
The superior vesical artery is divided at its origin. This can be accomplished by means of a 10 mm vessel sealing device or by division between laparoscopic clips.
The ureter is then further followed, completely dissected and divided between clips, close to its intramural portion. The last centimetre is resected and properly oriented for frozen section to exclude dysplasia of the lower ureter.
• Further dissection of lymph nodes
The lymph node dissection is extended to the common iliac lymph nodes, then to the presacral and para-aortic lymph nodes.
• Division of arterial branches
The inferior vesical artery and vesiculo-prostatic artery are then divided as described above. Their division is carried out in close vision of the lateral aspect of the seminal vesicle to which they provide arterial supply. The division of the successive pedicles is temporarily interrupted at the upper lateral edge of the prostate, on each side, in order to preserve temporarily the emergence of the neurovascular bundles.
So far, the bladder remains suspended through its anterior attachments and the Retzius’ space is kept closed except for its lateral aspects.
11. Anterior dissection of bladder
• Dissection of Retzius’ space
When the antegrade dissection and division of the bladder’s upper vascular elements are achieved, the umbilical ligaments are divided and the Retzius’ space is then opened. The high division of umbilical ligaments is enabled by the supraumbilical position of the telescope, by the working position of the scissors in the upper right trocar, and by a hemostatic forceps working through the left lateral trocar.
At this point, the anterior peritoneum is incised laterally to the umbilical arteries from the umbilicus to the inguinal ring. The prevesical space is entirely opened and the bladder is dissected from the anterior abdominal wall. With a combination of sharp and blunt dissection, the space between the lateral wall of the bladder and the pelvic side wall is developed until reaching the endopelvic fascia on both sides.
• Incision of endopelvic fascia
The superficial dorsal vein is then divided on the anterior aspect of the prostate and the endopelvic fascia is opened on its line of reflexion; the lateral surface of the prostate is separated from the levator ani muscle to carefully isolate the dorsal vein complex and the prostatic apex.
• Exposure of vesicoprostatic complex
At this time, the lateral aspect of the prostate is exposed by the first assistant exerting traction on the vesico-prostatic junction in the opposite direction. This maneuver exposes the superior vesiculo-prostatic pedicle left intact so far. In the meantime, the rectum is pushed downwards with the suction cannula in order to expose the medial aspect of the vesico-prostatic pedicle.
• Nerve-sparing dissection
Nerve-sparing dissection of vesicoprostatic complex:
Marching down the pelvis, the visceral fascia is opened on the lateral aspect of the prostate and the branches of the ipsilateral neurovascular bundle to the prostate are divided successively towards the apex of the prostate, on each side, using either an ultrasonic scalpel, a 5-10 mm vessel sealing device or a bipolar forceps.
12. Apical dissection
• Division of Santorini’s plexus
At this point, the vesico-prostatic complex is still attached to the pelvic floor by the deep dorsal vein complex and the urethra. The plexus of Santorini is divided after ligation or using a vessel sealing device.
• Freeing of vesicoprostatic complex
Division of urethra:
The anterior aspect of the urethra is exposed as proximal as possible to the prostatic parenchyma in order to maintain the puboprostatic ligaments intact as well as an adequate urethral stump, if an orthotopic neobladder reconstruction is planned.
From the points reached by the division of the visceral fascia, the lateral and posterior aspects of the urethra are then dissected with a 5 or 10 mm right-angled Maryland forceps. When free, the urethra is ligated with an intracorporeal knot or clamped by a 10 mm Hem-o-Lock® clip and divided after removal of the indwelling catheter.
The urinary lumen is never opened by this means in order to avoid any cell spillage.

Releasing the specimen:
The terminal plate and the distal insertions of Denonvilliers’ fascia are incised, releasing the specimen completely.
13. Lengthening techniques of ureter
If the available length of both ureters is considered too short by the surgeon, the former dissection is continued cranially. The left ureter is tunnelized behind the sigmoid loop to join the right ureter in the retroperitoneal space; a fenestrated atraumatic forceps is passed through the upper right trocar, lifting the posterior peritoneum caudally towards the aortoiliac bifurcation, and bluntly dissecting the sigmoid mesentery to allow the passage of the left ureter to the opposite side.
14. Extraction
After a last overview of main hemostatic controls, the pneumoperitoneum is temporarily deflated; lateral trocars remain as they are placed.
In case of an orthotopic bladder replacement, a midline laparotomy incision is made, unifying the two medial trocar holes; these trocars are temporarily removed.
The vesicoprostatic specimen is removed ‘en bloc’ through the incision; its entrapment into a bag is optional.
15. Orthotopic bladder replacement
• Preparation of neobladder
The orthotopic neobladder pouch is created by suturing opened small bowel together to form a new bladder. As usual, a 55 to 60cm segment of ileum located 15cm away from the ileocecal junction is isolated and detubularized, leaving intact a proximal 10cm isoperistaltic afferent Studer limb segment. Depending on the surgeon’s skills or preferences, a Hautmann’s ileal bladder can be built as well and the bowel prepared accordingly. The continuity of the small bowel is restored outside the body through the incision made for specimen retrieval; a spherical neobladder is constructed extracorporeally as well. A termino-terminal uretero-ileal anastomosis is then performed through the same incision, according to Wallace or to Bricker.
• Neobladder creation
Ureters are intubated with 8 French smooth catheters temporarily attached to the posterior wall of the pouch with rapidly absorbable sutures (Vicryl rapid® 2.0).
Both catheters are exteriorized through the anterior wall of the pouch, and subsequently, will be passed through the abdominal wall thereafter.
The anterior wall of the reservoir is closed by a running Connel-Mayo PGA 3.0 suture; the caudal part of this closure is left open in view of the vesicourethral anastomosis.
When the pouch is ready, it is placed into the abdomen and the mini-laparotomy is closed classically. The 10mm trocar is replaced for the lens, in an infraumbilical position and the pneumoperitoneum re-insufflated.
16. Vesicourethral anastomosis
After appropriate positioning of the ileal neobladder in its orthotopic position, a vesicourethral anastomosis is started between the ileal orifice left open and the urethral stump.
This technique is now widely adopted for the reconstructive part of radical prostatectomy. Briefly, the suture is started at six o’clock on the ileal edge of the suture; two 6-7 inches of 2.0 PGA monolayer threads knotted together are used; two hemi-running sutures are then built until twelve o’clock where the only knot tied intracorporeally is done.

When this suture is completed, a Jackson-Pratt drain is placed into the pelvis; the tube is exteriorized through a trocar hole in the right fossa. Fascial incisions of 10 mm are closed with interrupted 0 sutures. The skin is closed with surgical staples.
17. Postoperative management
In the first night, all patients were monitored on the intensive care unit for monitoring of vital parameters and adequate pain management. Parenteral nutrition was continued until complete oral feeding. The drains are removed after reduction of secretion below 50 ml. On day 10 the ureteral stents are removed without cystogram. The urethral catheter of neobladders is removed on postoperative day 18, after 48 hours of intermittent clamping every 2 hours.
18. Conclusion
Challenging procedure
Technically feasible in experienced hands
Expected benefits:
- minimize blood loss;
- minimize analgesic requirement;
- minimize hospital stay.
Lower morbidity
- standardization of the procedure mandatory
Selected indications for TCC

Oncologically complying with the rules of surgery for transitional cell carcinoma (TCC) of the bladder:
- Transperitoneal route;
- Urachal and peritoneal resection;
- Extended pelvic lymph node dissection;
- Hollow organs remain closed.

It may become a standard of care even in the elderly:
Neurogenic bladder, interstitial cystitis.
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