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LAPAROSCOPIC ROBOT ASSISTED RADICAL CYSTECTOMY WITH INTRACORPORAL URINARY DIVERSION
490
THE JOURNAL OF UROLOGY®
V1433 LAPAROSCOPIC ROBOT ASSISTED RADICAL CYSTECTOMY WITH INTRACORPORAL URINARY DIVERSION Hubert John*, Jean-Luc Fehr, Boris Fischer, Nadja Engel, Peter N Wiklund. Zurich, Switzerland and Stockholm, Sweden. INTRODUCTION AND OBJECTIVE: This video demonstrates the feasability of a radical cystectomy, extended pelvic lymph node dissection and intracorporal reconstruction of the upper urinary tract with a 3-arm robotic system. METHODS: The patient is placed in a supine Trendelenburg position with the legs moderately abducted. The peri-umbilical camera trocar and the two 8mm robotic trocars are placed. In addition, two 12mm assistant trocars are introduced into the right hemi-abdomen and one 15mm trocar near the left iliac crest. The left peritoneal border near the iliac vessels is incised and the left ureter mobilised. Two Hemolock clips are placed distally with a Biosyn 2-0 holding suture. The distal ureteral HQGLVVHQWIRUIUR]HQVHFWLRQ7KHULJKWXUHWHULVSUHSDUHGLQWKHVDPH way. The peritoneum is incised in the deep Douglas space and the seminal vesicles freed from the anterior rectal wall. The upper and lower bladder columns are cut with the Ligasure 5mm device. The endopelvic fascia is opened and the prostate dissected in descending technique. 7KH6DQWRULQLSOH[XVLVGLYLGHGDQGWKHXUHWKUDOVWXPSFXW$IWHUDIUR]HQ section of the distal urethral stump the urethra is closed with Biosyn 2-0. The obturator and external and internal iliac lymph nodes are dissected. To reconstruct the upper urinary tract an intracorpereal Bricker conduit is built. A Cadiere forceps is brought through the mesosigma at the level of the promontory. The left ureter is transposed to the right. An Endo GIA 60mm is placed 20cm above the ileocaecal valve and an ileum segment of 20 cm is excluded. Small incisions are made into the oral end of the bowel in order to introduce the Endo GIA at the antimesenterial side. Both ureters are spatulated over 2-3cm to build ureteral plate according to Wallace II. The conduit is brought down, approximated to the ureteral plate and incised to the ureteral side. Two 3mm trocars are introduced at the preplanned stoma location and guidewires with 70cm ureteral stents are introduced in both ureters. The ureteral plate sutured at the posterior and anterior border. The robot is disconnected and the Bricker FRQGXLWLVH[WUDFRUSRUDOL]HG RESULTS: No results for this instructive video CONCLUSIONS: Laparoscopic robot assisted radical cystectomy with intracorporal urinary diversion is faisable. While the cystectomy itself and the extendend lymphadenectomy are routinely performed today, the intracorporal reconstruction of the upper urinary tract remains a technically challenge and clinical experimental technique.
Vol. 179, No. 4, Supplement, Tuesday, May 20, 2008
WKHUHFRJQLWLRQRIODQGPDUNVRIGLVVHFWLRQ&RQWLQXDOYLVXDOL]DWLRQRIWKH anatomy using the three dimensional vision avoids dissection into the prostate compromising oncological outcomes. &21&/86,216 0DQDJHPHQWRIGLI¿FXOWSURVWDWHDQDWRP\ FDQEHRYHUFRPHZLWKVSHFL¿FPRGL¿FDWLRQVLQWHFKQLTXHREVHUYHGZLWK surgeon experience. Source of Funding: None
V1435 EXTRAPERITONEAL LAPAROSCOPIC RADICAL PROSTATECTOMY: WASHINGTON UNIVERSITY TECHNIQUE Ramakrishna Venkatesh, Matthew D Katz*, Margaret M Frisella, Gerald L Andriole. Saint Louis, MO. INTRODUCTION AND OBJECTIVE: Extraperitoneal laparoscopic radical prostatectomy (LRP) with pelvic lymph node dissection (PND) has proven to be a viable alternative approach to open or robotic assisted radical prostatectomy. However, LRP has a steep learning curve with associated longer operative times when performed by a novice surgeon. This video demonstrates techniques and instrumentation used to achieve shorter operative times and ease of surgery that has evolved from an experienced open oncological surgeon. METHODS: This video demonstrates 1) the use of a multi-joint ÀH[LEOHDQGVWDEOHFDPHUDKROGHU (QGRDUP&,9&2 WKDWORFNVLQWR place and can be adjusted with one hand by the surgeon or his assistant, D ¿[HG UHWUDFWRU HQGRKROGHU V\VWHP (QGRKROGHU &RGPDQ WKDW retracts and provides counter traction of tissues, 3) the use of knotless intracorporeal suturing, 4) a 3-D camera system (Viking© Systems Inc.), and 5) the articulating needle driver (Cambridge Endo™) for urethrovesical anastomosis. RESULTS: A total of 361 patients underwent extraperitoneal LRP from 2005-2006 by one senior surgeon (GLA).The median operative time was 190 minutes (range102-309 minutes) for LRP and bilateral PND, median blood loss was 350mL (range 20-1200mL), and the mean hospital stay was 1.28 days (range 1-14 days). Positive surgical margins were noted in 62 patients (17.1%). CONCLUSIONS: We believe the use of a single hand DGMXVWDEOH FDPHUD KROGHU DQG WKH ¿[HG UHWUDFWRU V\VWHP UHGXFHV DVVLVWDQW IDWLJXH DQG OHDGV PRUH HI¿FLHQW VXUJLFDO WHFKQLTXH GXULQJ LRP. Source of Funding: None
Prostate Cancer: Localized (IV)
Source of Funding: None
V1434 MANAGEMENT OF DIFFICULT ANATOMY DURING ROBOTIC ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY Nilesh N Patil*, Geoff Coughlin, Srinivas Samavedi, Kenneth J Palmer, Pankaj P Dangle, Vipul R Patel. Columbus, OH. INTRODUCTION AND OBJECTIVE: While the task of learning robotic prostatectomy can be challenging both for the novice and experienced surgeon, situations requiring variations in surgical WHFKQLTXH VXFK DV GLI¿FXOW SURVWDWH DQDWRP\ FRQWLQXH WR UHVHW WKH learning curve for the procedure. This video details our specific approaches to some of these areas. 0(7+2'6 &DVHVRIGLI¿FXOWSURVWDWHDQDWRP\FRQVLVWLQJRI large prostate(>100 gms), median lobe, history of trans-urethral resection RI SURVWDWH DQG GLI¿FXOW EODGGHU QHFN GLVVHFWLRQV DOO SHUIRUPHG E\ D single surgeon(VRP) were recorded after establishing a consensus PRGL¿FDWLRQRIWKHWHFKQLTXH RESULTS: Prostates > 100 grams cause limited mobility in the pelvis and potential problems with vascular control. Dissection with broad ¿HOGRIH[SRVXUHLQWKHFRUUHFWVXUJLFDOSODQHKHOSVWRHQVXUHDEORRGOHVV ¿HOG$PHGLDQOREHGLVWRUWVWKHSRVWHULRUEODGGHUQHFNDQGLVUHFRJQL]HG if a bladder “drop-off” is not seen. The lobe is retracted by the fourth arm of the robot to facilitate dissection. Prior history of transurethral resection of the prostate may cause a limited ability to identify the vesico-prostatic MXQFWLRQ,GHQWL¿FDWLRQRIWKHXUHWHUDORUL¿FHVLVFUXFLDOSULRUWRSRVWHULRU dissection. The nuances of bladder neck variability are managed with
Moderated Poster Session 50 Tuesday, May 20, 2008
1:00 - 3:00 pm
1436 RESIDUAL PROSTATE CANCER FOLLOWING RADIOTHERAPY: A STUDY OF RADICAL CYSTOPROSTATECTOMY SPECIMENS David J Kaplan*, Paul L Crispen, Richard E Greenberg, David Y T Chen, Rosalia Viterbo, Mark K Buyyounouski, Eric M Horowitz, Robert G Uzzo. Philadelphia, PA. INTRODUCTION AND OBJECTIVE: The incidence of KLVWRORJLFSURVWDWHFDQFHU &D3 IROORZLQJGH¿QLWLYHUDGLDWLRQWKHUDS\ 57 IRU ORFDOL]HG GLVHDVH LV UDUHO\ TXDQWLWDWHG +HUH ZH LQYHVWLJDWH the relationship between PSA and histologically residual CaP following GH¿QLWLYH57LQSDWLHQWVXQGHUJRLQJUDGLFDOF\VWRSURVWDWHFWRP\ 5&3 for unrelated indications. METHODS: We reviewed our prostate cancer database to LGHQWLI\ SDWLHQWV XQGHUJRLQJ 5&3 ZKR SUHYLRXVO\ UHFHLYHG GH¿QLWLYH 57IRUORFDOL]HG&D33UHUDGLDWLRQYDULDEOHVH[DPLQHGLQFOXGH36$ Gleason score, radiation modality and dose. Post-radiation variables reviewed include PSA, time to RCP, the presence of histologically proven prostate cancer, and Gleason score. 5(68/76 :H LGHQWL¿HG SDWLHQWV ZKR XQGHUZHQW 5&3 DWDPHGLDQRIPRQWKVIROORZLQJ57IRUORFDOL]HG&D33UHUDGLDWLRQ *OHDVRQVFRUHVZHUHORZ WRLQWHUPHGLDWHULVN LQ intermediate (4+3) to high (>8) in 18% (3/17), and unavailable in 5
THE JOURNAL OF UROLOGY®
V1433 LAPAROSCOPIC ROBOT ASSISTED RADICAL CYSTECTOMY WITH INTRACORPORAL URINARY DIVERSION Hubert John*, Jean-Luc Fehr, Boris Fischer, Nadja Engel, Peter N Wiklund. Zurich, Switzerland and Stockholm, Sweden. INTRODUCTION AND OBJECTIVE: This video demonstrates the feasability of a radical cystectomy, extended pelvic lymph node dissection and intracorporal reconstruction of the upper urinary tract with a 3-arm robotic system. METHODS: The patient is placed in a supine Trendelenburg position with the legs moderately abducted. The peri-umbilical camera trocar and the two 8mm robotic trocars are placed. In addition, two 12mm assistant trocars are introduced into the right hemi-abdomen and one 15mm trocar near the left iliac crest. The left peritoneal border near the iliac vessels is incised and the left ureter mobilised. Two Hemolock clips are placed distally with a Biosyn 2-0 holding suture. The distal ureteral HQGLVVHQWIRUIUR]HQVHFWLRQ7KHULJKWXUHWHULVSUHSDUHGLQWKHVDPH way. The peritoneum is incised in the deep Douglas space and the seminal vesicles freed from the anterior rectal wall. The upper and lower bladder columns are cut with the Ligasure 5mm device. The endopelvic fascia is opened and the prostate dissected in descending technique. 7KH6DQWRULQLSOH[XVLVGLYLGHGDQGWKHXUHWKUDOVWXPSFXW$IWHUDIUR]HQ section of the distal urethral stump the urethra is closed with Biosyn 2-0. The obturator and external and internal iliac lymph nodes are dissected. To reconstruct the upper urinary tract an intracorpereal Bricker conduit is built. A Cadiere forceps is brought through the mesosigma at the level of the promontory. The left ureter is transposed to the right. An Endo GIA 60mm is placed 20cm above the ileocaecal valve and an ileum segment of 20 cm is excluded. Small incisions are made into the oral end of the bowel in order to introduce the Endo GIA at the antimesenterial side. Both ureters are spatulated over 2-3cm to build ureteral plate according to Wallace II. The conduit is brought down, approximated to the ureteral plate and incised to the ureteral side. Two 3mm trocars are introduced at the preplanned stoma location and guidewires with 70cm ureteral stents are introduced in both ureters. The ureteral plate sutured at the posterior and anterior border. The robot is disconnected and the Bricker FRQGXLWLVH[WUDFRUSRUDOL]HG RESULTS: No results for this instructive video CONCLUSIONS: Laparoscopic robot assisted radical cystectomy with intracorporal urinary diversion is faisable. While the cystectomy itself and the extendend lymphadenectomy are routinely performed today, the intracorporal reconstruction of the upper urinary tract remains a technically challenge and clinical experimental technique.
Vol. 179, No. 4, Supplement, Tuesday, May 20, 2008
WKHUHFRJQLWLRQRIODQGPDUNVRIGLVVHFWLRQ&RQWLQXDOYLVXDOL]DWLRQRIWKH anatomy using the three dimensional vision avoids dissection into the prostate compromising oncological outcomes. &21&/86,216 0DQDJHPHQWRIGLI¿FXOWSURVWDWHDQDWRP\ FDQEHRYHUFRPHZLWKVSHFL¿FPRGL¿FDWLRQVLQWHFKQLTXHREVHUYHGZLWK surgeon experience. Source of Funding: None
V1435 EXTRAPERITONEAL LAPAROSCOPIC RADICAL PROSTATECTOMY: WASHINGTON UNIVERSITY TECHNIQUE Ramakrishna Venkatesh, Matthew D Katz*, Margaret M Frisella, Gerald L Andriole. Saint Louis, MO. INTRODUCTION AND OBJECTIVE: Extraperitoneal laparoscopic radical prostatectomy (LRP) with pelvic lymph node dissection (PND) has proven to be a viable alternative approach to open or robotic assisted radical prostatectomy. However, LRP has a steep learning curve with associated longer operative times when performed by a novice surgeon. This video demonstrates techniques and instrumentation used to achieve shorter operative times and ease of surgery that has evolved from an experienced open oncological surgeon. METHODS: This video demonstrates 1) the use of a multi-joint ÀH[LEOHDQGVWDEOHFDPHUDKROGHU (QGRDUP&,9&2 WKDWORFNVLQWR place and can be adjusted with one hand by the surgeon or his assistant, D ¿[HG UHWUDFWRU HQGRKROGHU V\VWHP (QGRKROGHU &RGPDQ WKDW retracts and provides counter traction of tissues, 3) the use of knotless intracorporeal suturing, 4) a 3-D camera system (Viking© Systems Inc.), and 5) the articulating needle driver (Cambridge Endo™) for urethrovesical anastomosis. RESULTS: A total of 361 patients underwent extraperitoneal LRP from 2005-2006 by one senior surgeon (GLA).The median operative time was 190 minutes (range102-309 minutes) for LRP and bilateral PND, median blood loss was 350mL (range 20-1200mL), and the mean hospital stay was 1.28 days (range 1-14 days). Positive surgical margins were noted in 62 patients (17.1%). CONCLUSIONS: We believe the use of a single hand DGMXVWDEOH FDPHUD KROGHU DQG WKH ¿[HG UHWUDFWRU V\VWHP UHGXFHV DVVLVWDQW IDWLJXH DQG OHDGV PRUH HI¿FLHQW VXUJLFDO WHFKQLTXH GXULQJ LRP. Source of Funding: None
Prostate Cancer: Localized (IV)
Source of Funding: None
V1434 MANAGEMENT OF DIFFICULT ANATOMY DURING ROBOTIC ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY Nilesh N Patil*, Geoff Coughlin, Srinivas Samavedi, Kenneth J Palmer, Pankaj P Dangle, Vipul R Patel. Columbus, OH. INTRODUCTION AND OBJECTIVE: While the task of learning robotic prostatectomy can be challenging both for the novice and experienced surgeon, situations requiring variations in surgical WHFKQLTXH VXFK DV GLI¿FXOW SURVWDWH DQDWRP\ FRQWLQXH WR UHVHW WKH learning curve for the procedure. This video details our specific approaches to some of these areas. 0(7+2'6 &DVHVRIGLI¿FXOWSURVWDWHDQDWRP\FRQVLVWLQJRI large prostate(>100 gms), median lobe, history of trans-urethral resection RI SURVWDWH DQG GLI¿FXOW EODGGHU QHFN GLVVHFWLRQV DOO SHUIRUPHG E\ D single surgeon(VRP) were recorded after establishing a consensus PRGL¿FDWLRQRIWKHWHFKQLTXH RESULTS: Prostates > 100 grams cause limited mobility in the pelvis and potential problems with vascular control. Dissection with broad ¿HOGRIH[SRVXUHLQWKHFRUUHFWVXUJLFDOSODQHKHOSVWRHQVXUHDEORRGOHVV ¿HOG$PHGLDQOREHGLVWRUWVWKHSRVWHULRUEODGGHUQHFNDQGLVUHFRJQL]HG if a bladder “drop-off” is not seen. The lobe is retracted by the fourth arm of the robot to facilitate dissection. Prior history of transurethral resection of the prostate may cause a limited ability to identify the vesico-prostatic MXQFWLRQ,GHQWL¿FDWLRQRIWKHXUHWHUDORUL¿FHVLVFUXFLDOSULRUWRSRVWHULRU dissection. The nuances of bladder neck variability are managed with
Moderated Poster Session 50 Tuesday, May 20, 2008
1:00 - 3:00 pm
1436 RESIDUAL PROSTATE CANCER FOLLOWING RADIOTHERAPY: A STUDY OF RADICAL CYSTOPROSTATECTOMY SPECIMENS David J Kaplan*, Paul L Crispen, Richard E Greenberg, David Y T Chen, Rosalia Viterbo, Mark K Buyyounouski, Eric M Horowitz, Robert G Uzzo. Philadelphia, PA. INTRODUCTION AND OBJECTIVE: The incidence of KLVWRORJLFSURVWDWHFDQFHU &D3 IROORZLQJGH¿QLWLYHUDGLDWLRQWKHUDS\ 57 IRU ORFDOL]HG GLVHDVH LV UDUHO\ TXDQWLWDWHG +HUH ZH LQYHVWLJDWH the relationship between PSA and histologically residual CaP following GH¿QLWLYH57LQSDWLHQWVXQGHUJRLQJUDGLFDOF\VWRSURVWDWHFWRP\ 5&3 for unrelated indications. METHODS: We reviewed our prostate cancer database to LGHQWLI\ SDWLHQWV XQGHUJRLQJ 5&3 ZKR SUHYLRXVO\ UHFHLYHG GH¿QLWLYH 57IRUORFDOL]HG&D33UHUDGLDWLRQYDULDEOHVH[DPLQHGLQFOXGH36$ Gleason score, radiation modality and dose. Post-radiation variables reviewed include PSA, time to RCP, the presence of histologically proven prostate cancer, and Gleason score. 5(68/76 :H LGHQWL¿HG SDWLHQWV ZKR XQGHUZHQW 5&3 DWDPHGLDQRIPRQWKVIROORZLQJ57IRUORFDOL]HG&D33UHUDGLDWLRQ *OHDVRQVFRUHVZHUHORZ WRLQWHUPHGLDWHULVN LQ intermediate (4+3) to high (>8) in 18% (3/17), and unavailable in 5