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Robotic-Assisted Laparoscopic Radical Cystectomy and Intra-Abdominal Formation of an Orthotopic Ileal Neobladder
European Urology
European Urology 44 (2003) 337–339
Robotic-Assisted Laparoscopic Radical Cystectomy and Intra-Abdominal Formation of an Orthotopic Ileal Neobladder W.-D. Beecken*, M. Wolfram, T. Engl, W. Bentas, M. Probst, R. Blaheta, A. Oertl, D. Jonas, J. Binder Department of Urology and Pediatric Urology, J.W. Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany Accepted 4 June 2003
Abstract Purpose: To describe our technique of robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic neobladder (Hautmann) for treatment of transitional cell carcinoma of the bladder. Methods: We describe our surgical technique in the worldwide first attempt to perform a robotic-assisted laparoscopic radical cystectomy and completely intra-abdominal formation of an orthotopic neobladder. The DaVinci SystemTM (Intuitive Surgical, Mountain View, CA, USA) was utilized to perform the procedure. Results: Utilizing the DaVinci System the operation could be performed without any complications. Operating time was 8.5 hours, blood loss was 200 ml. The oncologic as well as the functional result of the reservoir were excellent. Discussion: We here demonstrated that sophisticated laparoscopic procedures like the intra-abdominal formation of an orthotopic neobladder are accomplishable with robotic assistance. # 2003 Elsevier B.V. All rights reserved. Keywords: DaVinci; Radical cystectomy; Robotic-assisted
1. Introduction Laparoscopic surgery in conventional and especially robotic-assisted technique has expanded from simple ablative operations (e.g. nephrectomy) to more challenging ablative (e.g. radical prostatectomy) and even reconstructive (e.g. pyeloplasty) procedures. In case of tumor surgery, results of the laparoscopic approach equals that of open surgery [1]. Since the introduction of the robotic-assisted technique in urology in May 2000 this technique is preferred in our department [2]. Excellent three-dimensional (3D) vision (InSite Vision SystemTM),physiological eye-hand coordination, extended grades of freedom (EndowristTM technology) and a fast learning curve are the advantages of this system. Therefore, major surgical procedures can more *
Corresponding author. Tel. þ49-69-6301-7675; Fax: þ49-69-6301-6464. E-mail address: [email protected] (W.-D. Beecken).
easily be performed in a laparoscopic fashion. Here, we report the initial case of a laparoscopic robotic-assisted radical cystectomy and complete intra-abdominal formation of an orthotopic ileal neobladder for the treatment of transitional cell carcinoma of the bladder.
2. Patient and surgical technique A 58-year-old white male with a 9-year history of bladder carcinoma and multiple transuretheral resections as well as intravesical instillation therapy was transferred to our department for radical cystectomy for invasive transitional cell carcinoma. After obtaining informed consent and standard mechanical bowel preparation, we performed the whole procedure in a laparoscopic robotic-assisted manner. The procedure was performed using a DaVinci System (Intuitive Surgical, Mountain View, CA, USA). A two to three centimeter paraumbilical midline
0302-2838/$ – see front matter # 2003 Elsevier B.V. All rights reserved. doi:10.1016/S0302-2838(03)00301-4
338
W.-D. Beecken et al. / European Urology 44 (2003) 337–339
minilaparotomy is made (Hassan technique) and two special DaVinci 8 mm trocars are inserted by digital guidance in the pararectal lines on both sides. Hereafter, a 12 mm standard trocar is placed in the median laparotomy. After attaching the 3D endocamera to the medial robotic arm, two laparoscopic tools are inserted via the lateral 8 mm trocars under direct visual control and are connected to the left and right robotic arm. We usually start the procedure with a DeBakey forceps on the left and a cautery hook on the right side. Within the procedure the DeBakey forceps on the left side is rarely changed, while the cautery hook on the right side is inbetween changed to round tip scissors or a needle driver. For supportive actions of the assistant and the surgical nurse (e.g. holding of structures or evacuation of lymph nodes) we insert two additional 10 mm standard trocars. Trocar locations are demonstrated in Fig. 1a and b. After performing bilateral lymphadenectomy of the iliacal and fossa obturatoria lymph nodes, both ureters were clipped distally and transsected proximally to
Fig. 1. (a) Cartoon of trocar positions. (b) Photo of typical trocar positions. Initially, a standard 12 mm trocar is inserted paraumbilically for access of the 3D laparoscope (1); two special 8 mm trocars are placed pararectally for the access of the endowristed laparoscopic tools (2). During the procedure, two additional 10 mm trocars (3) were inserted bilaterally into the lower abdomen to allow access of standard laparoscopic tools as bipolar graspers, suction/irrigation device, clip applier and bowel stapler.
the clips. Then, the bladder peritoneum was dissected beginning at the Excavatio rectovesicalis. The seminal vesicles and spermatic ducts were developed and Denonvillier’ fascia was incised at the base of the seminal vesicles. Subsequently, the urachus was dissected close to the umbilicus and Retzius space thus entered. The endopelvic fascia was incised bilaterally, the puboprostatic ligaments cut and the venous plexus was ligated and dissected. Up to this point the technique was mainly adopted from our experience of performing robotic-assisted laparoscopic radical prostatectomy with the DaVinci System [2]. The bladder was then lifted anteriorly to allow dissection of the lateral pedicles of the bladder and the prostate. After dissection of the venous plexus, the urethra was transected with scissors at the prostatic apex. Upon completion of the dissection, the specimen was packed in a large organ bag and stored within the abdominal cavity until the end of the procedure. In order to construct the ileal neobladder according to Hautmann, the ileum was identified 15 to 20 cm proximal of the ileocecal valve and 60 cm of terminal ileum were dissected using a 35 mm ETS-FLEX-Endoscopic Articulating Linear Cutter (Endopath1, Ethicon Endo.Surgery, Inc., Norderstedt, Germany). First, the position of the neobladder neck was defined at the caudal end of the aboral ileal loop, 15 cm from the aboral end. After anti-mesenteric incision of this segment over a distance of 5 cm at and insertion of a 22 Chr. NeoblasenBallon-Katheter1 (Uromed, Oststeinbeck, Germany) through the urethra, the reservoir was sutured to the urethral stump using 5 interrupted vicryl 3-0 sutures. Hereafter, the anti-mesenteric incision of the whole bowel segment was completed with the exception of the oral and aboral ends that were left tubularized for ureteral anastomosis. After building the dorsal neobladder plate by 3 running sutures with Maxon 3-0, two 7 F 70 cm Optiflex MonoJ catheters (OptiMed, Ettlingen, Germany) were inserted via a cystostomy trocar into the abdomen and guided into the ureters and fixed to the cutis with a suture. The ureters were then spatulated and a wide anastomosis was formed with the respective tubular end of the bowel segment over the MonoJ catheter. Then, the anterior wall of the neobladder was closed with a fourth running suture. Hereafter, the midline incision was extended to fit the organ bag and the specimen was removed. As a final step, the ileal ends were exteriorized through the midline incision to facilitate the bowel-to-bowel anastomosis. Operation time was 8.5 hours and the intra-operative blood loss was 200 ml. There were no intra-operative complications. The patient was mobilized on the first
W.-D. Beecken et al. / European Urology 44 (2003) 337–339
post-operative day and there were no complications during the post-operative clinical course. Post operatively, the neobladder was drained for 10 days and a cystogram was performed before the cartheter was removed. The cystogram did not show any extravasations of urine. Histology indicated a large pT2a, G2 transitional cell carcinoma of the bladder. All margins were free of tumor infiltration and no metastases to the lymph nodes were observed. Therefore, we assume that the procedure had curative efficacy. Five months after the procedure the patient is well and free of tumor. The urine reservoir demonstrates excellent function.
3. Discussion We here present the worldwide first case of an robotic-assisted laparoscopic cystectomy and formation of an orthotopic ileal neobladder where the complete procedure was performed intra-abdominally. Turk et al. reported a case of a conventional laparoscopic cystectomy and insertion of the ureters in the sigmoid [3]. However, the formation of an orthotopic ileal neobladder has never been performed intraabdominally via a robotic-assisted laparoscopic approach. Meng et al. just recently reported the first case of a laparoscopic enterocystoplasty [4]. Operative time for this conventionally laparoscopic performed procedure was indicated with 9 hours. It is remarkable that in our case the whole operation did not take longer than 8.5 hours, while the procedure is much more complex. We understand this as an advantage of the robotic-assisted technique, which are the extended grades of freedome (EndowristTM technology), the superb 3D and 10 magnification visual system and the good eye-hand coordination enabled by the DaVinci System. On the other hand the DaVinci System is a new
339
and cost intensive laparoscopic tool what makes it available in specialized centers only. Concerning the surgical technique the early dissection of the ureters might lead to problems if, for any reasons, the procedure should be aborted. However, the early dissection of the ureters makes the bladder more mobile in this early operative stage. The ligation and dissection of the dorsomedial visical pedicles was performed relatively late during the procedure compared to open surgery. For oncological reasons the early transsection of the dorsomedial vesical pedicles might be advantageous to avoid tumor cell dissemination. However, the manipulation of the bladder is much less rigorous as it is during the open procedure. Furthermore, the pressure of the pneumo-peritoneum causes collapse of the vulnerable tumor vasculature therefore, the dissemination of tumor cells should be avoided or at least reduced anyway. Another difference to the open technique is that the ileal segment is anastomosed to the uretheral stump before the reservoir was constructed. This was done for a better view of the uretheral anastomosis that can be achieved with the DaVinci system. Possible traction on the anastomosis while suturing the ileal reservoir can be avoided because of the sensitive manipulation in connection with the 10 magnification visual system and the extended grades of freedom. Nerve-sparing technique was not attempted during this case however, using the exellent 3D and 10 magnified visual system the portrayal of the pedicle structures is much better compared to open surgery and nerve-spearing is possible in principle. However, while in this report we have demonstrated that the radical cystectomy and intra-abdominally construction of an ileal reservoir is possible via a laparoscopic approach in principle, large series have to determine if surgical results and functionality equal those of open surgery to make this approach a standard procedure.
References [1] Portis AJ, Yan Y, Landman J, Chen C, Barrett PH, Fentie DD, et al. Long-term followup after laparoscopic radical nephrectomy. J Urol 2002;167:1257–62. [2] Binder J, Kramer W. Robotically assisted laparoscopic redical prostatectomy. BJU Int 2001;87:408. [3] Turk I, Deger S, Winkelmann B, Schonberger B, Loening SA. Laparoscopic radical cystectomy with continent urinary diversion
(rectal sigmoid pouch) performed completely intracorporeally: the initial 5 cases. J Urol 2001;165:1863–6. [4] Meng MV, Anwar HP, Elliott SP, Stoller ML. Pure laparoscopic enterocystoplasty. J Urol 2002;167:1386.
European Urology 44 (2003) 337–339
Robotic-Assisted Laparoscopic Radical Cystectomy and Intra-Abdominal Formation of an Orthotopic Ileal Neobladder W.-D. Beecken*, M. Wolfram, T. Engl, W. Bentas, M. Probst, R. Blaheta, A. Oertl, D. Jonas, J. Binder Department of Urology and Pediatric Urology, J.W. Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany Accepted 4 June 2003
Abstract Purpose: To describe our technique of robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic neobladder (Hautmann) for treatment of transitional cell carcinoma of the bladder. Methods: We describe our surgical technique in the worldwide first attempt to perform a robotic-assisted laparoscopic radical cystectomy and completely intra-abdominal formation of an orthotopic neobladder. The DaVinci SystemTM (Intuitive Surgical, Mountain View, CA, USA) was utilized to perform the procedure. Results: Utilizing the DaVinci System the operation could be performed without any complications. Operating time was 8.5 hours, blood loss was 200 ml. The oncologic as well as the functional result of the reservoir were excellent. Discussion: We here demonstrated that sophisticated laparoscopic procedures like the intra-abdominal formation of an orthotopic neobladder are accomplishable with robotic assistance. # 2003 Elsevier B.V. All rights reserved. Keywords: DaVinci; Radical cystectomy; Robotic-assisted
1. Introduction Laparoscopic surgery in conventional and especially robotic-assisted technique has expanded from simple ablative operations (e.g. nephrectomy) to more challenging ablative (e.g. radical prostatectomy) and even reconstructive (e.g. pyeloplasty) procedures. In case of tumor surgery, results of the laparoscopic approach equals that of open surgery [1]. Since the introduction of the robotic-assisted technique in urology in May 2000 this technique is preferred in our department [2]. Excellent three-dimensional (3D) vision (InSite Vision SystemTM),physiological eye-hand coordination, extended grades of freedom (EndowristTM technology) and a fast learning curve are the advantages of this system. Therefore, major surgical procedures can more *
Corresponding author. Tel. þ49-69-6301-7675; Fax: þ49-69-6301-6464. E-mail address: [email protected] (W.-D. Beecken).
easily be performed in a laparoscopic fashion. Here, we report the initial case of a laparoscopic robotic-assisted radical cystectomy and complete intra-abdominal formation of an orthotopic ileal neobladder for the treatment of transitional cell carcinoma of the bladder.
2. Patient and surgical technique A 58-year-old white male with a 9-year history of bladder carcinoma and multiple transuretheral resections as well as intravesical instillation therapy was transferred to our department for radical cystectomy for invasive transitional cell carcinoma. After obtaining informed consent and standard mechanical bowel preparation, we performed the whole procedure in a laparoscopic robotic-assisted manner. The procedure was performed using a DaVinci System (Intuitive Surgical, Mountain View, CA, USA). A two to three centimeter paraumbilical midline
0302-2838/$ – see front matter # 2003 Elsevier B.V. All rights reserved. doi:10.1016/S0302-2838(03)00301-4
338
W.-D. Beecken et al. / European Urology 44 (2003) 337–339
minilaparotomy is made (Hassan technique) and two special DaVinci 8 mm trocars are inserted by digital guidance in the pararectal lines on both sides. Hereafter, a 12 mm standard trocar is placed in the median laparotomy. After attaching the 3D endocamera to the medial robotic arm, two laparoscopic tools are inserted via the lateral 8 mm trocars under direct visual control and are connected to the left and right robotic arm. We usually start the procedure with a DeBakey forceps on the left and a cautery hook on the right side. Within the procedure the DeBakey forceps on the left side is rarely changed, while the cautery hook on the right side is inbetween changed to round tip scissors or a needle driver. For supportive actions of the assistant and the surgical nurse (e.g. holding of structures or evacuation of lymph nodes) we insert two additional 10 mm standard trocars. Trocar locations are demonstrated in Fig. 1a and b. After performing bilateral lymphadenectomy of the iliacal and fossa obturatoria lymph nodes, both ureters were clipped distally and transsected proximally to
Fig. 1. (a) Cartoon of trocar positions. (b) Photo of typical trocar positions. Initially, a standard 12 mm trocar is inserted paraumbilically for access of the 3D laparoscope (1); two special 8 mm trocars are placed pararectally for the access of the endowristed laparoscopic tools (2). During the procedure, two additional 10 mm trocars (3) were inserted bilaterally into the lower abdomen to allow access of standard laparoscopic tools as bipolar graspers, suction/irrigation device, clip applier and bowel stapler.
the clips. Then, the bladder peritoneum was dissected beginning at the Excavatio rectovesicalis. The seminal vesicles and spermatic ducts were developed and Denonvillier’ fascia was incised at the base of the seminal vesicles. Subsequently, the urachus was dissected close to the umbilicus and Retzius space thus entered. The endopelvic fascia was incised bilaterally, the puboprostatic ligaments cut and the venous plexus was ligated and dissected. Up to this point the technique was mainly adopted from our experience of performing robotic-assisted laparoscopic radical prostatectomy with the DaVinci System [2]. The bladder was then lifted anteriorly to allow dissection of the lateral pedicles of the bladder and the prostate. After dissection of the venous plexus, the urethra was transected with scissors at the prostatic apex. Upon completion of the dissection, the specimen was packed in a large organ bag and stored within the abdominal cavity until the end of the procedure. In order to construct the ileal neobladder according to Hautmann, the ileum was identified 15 to 20 cm proximal of the ileocecal valve and 60 cm of terminal ileum were dissected using a 35 mm ETS-FLEX-Endoscopic Articulating Linear Cutter (Endopath1, Ethicon Endo.Surgery, Inc., Norderstedt, Germany). First, the position of the neobladder neck was defined at the caudal end of the aboral ileal loop, 15 cm from the aboral end. After anti-mesenteric incision of this segment over a distance of 5 cm at and insertion of a 22 Chr. NeoblasenBallon-Katheter1 (Uromed, Oststeinbeck, Germany) through the urethra, the reservoir was sutured to the urethral stump using 5 interrupted vicryl 3-0 sutures. Hereafter, the anti-mesenteric incision of the whole bowel segment was completed with the exception of the oral and aboral ends that were left tubularized for ureteral anastomosis. After building the dorsal neobladder plate by 3 running sutures with Maxon 3-0, two 7 F 70 cm Optiflex MonoJ catheters (OptiMed, Ettlingen, Germany) were inserted via a cystostomy trocar into the abdomen and guided into the ureters and fixed to the cutis with a suture. The ureters were then spatulated and a wide anastomosis was formed with the respective tubular end of the bowel segment over the MonoJ catheter. Then, the anterior wall of the neobladder was closed with a fourth running suture. Hereafter, the midline incision was extended to fit the organ bag and the specimen was removed. As a final step, the ileal ends were exteriorized through the midline incision to facilitate the bowel-to-bowel anastomosis. Operation time was 8.5 hours and the intra-operative blood loss was 200 ml. There were no intra-operative complications. The patient was mobilized on the first
W.-D. Beecken et al. / European Urology 44 (2003) 337–339
post-operative day and there were no complications during the post-operative clinical course. Post operatively, the neobladder was drained for 10 days and a cystogram was performed before the cartheter was removed. The cystogram did not show any extravasations of urine. Histology indicated a large pT2a, G2 transitional cell carcinoma of the bladder. All margins were free of tumor infiltration and no metastases to the lymph nodes were observed. Therefore, we assume that the procedure had curative efficacy. Five months after the procedure the patient is well and free of tumor. The urine reservoir demonstrates excellent function.
3. Discussion We here present the worldwide first case of an robotic-assisted laparoscopic cystectomy and formation of an orthotopic ileal neobladder where the complete procedure was performed intra-abdominally. Turk et al. reported a case of a conventional laparoscopic cystectomy and insertion of the ureters in the sigmoid [3]. However, the formation of an orthotopic ileal neobladder has never been performed intraabdominally via a robotic-assisted laparoscopic approach. Meng et al. just recently reported the first case of a laparoscopic enterocystoplasty [4]. Operative time for this conventionally laparoscopic performed procedure was indicated with 9 hours. It is remarkable that in our case the whole operation did not take longer than 8.5 hours, while the procedure is much more complex. We understand this as an advantage of the robotic-assisted technique, which are the extended grades of freedome (EndowristTM technology), the superb 3D and 10 magnification visual system and the good eye-hand coordination enabled by the DaVinci System. On the other hand the DaVinci System is a new
339
and cost intensive laparoscopic tool what makes it available in specialized centers only. Concerning the surgical technique the early dissection of the ureters might lead to problems if, for any reasons, the procedure should be aborted. However, the early dissection of the ureters makes the bladder more mobile in this early operative stage. The ligation and dissection of the dorsomedial visical pedicles was performed relatively late during the procedure compared to open surgery. For oncological reasons the early transsection of the dorsomedial vesical pedicles might be advantageous to avoid tumor cell dissemination. However, the manipulation of the bladder is much less rigorous as it is during the open procedure. Furthermore, the pressure of the pneumo-peritoneum causes collapse of the vulnerable tumor vasculature therefore, the dissemination of tumor cells should be avoided or at least reduced anyway. Another difference to the open technique is that the ileal segment is anastomosed to the uretheral stump before the reservoir was constructed. This was done for a better view of the uretheral anastomosis that can be achieved with the DaVinci system. Possible traction on the anastomosis while suturing the ileal reservoir can be avoided because of the sensitive manipulation in connection with the 10 magnification visual system and the extended grades of freedom. Nerve-sparing technique was not attempted during this case however, using the exellent 3D and 10 magnified visual system the portrayal of the pedicle structures is much better compared to open surgery and nerve-spearing is possible in principle. However, while in this report we have demonstrated that the radical cystectomy and intra-abdominally construction of an ileal reservoir is possible via a laparoscopic approach in principle, large series have to determine if surgical results and functionality equal those of open surgery to make this approach a standard procedure.
References [1] Portis AJ, Yan Y, Landman J, Chen C, Barrett PH, Fentie DD, et al. Long-term followup after laparoscopic radical nephrectomy. J Urol 2002;167:1257–62. [2] Binder J, Kramer W. Robotically assisted laparoscopic redical prostatectomy. BJU Int 2001;87:408. [3] Turk I, Deger S, Winkelmann B, Schonberger B, Loening SA. Laparoscopic radical cystectomy with continent urinary diversion
(rectal sigmoid pouch) performed completely intracorporeally: the initial 5 cases. J Urol 2001;165:1863–6. [4] Meng MV, Anwar HP, Elliott SP, Stoller ML. Pure laparoscopic enterocystoplasty. J Urol 2002;167:1386.