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V9 Genital organ preservation during radical cystectomy and orthotopic bladder substitution in selected women
V9
VIO
G E N I T A L O R G A N PRESERVATION D U R I N G R A D I C A L C Y S T E C T O M Y AND O R T H O T O P I C B L A D D E R SUBSTITUTION IN SELECTED WOMEN
L A P A R O S C O P I C R A D I C A L C Y S T E C T O M Y + I L E A L CONDUIT 1N WOMEN
Ali-E1-Dein B., Mosbah A., Osman Y., Abdel-Latif M., Eraky I., Shaaban A., Ghoneim M. Urology and Nephrology Centre, University of Mansoura, Dept. of Urology, Mansora, Egypt I N T R O D U C T I O N & O B J E C T I V E S : In previous studies the scientific background and rationale for genital organ preservation during radical cysteetomy in some selected women has been provided. The current video clip demonstrates the technique and results of this new approach. M A T E R I A L & METHODS: From Dec. 2002 to June 2004, 5 cases with a mean age of 48 years were included into this prospective study. Preoperative inclusion criteria included low stage (T2b NO Mo or less), low grade (G1 or G2), unifocal tumours and tumours away from the trigone. The women should be sexually active and relatively young. The internal genital organs should be free by clinical examination and imaging (CT or MRI). Bilateral iliac lymphadenectomy is carried out with preservation of the ovary and ovarian vessels on 1 or both sides. The peritoneum covering the vesicouterine pouch is incised and the plane between the bladder anteriorly and the uterus posteriorly is developed. The posterolateral band of tissue, which contains the vascular pedicle and extends between the bladder anteriorly and the uterus and rectum posteriorly, is then ligated and divided. The deep dorsal venous complex is ligated, the urethra is transected and the mass is removed. The urethral stump is held with six 3/0 vicryl sutures in preparation for orthotopic substitution. RESULTS: Follow-up ranged from 6 to 21 months with a mean of 13. So far no local recurrence in the retained genital organs as noted. Chronic retention was not demonstrated in any case. Daytime and nighttime continence was achieved in 100% and 80%, respectively. Sexual life was regained after 2 months. CONCLUSIONS: Genital sparing cystectomy for bladder cancer is feasible in some selected women. It provides a good functional outcome and a better quality of life. So far, the ontological outcome is favourable. However, a larger number of patients and longer follow-up are needed to assess the final oncological outcome of this new approach.
Baumert H. 1, Khan E 2, Morgan R. 2, Patel H. 2, A1-Akraa M. 2, Kaisary A. 2 IHospital Saint Joseph, Department of Urology, Paris, France, 2Royal Free Hospital, Department of Urology, London, United Kingdom I N T R O D U C T I O N & OBJECTIVES: This film demonstrates the feasibility of laparoscopic surgery in obese patients. M A T E R I A L & METHODS: Laparoscopic radical cystectomy was planned in a woman with a pT2 G3 + pTis bladder cancer. Her BMI was 44 (1.5m; 100 kg). The patient was placed supine with Trendelenberg tilt. Five trocars were used:one 10mm and four 5ram ports. The different steps of the operation were : 1- Extensive iliac lymph node dissection with frozen section, 2- Dissection of the tubo-ovarian structures, 3- Dissection and division of the ureters, 4- Dissection of the posterolateral aspect of the bladder up to the vaginal pouch which was located by introducing a vaginal valve, 5- Section of the urachus and dissection of the anterior part of the bladder, 6- Dissection of the bladder pedicles and resection of the anterior part of the vagina, 7- Dissection of the urethra, 8- Removal of the specimen in a bag through the vaginal opening, 9- Preparation of the bowel intracorporeally, 10- Extra-corporeal bowel anastomosis was done through a 2 cm incision, 11- Intra-corporeal uretero-ileal anastomosis using Wallace's technique, 12- Stoma formation. RESULTS: The operative time was 420 min and the blood loss 800 mls. There were no peri-operative complications. Intestinal transit recurred on day 2 and the patient began oral intake on day 3. Ureteral catheters were removed stepwise on day 6 and day 7. The patient was discharged on day 8. The residual mmour found in the bladder was classified pT1 G3 + pTis. The margins and the lymph nodes were negative. The post-operative IVP was normal. CONCLUSIONS: Cystectomy and ileal conduit formation is feasible by laparoscopy, even in obese patients. This approach allows a reduction of the postoperative ileus as well as a decrease in hospital stay.
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V12
LAPAROSCOPIC RADICAL CYSTECTOMY WITH MAINZ RECTAL
LAPAROSCOPIC RADICAL CYSTECTOMY WITH ORTHOTOPIC ILEAL NEOBLADDER
P O U C H URINARY DIVERSION IoualalenA., ZianiM. Capio Polyclinique du Parc, Urology, Toulouse, France I N T R O D U C T I O N & OBJECTIVES: This film describes the running-on of a radical cystectomy with a rectal mainz pouch urinary diversion totally laparoscopic. M A T E R I A L & METHODS: A sixty year old woman developed a grade 3 pt2 bladder carcinoma. This film shows first the laparoscopic radical cystectomy using 3 ten m m and 2 five m m trocars. Dissection of pelvic adhesions from a previous hysterectomy. Bilateral lymph node dissection is carried on. The surgical conventional procedure is briefly described (experience based on five cases), followed by the laparoscopic technique. Two 10 cmm sigmoid loops are anastomosed using stapler devices and running suture at the posterior wall, both ureteres are reimplanted with a carney anti reflux procedure. Both ureteral catheters are routed out through a 22 f rectal couvelaire catheter. Closure of the anterior wall of the pouch with running suture. Drainage. The specimen is removed through the enlarged port of the camera. RESULTS: Bloodless 500 ec, the operative time was 8 hours and 30 minutes, the
Hoznek A. 1, Vordos D. 1, Matthew G. 2, Salomon L / , De la Taille A. 1, Yiou R?, Abbou C.C. 1 I CHU Henri Mondor, Service d'Urologie, Cr6teil, France, 2Mayo Clinic, Department of Urology, Rochester, United States INTRODUCTION & OBJECTIVES: The technique of radical cystoprostatectomy and orthotopic ileal neobladder remains one of the most invasive surgical procedures in urology. With the rapid evolution of laparseopic surgery, this complex technique can now be performed using a minimally invasive approach. MATERIAL & METHODS: The intervention consists of the following steps: 1. Insertion of five trocars in a fan-like configuration. 2. Extended bilateral lymphadenectomy including obturator and iliac nodes. 3. The ureters are clipped and sectioned, a biopsy is sent for frozen section analysis. 4. Peritoneal incision at the Douglas pouch, dissection of seminal vesicles and posterior aspect of the prostate. 5. Seeti°n °f pr°static pedicles with an end°-GIA" 6. Incision of endopelvic fascia on both sides, dissection of the lateral prostate and apex. 7. Dissection of bladder from the anterior abdominal wall, ligature and section of Santorini plexus, ligature and section of the urethra. The operative specimen is put into an endo-catch. 8. The left utter is passed under the root of the sigmoid mesentery. 9. Section of 60 cm small bowel, stapled side-to-side anastomosis with an endo-GIA to re-establis bowel continuity. 10. Implantation of the ureters into the afferent loop according to the technique of Wallace. 11. Operative specimen is removed through a 7 cm median abdominal incision. The Studer type neobladder is created by exteriorizing the loop. 12. Closure of the parietal incison. 13. Ileal-urethral anastomosis with a running suture, according to the method of Van Velthovan.
hospital stay was 12 days, with no complication.
RESULTS: The procedure is feasible and reproducible. Operative time for the initial procedures was 6 hours.
CONCLUSIONS: Laparoscopic radical cystectomy with mainz rectal pouch
CONCLUSIONS: Based on our experience with laparoscopic radical prostatectomy, the learning curve of laparoscopic assisted radical cystectomy is short. Postoperative pain is decreased and recovery is quicker. The task that remains is to evaluate long term oncologic results.
diversion in woman is suitable, feasible, safe and effective. However it should be considered after significant experience with laparoscopic surgery.
European Urology Supplements 4 (2005) No. 3, pp. 274
VIO
G E N I T A L O R G A N PRESERVATION D U R I N G R A D I C A L C Y S T E C T O M Y AND O R T H O T O P I C B L A D D E R SUBSTITUTION IN SELECTED WOMEN
L A P A R O S C O P I C R A D I C A L C Y S T E C T O M Y + I L E A L CONDUIT 1N WOMEN
Ali-E1-Dein B., Mosbah A., Osman Y., Abdel-Latif M., Eraky I., Shaaban A., Ghoneim M. Urology and Nephrology Centre, University of Mansoura, Dept. of Urology, Mansora, Egypt I N T R O D U C T I O N & O B J E C T I V E S : In previous studies the scientific background and rationale for genital organ preservation during radical cysteetomy in some selected women has been provided. The current video clip demonstrates the technique and results of this new approach. M A T E R I A L & METHODS: From Dec. 2002 to June 2004, 5 cases with a mean age of 48 years were included into this prospective study. Preoperative inclusion criteria included low stage (T2b NO Mo or less), low grade (G1 or G2), unifocal tumours and tumours away from the trigone. The women should be sexually active and relatively young. The internal genital organs should be free by clinical examination and imaging (CT or MRI). Bilateral iliac lymphadenectomy is carried out with preservation of the ovary and ovarian vessels on 1 or both sides. The peritoneum covering the vesicouterine pouch is incised and the plane between the bladder anteriorly and the uterus posteriorly is developed. The posterolateral band of tissue, which contains the vascular pedicle and extends between the bladder anteriorly and the uterus and rectum posteriorly, is then ligated and divided. The deep dorsal venous complex is ligated, the urethra is transected and the mass is removed. The urethral stump is held with six 3/0 vicryl sutures in preparation for orthotopic substitution. RESULTS: Follow-up ranged from 6 to 21 months with a mean of 13. So far no local recurrence in the retained genital organs as noted. Chronic retention was not demonstrated in any case. Daytime and nighttime continence was achieved in 100% and 80%, respectively. Sexual life was regained after 2 months. CONCLUSIONS: Genital sparing cystectomy for bladder cancer is feasible in some selected women. It provides a good functional outcome and a better quality of life. So far, the ontological outcome is favourable. However, a larger number of patients and longer follow-up are needed to assess the final oncological outcome of this new approach.
Baumert H. 1, Khan E 2, Morgan R. 2, Patel H. 2, A1-Akraa M. 2, Kaisary A. 2 IHospital Saint Joseph, Department of Urology, Paris, France, 2Royal Free Hospital, Department of Urology, London, United Kingdom I N T R O D U C T I O N & OBJECTIVES: This film demonstrates the feasibility of laparoscopic surgery in obese patients. M A T E R I A L & METHODS: Laparoscopic radical cystectomy was planned in a woman with a pT2 G3 + pTis bladder cancer. Her BMI was 44 (1.5m; 100 kg). The patient was placed supine with Trendelenberg tilt. Five trocars were used:one 10mm and four 5ram ports. The different steps of the operation were : 1- Extensive iliac lymph node dissection with frozen section, 2- Dissection of the tubo-ovarian structures, 3- Dissection and division of the ureters, 4- Dissection of the posterolateral aspect of the bladder up to the vaginal pouch which was located by introducing a vaginal valve, 5- Section of the urachus and dissection of the anterior part of the bladder, 6- Dissection of the bladder pedicles and resection of the anterior part of the vagina, 7- Dissection of the urethra, 8- Removal of the specimen in a bag through the vaginal opening, 9- Preparation of the bowel intracorporeally, 10- Extra-corporeal bowel anastomosis was done through a 2 cm incision, 11- Intra-corporeal uretero-ileal anastomosis using Wallace's technique, 12- Stoma formation. RESULTS: The operative time was 420 min and the blood loss 800 mls. There were no peri-operative complications. Intestinal transit recurred on day 2 and the patient began oral intake on day 3. Ureteral catheters were removed stepwise on day 6 and day 7. The patient was discharged on day 8. The residual mmour found in the bladder was classified pT1 G3 + pTis. The margins and the lymph nodes were negative. The post-operative IVP was normal. CONCLUSIONS: Cystectomy and ileal conduit formation is feasible by laparoscopy, even in obese patients. This approach allows a reduction of the postoperative ileus as well as a decrease in hospital stay.
Vll
V12
LAPAROSCOPIC RADICAL CYSTECTOMY WITH MAINZ RECTAL
LAPAROSCOPIC RADICAL CYSTECTOMY WITH ORTHOTOPIC ILEAL NEOBLADDER
P O U C H URINARY DIVERSION IoualalenA., ZianiM. Capio Polyclinique du Parc, Urology, Toulouse, France I N T R O D U C T I O N & OBJECTIVES: This film describes the running-on of a radical cystectomy with a rectal mainz pouch urinary diversion totally laparoscopic. M A T E R I A L & METHODS: A sixty year old woman developed a grade 3 pt2 bladder carcinoma. This film shows first the laparoscopic radical cystectomy using 3 ten m m and 2 five m m trocars. Dissection of pelvic adhesions from a previous hysterectomy. Bilateral lymph node dissection is carried on. The surgical conventional procedure is briefly described (experience based on five cases), followed by the laparoscopic technique. Two 10 cmm sigmoid loops are anastomosed using stapler devices and running suture at the posterior wall, both ureteres are reimplanted with a carney anti reflux procedure. Both ureteral catheters are routed out through a 22 f rectal couvelaire catheter. Closure of the anterior wall of the pouch with running suture. Drainage. The specimen is removed through the enlarged port of the camera. RESULTS: Bloodless 500 ec, the operative time was 8 hours and 30 minutes, the
Hoznek A. 1, Vordos D. 1, Matthew G. 2, Salomon L / , De la Taille A. 1, Yiou R?, Abbou C.C. 1 I CHU Henri Mondor, Service d'Urologie, Cr6teil, France, 2Mayo Clinic, Department of Urology, Rochester, United States INTRODUCTION & OBJECTIVES: The technique of radical cystoprostatectomy and orthotopic ileal neobladder remains one of the most invasive surgical procedures in urology. With the rapid evolution of laparseopic surgery, this complex technique can now be performed using a minimally invasive approach. MATERIAL & METHODS: The intervention consists of the following steps: 1. Insertion of five trocars in a fan-like configuration. 2. Extended bilateral lymphadenectomy including obturator and iliac nodes. 3. The ureters are clipped and sectioned, a biopsy is sent for frozen section analysis. 4. Peritoneal incision at the Douglas pouch, dissection of seminal vesicles and posterior aspect of the prostate. 5. Seeti°n °f pr°static pedicles with an end°-GIA" 6. Incision of endopelvic fascia on both sides, dissection of the lateral prostate and apex. 7. Dissection of bladder from the anterior abdominal wall, ligature and section of Santorini plexus, ligature and section of the urethra. The operative specimen is put into an endo-catch. 8. The left utter is passed under the root of the sigmoid mesentery. 9. Section of 60 cm small bowel, stapled side-to-side anastomosis with an endo-GIA to re-establis bowel continuity. 10. Implantation of the ureters into the afferent loop according to the technique of Wallace. 11. Operative specimen is removed through a 7 cm median abdominal incision. The Studer type neobladder is created by exteriorizing the loop. 12. Closure of the parietal incison. 13. Ileal-urethral anastomosis with a running suture, according to the method of Van Velthovan.
hospital stay was 12 days, with no complication.
RESULTS: The procedure is feasible and reproducible. Operative time for the initial procedures was 6 hours.
CONCLUSIONS: Laparoscopic radical cystectomy with mainz rectal pouch
CONCLUSIONS: Based on our experience with laparoscopic radical prostatectomy, the learning curve of laparoscopic assisted radical cystectomy is short. Postoperative pain is decreased and recovery is quicker. The task that remains is to evaluate long term oncologic results.
diversion in woman is suitable, feasible, safe and effective. However it should be considered after significant experience with laparoscopic surgery.
European Urology Supplements 4 (2005) No. 3, pp. 274