Robot-Assisted Laparoscopic Cystoprostatectomy with Extended Pelvic Lymphadenectomy,Extracorporeal Enterocystoplasty,and Intracorporeal Enterourethral Anastomosis: Initial Montsouris Experience *

Abstract

Background and Purpose:

Radical cystectomy is the gold standard for management of invasive and recurrent high-grade superficial bladder cancer. We present our initial experience with robot-assisted laparoscopic cystoprostatectomy (RALCP) with extended pelvic lymphadenectomy (epLAD) and intracorporeal enterourethral anastomosis (IEUA). A video demonstrating our technique is available online at www.liebertonline.com/end.

Patients and Methods:

Between April 2008 and March 2009, nine patients underwent RALCP with epLAD and IEUA at our institution. Operative technique, as described in detail (with video), was assessed for feasibility. A video demonstrating this technique is available online at www.liebertonline.com/end. Preoperative patient characteristics, operative data, as well as perioperative and pathologic outcomes were analyzed. All data were collected prospectively.

Results:

Median total operative time was 270 minutes (range 210–330): 60 minutes, bilateral epLAD; 90 minutes, RALCP; 60 minutes, open enterocystoplasty; 60 minutes (range 45–90), IEUA. Median blood loss was 400 mL (range 200–900 mL). All surgical margins were negative. Median number of lymph nodes removed was 11 (range 4–21). Postoperative complications were noted in three patients and included urinoma (n = 1), pyelonephritis (n = 1), and hematoma (n = 1).

Conclusion:

RALCP is feasible and can be performed safely and effectively with acceptable operative, pathologic, and short-term clinical outcomes. More experience with longer follow-up is necessary to further assess clinical and oncologic outcomes of robotic assisted laparoscopic cystectomy for treatment of bladder cancer.

Introduction

R adical cystectomy with pelvic lymphadenectomy is the gold standard for management of invasive and recurrent high-grade superficial bladder cancer.^1,2 Widespread acceptance of laparoscopic urologic surgery for management of renal tumors and prostate cancer has led to increasing application of minimally invasive techniques for surgical management of bladder cancer.

The first laparoscopic cystectomy was reported by Parra and associates³ in 1992, followed by reports of laparoscopic radical cystectomy (LRC) for muscle-invasive bladder cancer by Sanchez de Badajoz and colleagues⁴ and Puppo and coworkers⁵ in 1993 and 1995, respectively. Gill and colleagues^6,7 performed LRC with the first purely intracorporeal ileoconduit urinary diversion in 2000 and first intracorporeal orthotopic Studer neobladder reconstruction in 2002.

As more procedures were performed, early series followed that suggested oncologic outcomes comparable to open cystectomy with less blood loss, decreased postoperative pain, and quicker recovery in patients who were undergoing LRC.^8

–11 More recently, robot-assisted laparoscopic radical cystectomy (RALC) has emerged as a minimally invasive alternative to pure LRC.

We present our technique and initial experience with robotic assisted laparoscopic cystoprostatectomy. In addition, we provide video description of our technique for RALCP with extended pelvic lymphadenectomy (epLAD) and intracorporeal enterourethral anastomosis (IEUA).

Patients and Methods

Nine patients underwent RALCP at our institution between April 2008 and March 2009. All RALCP were performed by one surgeon in a center at which there was extensive laparoscopic experience.

Preoperative preparation

All patients completed a mechanical bowel preparation and remained on a clear liquid diet the day before surgery.

Patient positioning and trocar placement

The procedure is performed with a three-arm da Vinci^® robot (Intuitive Surgical, Sunnydale, CA) with five infraumbilical trocars placed in similar configuration as in robot-assisted laparoscopic prostatectomy (RALP). The patient is placed in a modified lithotomy, Trendelenburg position and carefully secured and padded to avoid neuromuscular injury. Pneumoperitoenum is established via the midline infraumbilical (camera port) trocar placed using the Hassan technique.

The first step of the operation then begins with right followed by left extended pelvic lymphadenectomy (epLAD).

Pelvic lymphadenectomy

The peritoneum is incised to expose the iliac vessels. The lymphadenectomy begins distally at the node of Cloquet. The obturator nerve is then identified and its integrity maintained throughout this aspect of the procedure. Once identified, the ureter is dissected distally, ligated with Hem-o-Lok® clips, and transected. The most distal aspect of the free ureteral segment is sent for frozen section histopathologic evaluation. The lymphadenectomy is then continued proximally to just below the aortic bifurcation. The dissection continues laterally to include the external iliac chain.

The same procedure is performed contralaterally, including dissection of the iliac vein, identification of the obturator nerve and epLAD. The left ureter is similarly dissected, ligated with Hem-o-Lok clips, and transected. Once the epLAD is complete, the specimen is placed in an endobag and subsequently removed via the 12-mm camera port.

Cystectoprostatectomy

Posterior dissection: The cystectomy now begins with the posterior dissection. The peritoneum is incised at the pouch of Douglas facilitating dissection of the vasa deferentia and seminal vesicles. Following a plane of dissection close to the seminal vesicles, hemostasis is achieved with bipolar coagulation. Similar technique is used to liberate the seminal vesicles bilaterally. Once free, the glands are grasped and raised to provide anterosuperior traction. The posterior dissection is then continued, maintaining a wide margin with respect to the bladder and the prostate.

Management of the vascular pedicle: The vascular pedicles are next isolated and systematically controlled with Hem-o-Lok clips proximally and bipolar electrocautery distally on the specimen side. Of note, the vasa deferentia visualized laterally during this aspect of the procedure are clipped and then cut. The dissection continues, leading to the prostatic vascular pedicle, which is similarly controlled with Hem-o-Lok clips and then cut. The left vas deferens is similarly managed, as are the ipsilateral vesicoprostatic pedicles, which are controlled without significant blood loss.

Once the bladder and prostate are freed posteriorly, attention is directed toward the anterior dissection.

Anterior dissection: The anterior attachments of the bladder are incised to gain access to the space of Retzius. The obliterated umbilical arteries are ligated with Hem-o-Lok clips and then transected. As the dissection continues, the urachus is controlled and cut laparoscopically, with the most proximal portion later excised via the open incision used to extract the specimen and create the enterocystoplasty (EC). With the anterior aspect of the bladder completely mobilized, focus now turns to dissection of the puboprostatic ligaments and the dorsal vein complex (DVC).

Control of the DVC and apical dissection: The DVC is first controlled with atraumatic forceps, after which a meticulous dissection is performed just anterior to the urethra along the plane between the two structures. The urethra is completely liberated from its surrounding attachments, after which the DVC is controlled with 2.0 polyglactin suture ligature in figure-of-eight fashion. As a measure of security, the proximal urethra is ligated at the prostatourethral junction just before urethral transection. The urethra is then transected (along with fibers of the rectourethralis), thus completing the cystoprostatectomy.

Extracorporeal urinary diversion

Placed in an endobag, the specimen is removed via a 9-cm infraumbilical incision through which the EC is also created. The EC is constructed extracorporeally using our previously described Z configuration.¹⁰ When indicated, ileal conduit urinary diversions are also created extracorporeally in a manner as previously described.¹⁰

Enterourethral anastomosis

Once ready, the neobladder is positioned within the abdominal cavity, after which the robot is reintroduced and used to complete the enterourethral anastomosis. Interrupted 3.0 polyglactin suture is used posteriorly, with the first suture serving as a point of approximation to decrease tension on both the urethra and the EC. The anastomosis is continued anteriorly in running fashion, completing the enterourethral reapproximation. Once complete, an 18F urethral (Foley) catheter is placed, and the anastomosis is tested to ensure watertight closure. A 10-mm round Jackson-Pratt drain is placed via the 5-mm lateral assistant port.

Results

Nine patients underwent RALCP at our institution between April 2008 and March 2009. All patients were men. Preoperative patient characteristics are listed in Table 1. Median age was 63 years (range 44–82 yrs), body mass index 30 (24–32), and American Society of Anesthesiologists score 3 (2–3). One patient had a history of prostate cancer that had been treated with external beam radiation therapy. Three patients had undergone previous abdominal surgery (appendectomy, n = 1; inguinal herniorrhaphy, n = 1; and appen-dectomy and inguinal herniorrhaphy, n = 1).

Table 1.

Pre-operative Patient Characteristics

	Median	Range
Age (years)	63	(44–82)
Weight (kg)	79.5	(62–82)
BMI	30	(24–32)
ASA Score	3	(2–3)

BMI = body mass index; ASA = American Society of Anesthesiologists.

Patients underwent RALCP for clinical T₂ (n = 7) and recurrent high-grade T₁ disease (n = 2). Five patients received neoadjuvant chemotherapy. One patient had an abnormal staging CT scan (right hydronephrosis). Pathologic data are listed in Table 2. All surgical margins were negative.

Table 2.

Pathologic Data

Pre-operative Stage	Pathologic Stage	Histopathology
T2 G3	pT2N0Mx	TCC
T2 G3	pT2N0Mx	TCC
T2 G3	pT0N0Mx	TCC
T1 G3 (recurrent)	pT0N0Mx	TCC
T1 G3 (recurrent)	pTaN0Mx	TCC
T2 G3	pT3aNoMx	TCC
T2 G3	pT3bN0Mx	Adenocarcinoma
T2 G3	pT3aN1M0	TCC
T2 G3	pT3aN2Mx	TCC

All margins were negative for malignancy.

TCC = transitional cell carcinoma.

Operative data are listed in Table 3. Median total operative time was 270 minutes (range 210–330 min): 60 minutes, bilateral epLAD; 90 minutes, RALCP; 60 minutes, open EC; 60 minutes (range 45–90 min), IEUA. Median blood loss was 400 mL (range 200–900 mL). Five patients needed postoperative transfusions. Although we did not have any true open conversions, we did need to reposition the neobladder in one patient (via the previously made infraumbilical incision) secondary to a short mesentery that limited our ability to perform the enterourethral anastomosis. Hospital stay was 14 days (range 10–24 d).

Table 3.

Operative Data

	Median	Range
OR Time (minutes)	270	(210–330)
EBL (milliliters)	400	(200–900)
Hospital Stay (days)	14	(10–24)
Number of LNs	11	(4–21)

OR = operative; EBL = estimated blood loss; LN = lymph node.

Postoperative complications (n = 3) included pyelonephritis (n = 1) that was successfully managed with antibiotics, a urinoma (n = 1) that was associated with an obstructed ureteral stent, and a pelvic hematoma (n = 1) that necessitated percutaneous drainage. The urinoma was too small for drainage and was successfully managed with ureteral stent exchange. Five patients needed transfusions postoperatively.

Discussion

As mentioned, radical cystectomy with pelvic lymphadenectomy remains the gold standard for surgical management of invasive and recurrent high-grade superficial bladder cancer. Established use of laparoscopy in management of urologic malignancy, especially with regard to laparoscopic radical prostatectomy and prostate cancer, has led to increasing application of laparoscopic approaches to complex abdominopelvic procedures, including radical cystectomy.

LRC has been described in several series, some relatively large, with favorable results both in terms of feasibility and oncologic outcomes.^8

–12 Furthermore, studies that compare LRC with open radical cystectomy have demonstrated reduced blood loss, lower analgesic requirements, more rapid return of bowel function, and shorter hospital stay without any significant increase in postoperative complications; operative times are longer, however.^8,10,11

Most recently, robot-assisted approaches have gained increasing popularity as a minimally invasive alternative to pure laparoscopic surgery. Studies that specifically look at RALP suggest a more easily overcome learning curve when compared with pure laparoscopic techniques without any significant compromise in oncologic or functional results.^8,11,13,14 This perceived advantage is especially true for surgeons without previous laparoscopic experience.¹¹

Continued improvements in surgical technique coupled with advances in robotic technology have paved the way for expanding the applications of robot-assisted surgery. One such example is RALC, which presents an attractive, minimally invasive alternative to surgical management of bladder cancer.

The feasibility of RALC was first reported by Menon and coworkers¹⁵ in 2003. Small series that followed confirmed feasibility of the procedure with acceptable operative, pathologic, and clinical outcomes, although long-term data were lacking (Table 4). Mean total operative times ranged from 260 to 638 minutes and mean estimated blood loss (EBL) ranged from 150 to 555 mL.

Table 4.

Contemporary Robotic-Assisted Laparoscopic Radical Cystectomy Series

Series Author	n	Urinary Diversion	Mean Operative Time	Mean Estimated Blood Loss
Menon¹⁵	17	Ileoconduit (3) Neobladder (14)	260 308	150
Rhee¹⁶	7	Ileoconduit	638	479
Guru¹⁷	20	Ileoconduit (18) Neobladder (2)	442 (series)	555
Pruthi¹⁸	20	Ileoconduit (10) Neobladder (10)	336 (series)	313
Wang¹⁹	33	Ileoconduit (17) Neobladder (12) Indiana Pouch (3)	390 (series)	400
Murphy⁸	23	Ileoconduit (19) Studer pouch (4)	368 517	278
Current series	9	Ileoconduit (2) Neobladder (4)	210 285	511

In our series, both total operative time and EBL were comparable to those of the other studies listed. Furthermore, all of our surgical margins were negative.

When compared with other series, our results further reinforce the feasibility of RALC with maintenance of sound oncologic principles and favorable perioperative outcomes. Our mean total operative time was 268 minutes (median = 270 min), which is lower that all but one of the series listed. Of note, seven of our nine patients underwent EC with IEUA, showing that this more complicated urinary diversion can be performed with acceptable operative times.

Three of our nine patients had complications postoperatively. The first was a 48-year-old man with pT₂N₀M_x transitional-cell carcinoma (TCC) of the bladder who had a urinoma due to obstructed ureteral catheters after RALCP with EC. He required bilateral ureteral catheter exchanges. He also needed a transfusion postoperatively despite an intraoperative EBL of 400 mL. Operative time was 300 minutes. His hospital stay was prolonged at 24 days.

The next was a 60-year-old man who had pyelonephritis after RALCP with EC for pT_3aN₁M_x TCC of the bladder. Operative time was 330 minutes, and EBL was 500 mL. He was successfully treated with antibiotics and discharged to home on postoperative day 16.

Our final complication was an intra-abdominal hematoma that necessitated transfusion and percutaneous drainage. The patient was a 67-year-old man who underwent RALCP with EC for pT_3aN₂M_x. Operative time was 240 minutes, and EBL was 400 mL. He was discharged to home on postoperative day 21.

Five of our patients needed blood transfusions postoperatively. One such patient, described above, had a hematoma that ultimately required percutaneous drainage. The remaining four patients who needed blood transfusions postoperatively, including the one who suffered the urinoma requiring stent exchange, underwent neoadjuvant chemotherapy.

Baseline hemoglobin levels were low in these patients, consistent with anemia as a known side effect of chemotherapy.¹⁶ Postoperatively, we found that these patients remained anemic with downtrending hemoglobin levels despite acceptable intraoperative blood loss (median 600 mL, range 400 to 900 mL). Blood transfusions helped facilitate better postoperative recovery and convalescence in these patients. We continue to evaluate the relationship between preoperative and postoperative anemia as well as perioperative and clinical outcomes in our patients who undergo neoadjuvant chemotherapy for bladder cancer.

Although our sample size is small and long-term data are currently lacking, our early experience with RALCP is encouraging with regard to feasibility as well as oncologic and early clinical outcomes. We found the known technical advantages offered by the robotic interface, such as improved visualization and articulated instrumentation coupled with surgeon comfort, allow for an impressive instrument with which to apply the known advantages of minimally invasive laparoscopic approaches to radical cystectomy.^8,10,11

Conclusion

Robotic assisted laparoscopic cystoprostatectomy is feasible and can be performed safely and effectively with acceptable operative, pathologic, and short-term clinical outcomes. More experience with longer follow-up is necessary to further assess clinical and oncologic outcomes of RALC for treatment of patients with bladder cancer.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

*

A video demonstrating this technique is available online at www.liebertonline.com/end.

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