ENDOUROLOGY & LAPAROSCOPY

Laparoscopic radical cystectomy and extracorporeal urinary diversion: a single center experience of 48 cases with three years of follow-up
Hemal AK, Kolla SB, Wadhwa P, Dogra PN, Gupta NP
Department of Urology, All India Institute of Medical Sciences, New Delhi, India
Urology. 2008; 71: 41-6

• Objectives: To report our experience with laparoscopic radical cystectomy and extracorporeal urinary diversion for high-grade muscle invasive bladder cancer in a consecutive series of 48 patients with 3 years of follow-up.
• Methods: From June 1999 to April 2006, 48 patients (42 men and 6 women; mean age 59 years, range 24 to 80) with bladder cancer underwent laparoscopic radical cystectomy and bilateral pelvic lymph node dissection at our institution. Urinary diversion was done extracorporeally through the specimen extraction incision.
• Results: The mean operating time was 310 minutes, and the mean blood loss was 456 mL. In 1 patient, conversion to open surgery was required because of severe hypercarbia. Three major complications were observed intraoperatively (rectal injury in 2 and external iliac vein injury in 1 patient). However, all these complications were managed laparoscopically, with completion of the procedure laparoscopically. The mean hospital stay was 10.2 days (range 7 to 25). One patient died in the postoperative period of severe lower respiratory tract infection and septicemia. Histologic examination showed organ-confined tumors (Stage pT1/pT2/pT3a) in 34 patients (71%) and extravesical disease (pT3b/pT4) in 14 (29%). Of the 48 patients, 12 (25%) had lymph node involvement. The mean number of nodes removed was 14 (range 4 to 24). At a mean follow-up period of 38 months (range 10 to 72), 35 patients were alive with no evidence of disease (disease-free survival rate 73%).
• Conclusions: The results of our study have shown that laparoscopic radical cystectomy is a safe, feasible, and effective alternative to open radical cystectomy. Extracorporeal urinary diversion through a small incision decreases the operating time, while maintaining the benefits of laparoscopic surgery. The 3-year oncologic efficacy was comparable to that of open radical cystectomy.
  
  
• Editorial Comment
  The advantage of decreased blood loss provided by laparoscopy seems to be a major beneficial aspect of this approach compared to open surgery. This could be due to the insufflation, as well as, magnified vision that can provide better exposure of the anterior retropubic and posterior retrovesical dissection fields facilitating hemostasis.
  Another major advantage of laparoscopy in radical cystectomy is the smaller skin incision to remove the bladder without prolonged overstretching of the tissues, possibly decreasing postoperative pain.
  Controversy exists on whether urinary diversion should be performed intracorporeally or extracorporeally. Although the feasibility of total intracorporeal urinary diversion has been reported, it has been associated with prolonged operative times and prolonged anesthesia time may negate the benefits of laparoscopy. Moreover, prolonged operating time has also been associated with significant surgeon fatigue and increased cost of the procedure. In summary, this paper demonstrates the feasibility of the procedure but longer clinical follow-up is needed to validate the oncological outcomes of laparoscopic radical cystoprostatectmy in the treatment of localized invasive bladder cancer.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Director of Minimally Invasive Urological Oncology
Tony Grampsas Cancer Center
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA