© The Author (2008). Published by Oxford University Press. All rights reserved
Minilaparotomy Radical Cystoprostatectomy (Minilap RCP) in the Surgical Management of Urinary Bladder Carcinoma: Early Experience
Department of Uro-oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
For reprints and all correspondence: Sudhir Rawal, Department of Uro-oncology, Rajiv Gandhi Cancer Institute and Research Center, Sector 5, Rohini, New Delhi 110085, India. E-mail: dr_rawal{at}yahoo.com
Received February 6, 2008; accepted July 22, 2008
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Abstract |
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Objective: To assess the feasibility of minilaparotomy for radical cystoprostatectomy (RCP) and urinary diversion in the management of urinary bladder carcinoma.
Methods: A total of 45 consecutive patients with muscle invasive urinary bladder cancer underwent RCP and urinary diversion [32, 12 and 1 patients with pitchers pot orthotopic neobladder (NB), ileal conduit (IC) and sigma rectal pouch respectively], between May 2006 and June 2007, using 8–12 cm infraumbilical midline vertical incision from pubic symphysis, were prospectively analyzed for technical feasibility, operative time, blood loss, intraoperative and postoperative complications and return of bowel function.
Results: All the patients were males with average age of 59.65 years (44–79 years) and average body mass index of 23.97(17.7–29.5). The length of the incision was 8, 10 and 12 cm in 4, 39 and 2 patients, respectively. The average number of lymph nodes removed on the right and left side was 14 and 16, respectively. The average blood loss was 1046 ml (595–2100 ml). Return of bowel sounds was observed on an average by second postoperative day (1–5 days). Average postoperative stay was 14 days (range 10–24 days) for NB and 7 days (6–8 days) for IC patients. One (2.22%) patient died on the 18th postoperative day due to septicemia and acute renal failure.
Conclusion: Minilaparotomy RCP is technically feasible without compromising the oncological principles. Complete removal of urachus and adequate clearance of pelvic lymph nodes is not difficult with the small incision. Early restoration of bowel function, early postoperative recovery and good cosmesis seem to be the main advantages.
Key Words: minilaparotomy radical cystoprostatectomy • radical cystoprostatectomy • orthotopic neobladder • ileal conduit • sigma rectum pouch
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INTRODUCTION |
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Radical cystoprostatectomy (RCP) with pelvic lymphnode dissection (PLND) is the standard treatment for the muscle invasive urinary bladder cancer. Whitmore and Marshall (1) described the basic surgical principles of RCP in 1949. Owing to prolonged and extensive surgery with a long incision, delayed recovery of bowel function and prolonged hospital stay are unavoidable. Attempts have been made to reduce the morbidity and complications by performing the procedure extraperitoneally (2). Minimally invasive laparoscopic procedures are gaining popularity; however, learning curve to master the technique is steep and it lacks tactile feedback to assess the extent of tumor, and they generally are significantly longer procedures than open counterparts. Selective reports of completely intracorporeal reconstruction of ileal conduit are present in the literature (3). Complete intracorporeal reconstruction of urinary diversion is possible (4,5) and is done at specialized centers only. Robot-assisted RCP with ileal conduit or orthotopic neobladder reconstruction is done only in few centers and it is time consuming (6), hence commonly cystoprostatectomy is done by laparoscopic approach and removal of specimen and ileal conduit or neobladder reconstruction are done through small incision.
We are presenting our early experience with minilaparotomy radical cystoprostatectomy technique (minilap RCP; i.e. surgery through a small 8–12 cm incision), which has the advantages of both open and laparoscopic procedures and reduces the morbidity associated with open radical surgery.
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PATIENTS AND METHODS |
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A total of 45 consecutive patients of invasive carcinoma of urinary bladder who underwent RCP using 8–12 cm infraumbilical vertical incision from pubic symphysis were prospectively assessed for technical feasibility, operative time, blood loss, intraoperative and postoperative complications. Decision regarding the type of urinary diversion was made preoperatively after extensive discussion and counseling of patients and relatives, based on their socioeconomic conditions or intraoperatively depending on the involvement of urethral cut margin by frozen section report.
Preparation and position
The gut preparation was done with polyethyleneglycol (peglac) on the evening before the surgery and two doses of oral streptomycin and metronidazole were administered. At the time of induction, cefpirome, gentamicin and metronidazole were administered. Intermittent pneumatic compression device applied to both legs helped to prevent deep vein thrombosis. Patients were positioned by hyperextension of lumbar spine by placing a sand bag at the lower lumber vertebral level, and 200 Trendelenburg position was given to increase the distance between the umbilicus and pubic symphysis.
Surgical technique
Surgery was done under endotrachial anesthesia with No 18 Fr foleys catheter inserted into the urinary bladder. An 8–12 cm infraumbilical midline vertical incision was made from pubic symphysis toward the umbilicus, which generally stops 6–8 cm short from umbilicus. The incision was extended superiorly only if difficulty was encountered during the procedure. The linea alba was cut in the midline and the rectus abdominis muscle separated. Transversalis fascia was divided to delineate the urachus. Balfour retractor with two blades was used and space of Retzius and paravesical spaces were exposed by blunt and sharp dissection. Operability, the extent of disease and lymphnode enlargement was assessed.
Bilateral pelvic lymphadenectomy was performed by removing all fibrofatty and lymphatic tissue, medial to genitofemoral nerve, which is the lateral limit, external iliac artery and vein dissected up to the bifurcation of common iliac artery, which is the cephalad limit of dissection, endopelvic fascia and inguinal canal is the caudal extent and bladder is the medial extent of dissection.
Obliterated umbilical ligaments and vasa deferentia were cut between ligatures individually away from the bladder extraperitoneally. Further deeper dissection was done medial to obliterated umbilical ligaments to expose the ureters and vesical pedicles. The vesical pedicles were skeletenized and cut between ligatures individually away from the bladder. The ureters were transected 1.5–2 cm proximal to ureterovesical junction and the proximal cut ends were sent for frozen section examination. The ureters were stented with no 6/7 Fr infant feeding tubes and anchored loosely to ureter with 5–0 catgut, to divert the urine to avoid contamination of the wound and avoid contact with bowel to reduce chances of postoperative paralytic ileus (7). Then the dissection proceeded to the apex of prostate. Fat over the prostate was gently teased out, endopelvic fascia was cut anteriorly and extended posteriorly. Venous tributaries and levater ani muscle fibers which run toward the prostate were coagulated with bipolar forceps and cut. Occasionally, encountered accessory pudendal vessels were dissected carefully and safeguarded. Puboprostatic ligaments were cut and superficial branch of dorsal venous complex (DVC) was clipped and divided. Deep DVC was suture ligated with 1–0 vicryl proximally and with 3–0 monocryl distally and cut with knife. Minor bleeding was controlled by oversewing the distally ligated DVC.
Urethra was identified and cut anteriorly with knife and the catheter was taken into the wound, clamped and cut distally. No 2–0 monocryl suture taken through the urethra at 12 o'clock position, which helps in transecting rest of the urethra. Posterior aspect of the transected urethra was better seen by gently retracting the prostate superiorly. Now, the urethral transection was completed with the knife, and cut margin sent for frozen section. Foleys catheter was taken out from bladder carefully and prostatic urethra suture ligated to prevent spillage of tumor. The neurovascular bundle (NVB) on either side was dissected off the urethra and safeguarded. Levator fascia over the lateral aspect of the prostate incised and high release of NVBs done.
Denonvilliers fascia identified and cut with knife transversely to enter the prerectal fat plane. Further dissection of the prostate proximally is continued in this plane. Small vascular branches running into the prostate were clipped and cut. Lateral prostatic pedicle identified and cut between ligatures. Denonvilliers fascia was cut again at the level of seminal vesicles to expose seminal vesicle and vasa differentia. Now the bladder and prostate were attached to the peritoneum with fibrofatty tissue posterior to the bladder.
Now the urachus was dissected up to the umbilicus by retracting the rectus sheath at the cranial end of incision and disconnected. Peritoneum was opened only at this point of dissection on either side of the urachus up to the bladder. The peritoneum at the rectovesical pouch was incised in a U manner to carefully dissect and safeguard the NVB at the apex of the seminal vesicles in case the disease was not involving the nerves otherwise it was excised on that particular side. Lateral vesical ligaments were cut and suture ligated, and the specimen was removed. Ureters were dissected proximally for about 8–10 cm. Left ureter was taken to the right side through the mesentery of the sigmoid colon. Creation of ileal conduit or pitcher pot ileal neobladder (8) was done as per the preoperative or intraoperative decision.
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RESULTS |
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All 45 patients were males, with average age of 59.65 years (44–79 years). Thirty-two and 12 patients underwent pitcher's pot neobladder and ileal conduit, respectively, following RCP. One patient underwent RCP, urethrectomy with sigma rectum pouch in which urethral cut margin was positive and patient wanted to have only continent diversion. NVB could be preserved bilaterally and unilaterally in 38 and 3 patients, respectively, and excised bilaterally in 4 patients. The average number of lymph nodes removed were 14 (range, 6–19) and 16 (range, 6–20) on the right side and on the left side, respectively. Results of minilaparotomy RCP are shown in Table 1. Histology, pathological stage, grade and lymph node status and complications are detailed in Tables 2 and 3, respectively. The operative scar of RCP and orthotopic neobladder is shown in Figs 1 and 2. Results from 40 patients who underwent RCP through a long conventional incision are given in Tables 4
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Urethral cut margin and posterior surgical margins were positive each in 1 (2.22%) patient. In the initial four patients, 8 cm incision was used but dissection was difficult; hence, 10 cm incision was made in later patients. In two obese patients (BMI > 28), 10 cm incision was extended by 2 cm to make the uretero-ileal anastomosis with ease. All the procedures were done successfully without compromising oncological principles. Postoperatively, bowel sounds were heard on an average second day (1–4 days) and time to oral intake was average 3.8 days (2–7 days). One patient died 8 months after surgery with bone and visceral metastasis, who had PT3bN3 disease and received adjuvant chemotherapy. Mean follow-up was 8.4 months (range, 3–14 months).
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DISCUSSION |
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Radical cystoprostatectomy remains an effective treatment for muscle invasive localized urinary bladder carcinoma, and the open approach is the most frequent method of choice. The minilap RCP and laparoscopic approaches are procedures designed to minimize the morbidity, while still providing the same standard of care.
The main author has done more than 200 RCP and neobladders using incision up to or above the umbilicus, before started using the mini incision, and he did not have any difficulty while operating through a small incision.
The minilap RCP has several advantages over classical open and laparoscopic approaches that contribute to decrease the morbidity. The procedure is performed through a small 10 cm incision. Initial part of cystoprostatectomy is performed extraperitoneally that provides unobstructed field and obviates the need to retract to bowel. This minimizes the exposure of bowel to atmosphere and handling of bowel (2). The need to use third blade for bowel retraction in long incisions that may compress inferior vena cava does not arise. Generally, pulmonary complications are common with conventional incisions extending above the umbilicus, which are less common with minilap RCP incision. Surgery was done with the help of one operative assistant and using Balfour rector with two blades without overzealous retraction for better exposure.
Meticulous dissection of NVB (if not involved by the tumor) and preservation of the maximum length of urethra are easily done to preserve the potency and continence with small incision, as this is the extension of minilap Radical prostatectomy (9), however head light is mandatory for clear vision.
Lymphadenectomy is described to be done before or after cystoprostatectomy in the literature. In our series, we have done it extraperitonealy before removing the bladder to delay the opening of the peritoneum.
Incidence of rectal injury is 0.4% during conventional cystectomy (10). This is attributed to difficult dissection between the rectum and the bladder or if the rectum is involved by the tumor. This is described in obese patients and as well as in thin patients (11,12).
We encountered this complication in a 79-year-old patient, with dense fibrosis of rectovesical planes, who received neoadjuvant chemotherapy for T4 disease. In this patient, rectal wall was cut deliberately rather than accidentally to get a negative surgical margin and repaired.
The postoperative hospital stay with neobladder group was more for initial 10 cases as there was leak from the neobladder. After slight modification of technique of neobladder creation, leak was not seen and hospital stay reduced to 12–14 days. (Earlier, we used to incorporate the detubularized distal end of the ileum to form the neobladder. At this part of neobladder, urine used to leak, due to tension on the anastomosis. Urine leak at this site stopped once we realized this and started closing the distal end of ileum and detubularizing the end 1 cm proximal to the closed distal end, to reduce the tension on the anastomosis.) Most of our patients are from far off places and they preferred to go home off all the catheters. Our protocol is to remove the Foleys catheter on 10th postoperative day, abdominal drain on 11th day and the discharge the next day, hence hospital stay was more.
It is our observation that postoperative pain and wound-related complications are less in minilap patients compared with conventional radical cystoprostatectomies with incision up to or above the umbilicus, which we used to do before. There was no case of burst abdomen in our series of minilap RCP compared with three cases in our earlier series with conventional incision. Cosmesis is better with small incision compared with long incisions. However, in this series, we have not studied these parameters objectively.
In the patients who underwent minilap RCP, postoperatively bowel sounds were heard on an average second day (1–4 days) and time to oral intake was average 3.8 days (2–7 days) compared with an average of fifth day (4–8 days) of appearance of bowel sounds and sixth day (5–9 days) of starting oral intake in patients with a long conventional incision.
In most large series, postoperative mortality rate is 2–5% (13), re-operation rate is 210% (14) and complications rate is 25–35% (15). In our series, one 75-year-old patient died of septicemia and acute renal failure, which accounts for 2.22% mortality. Re-operation was required in two patients (4.44%) and complications rate was 26.4%. Thus, Minilap RCP complications are comparable with conventional procedure.
Pathological parameters must also be considered while doing oncological surgical procedures. The posterior surgical margin was positive in only one patient, who received neoadjuvant chemotherapy due to preoperative T4 stage. We could remove a maximum of 20 lymph nodes (average 15) though our cephalad limit of lymphadenectomy that was up to bifurcation of common iliac artery.
Out of 41 patients who underwent nerve sparing RCP, 35 had bilateral and 6 had unilateral nerve preservation. Twenty-one (60%) and 2 (33%) of bilaterally and unilaterally nerve preserved patients, respectively, are achieving erection sufficient for penetration with 50 mg of sildenafil at a mean follow-up of 1 year.
As far as RCP and urinary diversion is concerned, it is technically demanding not only to remove the bladder but to reconstruct the orthotopic neobladder, which is more complex by laparoscopy or by robot. Therefore, in the international registry for laparoscopic RCP, only 308 cases have been registered till May 2006 (16). This means that open RCP and urinary diversions are done at many centers all over the world. Main reduction in the morbidity by laparoscopic and robotic surgery is because of small size of incision as it is obvious on comparing minilap radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted radical prostatectomy. Open surgery had been time tested and gold standard in oncologic practice. With minilap RCP and urinary diversion, we achieved our goal in both reducing the morbidity and maintaining oncological principles; however, the duration of follow-up is short to comment about oncological outcome. In addition, there is no compromise in the quality of uretero ileal anastomosis, which will always be questionable with intracorporeal technique.
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CONCLUSION |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONReferences |
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Minilap RCP is technically feasible without compromising the oncological principles; however, the duration of follow-up is short to comment about the oncological outcome. Complete removal of urachus and adequate clearance of pelvic lymph nodes are not difficult with the small incision. Early restoration of bowel function, early postoperative recovery and good cosmesis seems to be the main advantages.
Conflict of interest statement
None declared.
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References |
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