LAPARASCOPIC RADICAL CYSTECTOMY
Indications
- Usual patients
- Patients with muscle-invasive bladder cancer (T2-T4a)
- Selected patients
- Patients with high risk, recurrent Tis and/or T1G3 after BCG failure
- Patients with large papillary tumors refractory to TUR and intravesical treatment
- Salvage cystectomy for patients with tumors refractory to standard therapies
- Palliative cystectomy for patients with severe complications from tumor extension
Methods
• Positioning of patient (supine with deep Trendelenburg)
• Planning and placement of trocars
• Entry into peritoneal cavity
o Dissection of prerectal space (seminal vesicles left intact)
o High peritoneal incision from along the ureters until internal inguinal ring
• Division of ductus deferens, using a medial retractor
• Extended pelvic lymph node dissection (ilio-obturator, internal iliac/medial external iliac): both the extent of node dissection and the number of lymph nodes removed has a direct impact on survival for both negative and positive node patients)
• Division of ureter (once clamped)
• Merging of peritoneal incisions; division of superior, inferior vesical artery, vesicular arteries
• Late division of urachus and umbilical ligaments
• Dissection of Retzius’ space
• Complete dissection of the endopelvic fascia
• Dissection along the prostate for preservation of neurovascular bundles (intrafascial: Aphrodite’s veil)
• Complete dissection of urethra
• Retrieval of the closed specimen “en bloc”
• Laparoscopic anastomosis to the urethra in orthotopic bladder replacement
o Heterotopic
o Orthotopic
– Abol –Enein
Studer
o Cutaneous diversion
o Ileo-uretero-dermostomy (Bricker, Wallace, etc)