Objective To assess the feasibility and intermediate-term outcome of laparoscopic radical cystectomy (LRC) with ileal conduit urinary diversion in patients with organ-confined muscle-invasive carcinoma of the urinary bladder, the entire procedure undertaken intracorporeally only using laparoscopic techniques.
Patients and methods Five patients (four men and one woman) underwent LRC with intracorporeal ileal conduit diversion in February 2000, using a six-port transperitoneal technique. LRC, ileal conduit exclusion, restoration of ileo-ileal continuity, and bilateral stented uretero-ileal anastomoses were completed intracorporeally in all patients. The follow-up data up to 2 years are reported.
Results All procedures were completed laparoscopically with no open conversion or intraoperative complications. The mean duration of surgery was 7.5 h; the blood loss was 360 mL and no patient required perioperative blood transfusion. The mean (range) hospital stay was 7 (6–22) days; the specimen weight was 225–400 g. The surgical margins of the bladder specimen were negative in each patient. One patient developed intestinal obstruction after surgery, requiring a diverting ileostomy for 12 weeks. At a follow-up of 2 years, two patients died, both from unrelated causes (myocardial infarction and septicaemia from pulmonary infection in one each). The three surviving patients are asymptomatic with normal upper tracts and no evidence of local recurrence or metastatic disease.
Conclusion LRC with ileal conduit diversion undertaken completely intracorporeally is a feasible option for muscle-invasive organ-confined carcinoma of the urinary bladder, with good outcomes over a 2-year follow-up.
Laparoscopic surgery in urology has progressed significantly during the last decade. From simple ablative procedures, increasingly complex reconstructive procedures are now being undertaken laparoscopically. Radical cystectomy is the preferred treatment for locally invasive, organ-confined carcinoma of the urinary bladder in patients who are medically fit . The ileal conduit is a popular technique of urinary diversion after radical cystectomy. Orthotopic neobladder reconstruction is another choice in selected patients with a useable urethra who are motivated to use CISC if required. With advances in anaesthetic and surgical techniques, the morbidity and mortality of these major open surgical procedures has decreased significantly .
Since the initial report of laparoscopic simple cystectomy by Parra et al. in 1992, others have reported more recent experience; in all the reports, although the cystectomy was undertaken laparoscopically, the accompanying urinary diversion was conducted either extracorporeally or through a limited laparotomy incision. Gill et al. reported the initial experience with laparoscopic radical cystectomy (LRC) and creation of an ileal conduit undertaken completely intracorporeally in two patients. Turk et al. reported five cases of radical cystectomy with a rectal sigmoid pouch continent diversion undertaken completely intracorporeally. Most recently, Gill et al. reported the first two patients with bladder cancer undergoing LRC with an orthotopic ileal (Studer) neobladder, the entire procedure undertaken intracorporeally. Herein, we report our developing experience, including a 2-year follow-up, with LRC and intracorporeal ileal conduit diversion in five patients, carried out at the institute in India.
Patients and methods
Five patients (four men and one woman) with locally invasive but organ-confined carcinoma of the urinary bladder underwent LRC with intracorporeal ileal conduit diversion in February 2000. Radiological tests before surgery (IVU, abdominopelvic CT and chest X-ray) were negative for metastatic disease. The disease was staged clinically using the TNM classification and detailed informed consent was obtained for the laparoscopic procedure. All procedures were undertaken by one staff surgeon (I.S.G.).
On the day before surgery the patient's bowel was prepared mechanically using polyethylene glycol and chemically using oral neomycin and metronidazole. All patients received parenteral antibiotics before surgery and general anaesthesia with endotracheal intubation was used.
For the LRC  the patient is placed supine in the modified lithotomy (abducted thighs) position and secured to the table to allow simultaneous abdominal and perineal access during surgery. A sterile Foley catheter is passed into the bladder from the operative field. Pneumoperitoneum is induced through a Veress needle placed at the umbilicus to a pressure of 15 mmHg. A six-port transperitoneal technique is used. A primary 10 mm port is placed at the umbilicus for the laparoscope (10 mm, 0°). Four secondary ports are placed: a 12-mm port to the left of the umbilical port, and two 10 mm ports, one each, in the right and left lower quadrants. At the pre-selected stoma site on the right side of the abdomen, a button of skin is excised, the subcutaneous fat divided and a 12-mm port secured. The table is inclined to a 30° Trendelenberg position.
Cystoprostatectomy is initiated by dissecting sigmoid or bowel adhesions from the pelvic wall and incising the peritoneum at the recto-vesical cul-de-sac transversely, to identify the posterior plane between the bladder and the rectum. This plane is followed distally by incising Denonvillier's fascia towards the apex of the prostate. On completing the posterior dissection, the peritoneal incision in the cul-de-sac is extended along the peritoneum of the pelvic side-wall overlying the ureters towards the pelvic brim. The ureters are then mobilized, this being technically easier with the ureters in continuity. Distal ureteric mobilization facilitates the identification of the vesical pedicles bilaterally. The right ureter is mobilized proximally for a short distance cephalad to the iliac vessels. The left ureter is mobilized considerably more proximally to allow subsequent retroperitoneal transfer to the right side of the abdomen with no tension or angulation.
The lateral pedicles are identified by careful mobilization of the lateral walls of the bladder, bluntly separating the perivesical fat from the pelvic side-wall (Fig. 1a). The posterior and lateral pedicles are controlled and transected with sequential firing of an Endo-GIA stapler (US Surgical, Norwalk, CT; staples 35 mm long and 2.5 mm high). Both ureters are clipped and divided, and the distal margin sent for frozen-section analysis. The clip-occluded ureters are allowed to hydrodistend during the subsequent steps of the operation. The distal extent of the lateral and posterior pedicles are now visualized by applying upward traction on the bladder (Fig. 1a). The pedicles are divided with the Endo-GIA stapler until the endopelvic fascia and levator ani muscles are reached. Both vasa deferentia are divided.
The peritoneal incisions are extended onto the undersurface of the abdominal wall in a triangular fashion subtending the urachus, which is divided high adjacent to the umbilicus. Keeping all the extraperitoneal and perivesical fat attached to the bladder, the bladder is mobilized from the anterior abdominal wall towards the pelvis, opening the space of Retzius. This mobilization is facilitated by filling the bladder with 150 mL of 10% formalin, which also serves to sterilise the cancerous cells in the bladder. The puboprostatic ligaments are divided and the endopelvic fascia opened to visualize the prostate apex. After emptying the bladder, the dorsal vein complex is controlled by one or two firings of the Endo-GIA stapler, exposing the anterior surface of the urethra. The Foley catheter is removed and the urethra sectioned distal to the prostate apex using endoshears. The remaining attachments of the prostate to the rectum are sharply divided, completely freeing the specimen. A 15-mm Endocatch II impermeable bag (US Surgical) is passed into the abdomen to entrap the specimen immediately. Haemostasis is confirmed and bilateral pelvic lymphadenectomy completed.
The sixth port (5 mm) is placed in a midline suprapubic location. The laparoscope is replaced in the left lower quadrant port, and using the suprapubic and left-sided abdominal ports, the ileocaecal junction identified. At 15–20 cm proximal to the ileo-caecal junction, a suitable 10–15 cm length of ileum is selected for use as the conduit (Fig. 1b). This bowel segment, based on a wide mesenteric pedicle, is isolated using the Endo-GIA stapler. A staple height of 3.5 mm (blue cartridge) is used for the bowel, and a staple height of 2.5 mm (grey cartridge) for the mesentery. Two firings are used to complete the distal mesenteric division, and one for the proximal mesenteric division (Fig. 1b). During mesenteric division, care is taken not to compromise the main mesenteric arterial arcade supplying the conduit. Ileo-ileal continuity is restored cephalad (anterior) to the isolated conduit segment with a stapled side-to-side anastomosis, closing the open end of the bowel also using the Endo-GIA stapler. The mesenteric window is closed using 3–0 silk sutures. The distal end of the conduit is extruded through the pre-selected right pararectal stoma site, and an end-stoma created at the skin level using conventional techniques.
The left ureter is passed to the right side of the abdomen through a hiatus created in the base of the sigmoid mesentery. The proposed individual locations of the two uretero-ileal anastomoses are scored on the ileal conduit with J-hook electrocautery. A 6 F feeding tube grasped by a right-angled laparoscopic clamp is inserted retrogradely into the lumen of the conduit from the open stoma. Under laparoscopic guidance, the conduit is tented at the pre-selected site for the left ureteric anastomosis. Using electrocautery, a small ileotomy is created and the feeding tube passed into the abdominal cavity. The ureteric edge is freshened and spatulated. A full-thickness, stented, mucosa-to-mucosa running anastomosis is created laparoscopically using two separate sutures of 4–0 polyglactin on an RB-1 needle (Fig. 1c). Similarly, the right ureter is anastomosed to the conduit at a site more distal than the left ureter. Both stents are secured at the skin level. The specimen is retrieved intact through an extension of the umbilical port site incision. A urethral pelvic drain (24 F) and a right lower quadrant drain are left in the abdomen, followed by withdrawal of the laparoscope.
In the woman (who had previously undergone a total abdominal hysterectomy) a modified technique was used for the cystectomy. After the lateral pedicles were divided, a sponge stick was placed in the vaginal vault and the vaginal apex opened. The vaginal incision was extended along both sides of the vagina lateral to the bladder base and continued distally towards the urethra. Thus the anterior vaginal wall was excised en bloc with the specimen. The bladder specimen was completely mobilized except for its urethral attachment. The urethral meatus and the distal urethra were dissected vaginally, and the completely freed intact specimen extracted vaginally. The vagina was closed transversally and laparoscopically using 2–0 polyglactin sutures. In all five patients the suturing and knot tying in the entire procedure was undertaken intracorporeally using only free-hand laparoscopic techniques.
Table 1 shows the detailed data from the five patients; the clinical stage of the bladder cancer was T2–T3b. All five procedures were completed laparoscopically as planned, with no intraoperative complication or open conversion. The total duration of surgery (initial skin incision to final skin suture) was 7–8 h and the estimated blood loss 300–400 mL. No patient required a blood transfusion during or after surgery; one patient developed bowel obstruction 5 days after surgery, and exploratory laparotomy revealed twisting of the bowel mesentery proximal to the ileo-ileal anastomosis, leading to concerns about the viability of the bowel. A temporary diverting ileostomy was placed and after intensive care, the patient recovered and bowel continuity was restored at 12 weeks. Three weeks after surgery one patient had abdominal distension and low-grade fever for 10 days, which responded to antibiotics. One patient developed transient left adductor spasm after surgery, which recovered within a week. The mean (range) hospital stay was 7 (6–22) days. The specimen weight was 225–400 g. Histopathology showed TCC in four patients (stage pT3bN0 in two and pT3aN1 in two) and squamous cell carcinoma (stage pT3bN0) in one. The surgical margins of the bladder specimen were negative for cancer in all five patients; three received adjuvant chemotherapy.
Over a follow-up of 2 years, two patients died (one from septicaemia after an unrelated pulmonary infection and multi-organ failure at 9 months, and the other from myocardial infarction at 12 months). Both patients had normal renal function and no evidence of metastases or upper tract changes at the time of death. All surviving patients are faring well, with normal upper tracts on IVU and no evidence of local recurrence or metastatic disease.
Radical cystectomy with urinary diversion remains the treatment of choice for organ-confined muscle-invasive bladder carcinoma . One of the major surgical procedures undertaken by urologists, this procedure involves several hours of operating time, and a prolonged hospital stay and recovery period for the patient. With recent advances in minimally invasive surgery, attempts have been made to explore the application of laparoscopy for radical bladder surgery [3–13].
Parra et al. initially reported laparoscopic simple cystectomy with no urinary diversion in one patient with benign, symptomatic pyocystis in an abandoned bladder. Kozminski and Partamian  reported a laparoscopically assisted ileal conduit construction, wherein the uretero-ileal anastomoses were made extracorporeally. Sanchez et al. reported a laparoscopically assisted cystectomy and ileal conduit for removing an infiltrating bladder cancer. The bladder was dissected free laparoscopically and extracted through an enlarged incision. The ileal loop segment was isolated, and intestinal continuity and uretero-ileal anastomosis carried out extracorporeally through the open incision. Puppo et al. undertook laparoscopically assisted radical cystectomy in five women, wherein the accompanying ileal conduit diversion was created extracorporeally through a mini-laparotomy incision. Denewer et al. reported 10 patients with bilharzial squamous cell bladder cancer who underwent laparoscopically assisted cystectomy and sigmoid pouch urinary diversion through a mini-laparotomy incision. As such, in all the published reports [7–12], the technically challenging urinary diversion accompanying LRC has only been undertaken extracorporeally through a mini-laparotomy incision.
Recently, Fergany et al. developed a completely intracorporeal technique in 10 pigs for undertaking the entire ileal conduit procedure laparoscopically. In that study, reproducible techniques for isolating the ileal loop, creating the ileo-ileal re-anastomosis and bilateral uretero-ileal anastomosis were developed and refined. Taking this into clinical use, Gill et al. reported the initial experience in two patients undergoing LRC, bilateral pelvic lymphadenectomy and ileal conduit diversion, with the entire procedure carried out exclusively by intracorporeal laparoscopic techniques. Encouraged by these initial results, the five patients reported herein were treated by a combined team from the two institutes, and underwent surgery in India.
In all five patients the procedures were completed intracorporeally, although the total surgical time was longer than is usually expected with open surgery. However, blood loss was less and none of the patients required a blood transfusion. The video-endoscopic vision allowed the tissue planes to be identified clearly and permitted excellent haemostasis. The Endo-GIA stapler significantly facilitated control of the vascular pedicles of the bladder. The other stages (endopelvic fascia incised, dorsal venous complex controlled, prostate detached from the urethra, and cystectomy specimen mobilized from the rectum) were undertaken adequately. Retrieval of the intact specimen, essential for accurate histopathological staging, determined the need for adjuvant chemotherapy in three patients. The recovery after surgery was good, with an early return of bowel function. The combination of decreased bowel manipulation, minimal postoperative pain and the resultant reduction in narcotic analgesics, are potential benefits of laparoscopic surgery that may reduce postoperative ileus.
The most challenging part of the procedure is to create the laparoscopic urinary diversion intracorporeally. Well-established colorectal techniques can be adopted to isolate the ileal loop [14–16]. Bowel continuity can be attained by side-to-side ileo-ileal anastomosis using the Endo-GIA stapler. To date, suturing for laparoscopic urinary diversion has used one of three different approaches: (i) extracorporeal suturing outside the port site; (ii) diversion through a mini-laparotomy incision; and (iii) intracorporeal suturing. Extracorporeal suturing can be undertaken by pulling the ends of the bowel loop outside the abdomen and subsequent making the anastomosis. Hence, suturing requires conventional open surgical techniques and is technically easier. However, we are concerned about the orientation and positional distortion of the ureter in relation to the ileal loop. Further, considerable mobilization of the ureter with no stripping is necessary to provide sufficient length for exteriorization through the abdominal incision, a feat that may be even more difficult in the obese patient. Free-hand intracorporeal laparoscopic suturing for uretero-ileal anastomosis has the considerable advantage of the magnification offered by the laparoscope for a precise mucosa-to-mucosa anastomosis in the correct anatomical position. However, it is without doubt a technically demanding procedure that requires extensive experience in laparoscopic surgery.
In conclusion, LRC and intracorporeal ileal conduit formation is technically feasible, with good results over a 2-year follow-up. With the continued development of urological laparoscopic surgery, we anticipate that the duration of such sophisticated reconstructive procedures will decrease, allowing more urologists to incorporate these techniques into their armamentarium.
I.S. Gill, Section of Laparoscopic and Minimally Invasive Surgery, Department of Urology, A-100 Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA e-mail: firstname.lastname@example.org