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Adult Bladder Diverticulectomy and Partial Cystectomy
Abstract
Partial cystectomy is an option when considering bladder preservation in the management of a solitary bladder tumor and may be performed in conjunction with pelvic lymphadenectomy. Multifocal disease is a contraindication to partial cystectomy. Bladder diverticulectomy can be performed for oncological causes or in the setting of benign disease. The etiology of a bladder diverticulum should be addressed prior to consideration of surgery. Partial cystectomy and bladder diverticulectomy can be performed safely using laparoscopic and robotic approaches with a variety of techniques that can be employed as per surgeon preference for identification of the portion of the bladder to be excised. Attention should be paid to complications that can arise from a minimally invasive approach. Vascular and bowel injuries should be identified and addressed promptly. Steps should be taken to mitigate the risk of other complications such as infection, bleeding, and urine leak.
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Abstract
Purpose of Review Improving patient outcomes from major
urological surgery requires not only advancement in surgical
technique and technology, but also the practice of patient-centered,
multidisciplinary, and integrated medical care of these
patients from the moment of contemplation of surgery until
full recovery. This review examines the evidence for recent
developments in preoperative assessment and optimization
that is of relevance to major urological surgery.
Recent Findings Current perioperative medicine recommendations
aim to improve the short-term safety and long-term
effectiveness of surgical treatments by the delivery of multidisciplinary
integrated medical care. New strategies to deliver
this aim include preoperative risk stratification using a frailty
index and cardiopulmonary exercise testing for patients undergoing
intra-abdominal surgery (including radical
cystectomy), preoperative management of iron deficiency
and anemia, and preoperative exercise intervention.
Summary Proof of the utility and validity for improving
surgical outcomes through advances in preoperative care
is still evolving. Evidence-based developments in this
field are likely to benefit patients undergoing major urological
surgery, but further research targeted at high-risk
patients undergoing specific urological operations is
required.
Objective. To report our contemporary experience with partial cystectomy after neoadjuvant chemotherapy. Patients and Methods. Retrospective review of patients who underwent neoadjuvant chemotherapy and partial cystectomy for urothelial cell carcinoma of the bladder at Memorial Sloan Kettering Cancer Center from 1995 to 2013. Log-rank test and Cox regression models were used to analyze variables possibly associated with recurrence-free, advanced recurrence-free (free from recurrence beyond salvage with intravesical therapy or radical cystectomy), and overall survival. Results. All 36 patients had a solitary tumor <5 cm in size. Twenty-one patients (58%) achieved cT0 following neoadjuvant chemotherapy with 7 (33%) having residual disease at PC. At last follow-up, 19 (53%) patients had recurrence, 15 (42%) had advanced recurrence, 10 (28%) died of disease, and 22 (61%) maintained an intact bladder. Median follow-up of those who were with no evidence of disease was 17 months. On univariable analysis, after neoadjuvant chemotherapy positive nodes on imaging and positive surgical margin at partial cystectomy were both associated with worse recurrence-free, advanced recurrence-free, and overall survival. Five-year recurrence-free, advanced recurrence-free, and overall survival were 28%, 51%, and 63%, respectively. Conclusion. Partial cystectomy following neoadjuvant chemotherapy provides acceptable oncologic outcomes in highly selected patients with muscle-invasive bladder cancer.
We present a case of an 84-year-old man presenting with painless visible hematuria. Further investigation revealed a primary G3pT1 transitional cell carcinoma confined to a bladder diverticulum. In view of bladder-sparing therapy, he underwent a robot-assisted laparoscopic bladder diverticulectomy with ureteral re-implantation. This report demonstrates a minimally invasive approach offering radical treatment without having to recur to partial or radical cystectomy. We discuss the operative steps, the significance of this case with a review of the literature, and the future potential this may represent for the treatment of tumor-containing bladder diverticula.
Purpose:
To describe our technique for robot-assisted bladder diverticulectomy (RABD).
Patients and methods:
Ten patients underwent RABD using an extra- or transvesical approach. Three (30%) patients underwent concomitant procedures: Robot-assisted radical prostatectomy, robot-assisted simple prostatectomy, and transurethral resection of the prostate.
Results:
All RABDs were performed successfully. Median estimated blood loss, operative time, and diverticulectomy time were 75 mL, 210 minutes, and 80 minutes, respectively. Median follow-up time was 18 months. Median International Prostate Symptom Score decreased by 57%, P=0.001.
Conclusions:
RABD is feasible and safe. It can be performed via a trans- or extravesical approach, as a stand-alone, or concomitant procedure.
Congenital bladder diverticulum is an uncommon anomaly of the bladder. Patients can present with urinary infection, heamaturia, and/or urinary obstruction. We report the case of a seven-year-old boy who presented with painful micturition and terminal haematuria due to a congenital bladder diverticulum. Robot-assisted laparoscopic diverticulectomy was performed. The patient had an uneventful recovery. We describe the points of technique pertinent to the procedure.
Introduction:
Partial cystectomy (PC) for urothelial carcinoma (UC) in selected patients may avoid the morbidity of radical cystectomy (RC). We describe utilization and outcomes of PC for UC in routine clinical practice.
Methods:
All patients with urothelial carcinoma of the bladder (UCB) undergoing PC or RC in Ontario from 1994-2008 were identified using the Ontario Cancer Registry and linked electronic records. Pathology reports were reviewed. Variables associated with PC use were identified using logistic regression. Cox proportional hazards model identified factors affecting cancer-specific (CSS) and overall survival (OS).
Results:
A total of 3320 patients underwent PC (n=181; 5%) or RC (n=3139; 95%) from 1994-2008. PC patients were older (36% 80+ years vs. 19%; p<0.001) and more likely to have organ-confined (<pT3) disease (54% vs. 36% RC; p<0.001). Two-thirds (67%) of PC patients did not undergo lymph node dissection (24% for RC; p<0.001). Factors associated with having PC included older age (odds ratio [OR] 1.55; 95% confidence interval [CI] 0.96-2.51 for 70+ years), moderate comorbidity (OR 1.95; 95% CI 1.13-3.37), and surgery outside of a comprehensive cancer centre (OR 1.44; 95% CI 1.03-2.01). Unadjusted five-year OS for PC and RC cases was 34% and 33%, respectively (p=0.455); CSS at five years was 43% and 37% (p=0.045). On adjusted analysis, PC was associated with comparable CSS (hazard ratio [HR] 0.87, 95% CI 0.70-1.09) and OS (HR 0.95, 95% CI 0.79-1.14) as RC.
Conclusions:
In routine clinical practice, PC is not common. A substantial proportion of patients treated with PC achieve long-term survival. PC remains a treatment option in selected patients with UCB.
Purpose:
This multi-disciplinary, evidence-based guideline for clinically non-metastatic muscle-invasive bladder cancer focuses on the evaluation, treatment, and surveillance of muscle-invasive bladder cancer guided toward curative intent.
Materials and methods:
A systematic review utilizing research from the Agency for Healthcare Research and Quality (AHRQ) as well as additional supplementation by the authors and consultant methodologists was used to develop the guideline. Evidence-based statements were based on body of evidence strengths Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions. (Table 1) RESULTS: For the first time, for any type of malignancy, the American Urological Association (AUA), the American Society of Clinical Oncology (ASCO), the American Society for Radiation Oncology (ASTRO), and the Society of Urologic Oncology (SUO) have formulated an evidence-based guideline based on a risk-stratified clinical framework for the management of muscle-invasive urothelial bladder cancer. This document is designed to be used in conjunction with the associated treatment algorithm.
Conclusions:
The intensity and scope of care for muscle-invasive bladder cancer should focus on the patient, disease, and treatment response characteristics. This guideline attempts to improve a clinician's ability to evaluate and treat each patient, but higher quality evidence in future trials will be essential to improve level of care for these patients.
Access may often be overlooked or minimized as an integral part of any laparoscopic case. However, difficulty or error in obtaining proper access can prove disastrous in its consequences for both the surgeon and the patient. This chapter details safe and reliable techniques used to gain laparoscopic access into the abdominal cavity, including both open and closed access. Each method is reviewed, along with the advantages and disadvantages of each. Tips for confirmation of successful entry into the peritoneal cavity are included. In addition, the complications associated with laparoscopic access, both immediate and delayed, are examined. More importantly, the recognition and management of these complications are outlined. The various types to trocars are discussed, along with the characteristics of each that may influence surgeon preference. Finally, the process of exiting the abdomen is explained, as well as when and how to close laparoscopic port sites.
Purpose:
To endorse the European Association of Urology guideline on muscle-invasive (MIBC) and metastatic bladder cancer. The American Society of Clinical Oncology (ASCO) has a policy and set of procedures for endorsing clinical practice guidelines that have been developed by other professional organizations.
Methods:
The guideline on MIBC and metastatic bladder cancer was reviewed for developmental rigor by methodologists. The ASCO Endorsement Panel then reviewed the content and recommendations.
Results:
The ASCO Endorsement Panel determined that the recommendations from the European Association of Urology guideline on MIBC and metastatic bladder cancer, published online in March 2015, are clear, thorough, and based on the most relevant scientific evidence. ASCO endorses the guideline on MIBC and metastatic bladder cancer and has added qualifying statements, including highlighting the use of chemoradiotherapy for select patients with MIBC and recommending a preference for clinical trials in the treatment of metastatic disease in the second-line setting.
Recommendations:
Multidisciplinary care for patients with MIBC and metastatic bladder cancer is critical. The standard treatment of MIBC (cT2-T4a N0M0) is neoadjuvant cisplatin-based combination chemotherapy followed by radical cystectomy. In cisplatin-ineligible patients, radical cystectomy alone is recommended. Adjuvant cisplatin-based chemotherapy may be offered to high-risk patients who have not received neoadjuvant therapy. Chemoradiotherapy may be offered as an alternative to cystectomy in appropriately selected patients with MIBC and in some patients for whom cystectomy is not an option. Metastatic disease should be treated with cisplatin-containing combination chemotherapy or with carboplatin combination chemotherapy or single agents in patients ineligible for cisplatin.Additional information is available at http://www.asco.org/endorsements/MIBC and www.asco.org/guidelineswiki.
Primary adenocarcinomas of the bladder and urachus are extremely rare, accounting for 0.5% to 2.0% of all bladder malignancies. During fetal development, the urachus develops into the median umbilical ligament that stretches from the umbilicus to the bladder. Adenocarcinoma accounts for 90% of all cases of urachal carcinoma. There is no consensus regarding the management of urachal carcinoma. Although the preferred treatment is wide local excision with partial or radical cystectomy, bladder-sparing management is increasing. We report a case of robot-assisted laparoscopic partial cystectomy with en bloc resection of the urachus and bilateral pelvic lymphadenectomy for urachal carcinoma. The robot-assisted laparoscopic approach allowed us to minimize surgical morbidity, postoperative pain, and convalescent time while maintaining the oncologic principle of wide local excision.
Preamble e280
1. Introduction e282
2. Clinical Risk Factors e283
3. Calculation of Risk to Predict Perioperative Cardiac Morbidity e289
4. Approach to Perioperative Cardiac Testing e292
5. Supplemental Preoperative Evaluation e292
6. Perioperative Therapy e298
We present the largest reported consecutive series on robotic partial cystectomy in the management of patients with primary urachal adenocarcinoma. Eight patients with primary urachal adenocarcinoma of the urinary bladder underwent a robotic partial cystectomy (RPC). The mean operative time, including trocar placement as well as robotic docking and closure was 184 minutes (range, 130-240 minutes). The mean console time was 120 minutes (range, 70-170 minutes). The mean estimated blood loss was 50 ml. There were no conversions to open surgery. The mean hospital stay was 4 days (range, 3-7 days). Drain removal was performed at postoperative day 2.5 (range, 2-3 days). Each patient underwent postoperative cystography on day 10 postoperatively and no patients had evidence of extravasation. There were no major complications. Histological analysis of all tumours confirmed primary urachal adenocarcinoma of the urinary bladder. There were no positive surgical margins. At a mean follow up of 32 months none of the patients have had a disease recurrence with any evidence of disease recurrence. Our initial data indicates that with RPC for primary urachal adenocarcinoma of the urinary bladder is a safe surgical and oncological procedure. However, longer follow up and larger patient numbers are required to validate this further.
While radical cystectomy continues to be the gold standard for surgical management of muscle invasive bladder cancer, there has been a renewed interest in partial cystectomy as a viable treatment alternative. The purpose of this review is to summarize and discuss the recent literature regarding partial cystectomy for bladder cancer.
Utilization of partial cystectomy has remained stable, at a rate of 7-10% of all cystectomies performed nationally. Additionally, recent population-based series as well as single institution cohorts have found that partial cystectomy did not compromise survival when compared to radical cystectomy. While patients may recur, those with organ-confined disease had no difference in survival following salvage cystectomy when compared to primary radical cystectomy. Current data indicate 14% of patients experience an in-hospital complication, which is a marked decrease compared to radical cystectomy. Finally, innovations in surgical technique, such as robotics, as well as the inclusion of partial cystectomy into trimodal therapy, offer exciting new frontiers in bladder cancer treatment.
Once maligned, partial cystectomy now represents a standard-of-care option for management of bladder cancer. Although additional research is needed to clarify patient selection and outcomes, partial cystectomy is an important treatment option for appropriately selected patients.
To compare long-term cancer outcomes after radical cystectomy (RC) alone or RC with pelvic lymph node dissection (PLND) according to different age and comorbidities categories.
Using the SEER-Medicare dataset, 3314 patients diagnosed with urothelial carcinoma of the urinary bladder and treated with RC alone or RC with PLND were identified. After propensity score matching to reduce potential selection bias, all cause mortality (ACM)-free and cancer specific mortality (CSM)-free survival rates were estimated. Multivariable regression models (MVA) addressed the effect of PLND on ACM and CSM. Subgroups analyses according to age and comorbidities were performed.
After matching, 688 and 688 patients treated with RC alone or RC with PLND remained. The 5-year ACM-free survival rate was 36 after RC alone and 45% after RC with PLND (p < 0001). In MVA, PLND exerted a protective effect on ACM (HR 0.77, p < 0.001). The 5-year CSM-free survival rate was 54 after RC alone and 65% after RC with PLND (p < 0.001). In MVA, PLND exerted a protective effect on CSM (HR 0.71, p < 0.001). Similar results were observed in younger (age ≤75) and healthier (CCI = 0) patients, where PLND exerted a protective effect on ACM (HR 0.64, p = 0.001) and CSM (HR 0.65, p = 0.01). Conversely, in older (age >75) and sicker (CCI ≥1) patients, PLND was not associated with ACM (HR 0.98, p = 0.8) or CSM (HR 1.01, p = 0.9).
RC with PLND is associated with improved all cause and cancer specific survival in younger and healthier RC candidates but not in older and sicker patients.
Copyright © 2014. Published by Elsevier Ltd.
BACKGROUND:Procedure-based surveys of laparoscopic entry access injuries show a reassuringly low incidence, varying from 5 per 10,000 to 3 per 1,000, and, consequently, can provide only limited specific injury data. The current study uses existing injury-based reporting systems to access a uniquely large number of entry injuries to define the nature and outcomes of such events.STUDY DESIGN:Claims arising from US and non-US entry access injuries, between 1980 and 1999, reported to the Physicians Insurers Association of America by their member and affiliate companies and entry-injury medical device reports to the US FDA, from 1995 through October 1997, were analyzed to determine operative procedures, physician specialties, entry devices, and techniques associated with specific injuries. Individual injuries were analyzed for their relative incidence and potential to cause disability and death.RESULTS:Five hundred ninety-four structures or organs were injured in 506 patients, resulting in 65 deaths (13%). General surgical procedures made up at least 67% of combined medical device reports and US Physicians Insurers Association of America cases, and gynecologic procedures accounted for 63% of non-US claims. Bowel and retroperitoneal vascular injuries comprised 76% of all injuries incurred in the process of establishing a primary port. Nearly 50% of both small and large bowel injuries were unrecognized for 24 hours or longer. Delayed recognition, along with age greater than 59 years and major visceral vascular injuries, were each independent significant predictors of death.CONCLUSIONS:No entry technique or device is absolutely safe. Avoidance of entry injuries depends on patient-specific anatomic orientation and control of entry axial force. Certain entry devices can be facilitating in controlling axial force. Overall, this large aggregate of entry access injuries shows them to be more serious and, along with other data, implies that they might be more common than reported in procedure-based studies.
PURPOSE: To identify predictive factors underlying recurrence and survival after partial cystectomy for pelvic lymph node-negative muscle-invasive bladder cancer (MIBC) (urothelial carcinoma) and to report the results of partial cystectomy among select patients. METHODS: We retrospectively reviewed 101 cases that received partial cystectomy for MIBC (pT2-3N0M0) between 2000 and 2010. The log-rank test and a Cox regression analyses were performed to identify factors that were predictive of recurrence and survival. RESULTS: With a median follow-up of 53.0 months (range 9-120), the 5-year overall survival (OS), cancer-specific survival (CSS) and recurrence-free survival (RFS) rates were 58%, 65% and 50%, respectively. A total of 33 patients died of bladder cancer and 52 patients survived with intact bladder. Of the 101 patients included, 55 had no recurrence, 12 had non-muscle-invasive recurrence in the bladder that was treated successfully, and 34 had recurrence with advanced disease. The multivariate analysis showed that prior history of urothelial carcinoma (PH.UC) was associated with both CSS and RFS and weakly associated with OS; lymphovascular invasion (LVI) and ureteral reimplantation (UR) were associated with OS, CSS and RFS. CONCLUSIONS: Among patients with pelvic lymph node-negative MIBC, PH.UC and UR should be considered as contraindications for partial cystectomy, and LVI is predictive of poor outcomes after partial cystectomy. Highly selective partial cystectomy is a rational alternative to radical cystectomy for the treatment of MIBC with negative pelvic lymph nodes.
Unlabelled:
WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Bladder cancer (BC) is a public health problem throughout the world, and now radical cystectomy (RC) has been introduced as a standard treatment for BC invading muscle and some BCs not invading muscle. Pelvic lymph node dissection (PLND) is considered an integral part of RC for its prognostic and therapeutic significance, but the extent of the PLND has not been precisely defined. Computed tomography is considered one of the most preferable methods to assess the BC stage preoperatively because of its high sensitivity and specificity. However, there are few articles referring to CT as an aid in deciding the extent of lymphadenectomy during RC. In the present study, we prospectively studied the clinical value of preoperative CT staging of primary tumours in deciding the extent of PLND during laparoscopic RC in the management of BC. The preliminary findings suggested that all patients with higher preoperative CT stage should be given super-extended PLND during RC. For those with lower CT stage, careful and thorough clearance of all lymphatic and adipose tissues within the true pelvis could be more helpful than super-extended PLND.
Objective:
To study prospectively the clinical value of preoperative spiral computed tomography (CT) staging of primary tumours in deciding the extent of pelvic lymph node dissection (PLND) during laparoscopic radical cystectomy (RC) in the management of bladder cancer (BC).
Patients and methods:
Between January 2010 and December 2011, a total of 63 patients with urothelial BC received laparoscopic RC, super-extended PLND and ileac conduit. The super-extended PLND removed all lymphatic tissues in the boundaries at the level of the inferior mesenteric origin from the aorta (cephalad), the pelvic floor (distally), the genitofemoral nerve (laterally) and the sacral promontory (posteriorly). All of the operations were performed by one experienced surgeon, and all harvested lymph nodes were submitted separately. CT was used to evaluate the preoperative CT stage (CTx) of each primary bladder tumour.
Results:
All patients were divided into five categories according to their CTx stages: three at CT1, seven at CT2a, 38 at CT2b, seven at CT3b, and eight at CT4a. All 63 procedures were completed successfully without any conversion to open surgery. The mean estimated blood loss was 450 mL, and 14 patients (22.2%) had postoperative lymphatic leakage. Each case was pathologically confirmed as transitional cell carcinoma with negative margins at the urethral and ureteric stumps. None of the patients with a low CTx stage (CT1-CT2a) had positive lymph nodes above the level of the common iliac artery bifurcation. There was no jump lymph node metastasis, and no positive lymph node was detected above the level of aortic bifurcation in all cases.
Conclusion:
Based on the preoperative CT staging, urological surgeons can determine the boundaries of PLND to reduce intraoperative injury and postoperative complications in patients with BC, especially those at the lower CTx stages (CT1 and CT2a).
Robot-assisted laparoscopic bladder diverticulectomy (RALBD) has been increasingly reported in recent years. We review the technique of RALBD and the perioperative outcomes. We searched online databases to identify original articles related to RALBD. In the Method section, we describe our technique and reviewe several techniques for identification and robotic management of bladder diverticula. We identified 13 retrospective studies that met our criteria, with a total of 44 patients. The mean diverticulum size was 8.3 ± 3.6 cm, mean operative time was 186 ± 68 min, mean estimated blood loss was 86 ± 64 ml, and mean length of stay was 2.4 ± 1.7 days. In the majority of cases, patients with acquired diverticula underwent urethral catheter removal between 7 and 14 postoperative days while in the pediatric population with congenital bladder diverticula, Foley catheter removal usually occurred on postoperative day one. We conclude that a robotic technique is a feasible minimally invasive approach for bladder diverticulectomy. Potential benefits may include precise dissection of adjacent structures, as well as easier intracorporeal suturing. Further studies are needed to compare outcomes and costs versus other existing procedures.
To our knowledge long-term oncologic outcomes following partial cystectomy for urothelial carcinoma remain to be defined. We evaluated patterns of recurrence and survival among matched patients treated with partial vs radical cystectomy for bladder cancer.
We identified 86 patients who underwent partial cystectomy for pT1-4N0-1Mx urothelial carcinoma between 1980 and 2006 at our institution. They were matched 1:2 to patients undergoing radical cystectomy based on age, gender, pathological T stage and receipt of neoadjuvant chemotherapy. Survival was estimated using Kaplan-Meier analysis and compared with the log rank test.
Median postoperative followup was 6.2 years (range 0 to 27). No difference was noted for 10-year distant recurrence-free survival (61% vs 66%, p = 0.63) or cancer specific survival (58% vs 63%, p = 0.67) between patients treated with partial and radical cystectomy, respectively. Interestingly, 4 of 86 patients (5%) who underwent partial cystectomy showed extravesical pelvic tumor recurrence postoperatively vs 29 of 167 (17%) who underwent radical cystectomy (p = 0.004). In addition, 33 of 86 patients (38%) were diagnosed with intravesical recurrence of tumor after partial cystectomy and 16 of 86 (19%) initially treated with partial cystectomy ultimately underwent radical cystectomy.
Our matched analysis demonstrated no difference in metastasis-free or cancer specific survival between select patients undergoing partial cystectomy and those undergoing radical cystectomy. Nevertheless, patients treated with partial cystectomy remain at risk for intravesical recurrence and, thus, they should be counseled and surveilled accordingly.
The aim of this report is to describe our surgical technique for robot-assisted laparoscopic bladder diverticulectomy. In this technique, methylene blue is instilled into the bladder to aid in intra-abdominal identification of the diverticular neck.
We retrospectively reviewed the records of patients who underwent robot-assisted bladder diverticulectomy by a single surgeon.
Between September 2008 and January 2011, 5 patients successfully underwent robot-assisted laparoscopic bladder diverticulectomy using 1% intravesical methylene blue. All cases were completed without intraoperative complication or need for open conversion. Mean operative time was 216 minutes, with a mean estimated blood loss of 45 mL. Patients were discharged 1-2 days following surgery. No patient experienced a perioperative complication.
The robot-assisted approach for bladder diverticulectomy is a viable alternative to both open and laparoscopic surgery. The use of intravesical methylene blue greatly aids in identification of the diverticular neck during this procedure.
To examine the effect of stage-specific pelvic lymph node dissection (PLND) on cancer-specific (CSM) and overall mortality (OM) rates at radical cystectomy (RC) for bladder cancer.
Overall, 11,183 patients were treated with RC within the Surveillance, Epidemiology, and End Results database. Univariable and multivariable Cox regression analyses tested the effect of PLND on CSM and OM rates, after stratifying according to pathological tumour stage.
Overall, PLND was omitted in 25% of patients, and in 50, 35, 27, 16 and 23% of patients with respectively pTa/is, pT1, pT2, pT3 and pT4 disease (P < 0.001). For the same stages, the 10-year CSM-free rates for patients undergoing PLND compared with those with no PLND were, respectively, 80 vs 71.9% (P = 0.02), 81.7 vs 70.0% (P < 0.001), 71.5 vs 56.1% (P = 0.001), 43.7 vs 38.8% (P = 0.006), and 35.1 vs 32.0% (P = 0.1). In multivariable analyses, PLND omission was associated with a higher CSM in patients with pTa/is, pT1 and pT2 disease (all P ≤ 0.01), but failed to achieve independent predictor status in patients with pT3 and pT4 disease (both P ≥ 0.05). Omitting PLND predisposed to a higher OM across all tumour stages (all P ≤ 0.03).
Our results indicate that PLND was more frequently omitted in patients with organ-confined disease. The beneficial effect of PLND on cancer control outcomes was more evident in these patients than in those with pT3 or pT4 disease. PLND at RC should always be considered, regardless of tumour stage.
We describe the technique and our evolving outcomes of laparoscopic extended pelvic lymphadenectomy for bladder cancer.
Since 1999 laparoscopic radical cystectomy with pelvic lymphadenectomy and intracorporeal urinary diversion has been performed in 22 patients. The initial 11 patients underwent limited dissection (group 1) and the subsequent 11 consecutive patients underwent extended lymphadenectomy (group 2). Our split-and-roll technique of laparoscopic extended pelvic lymphadenectomy has evolved to achieve lymphatic tissue clearance by bilaterally skeletonizing the genitofemoral nerve, external iliac artery, external iliac vein, obturator nerve, hypogastric artery, common iliac artery and pubic bone.
Extended lymphadenectomy added 1.5 hours of operative time. The median number of nodes retrieved was 3 and 21 in groups 1 and 2, respectively (p = 0.001). Three patients per group were found to have positive nodal disease. In 1 patient undergoing extended dissection injury to a deep pelvic vein was managed by intracorporeal suturing and resulted in 200 ml blood loss. Two other patients had deep venous thrombosis. At a mean followup of 11 months (range 2 to 43) there were no port site recurrences.
Laparoscopic extended pelvic lymphadenectomy for bladder cancer can be performed with anatomical boundaries and nodal yields commensurate with those of current recommendations for open surgery.
To report the first series of laparoendoscopic single-site surgery for radical cystectomy and bilateral pelvic lymph node dissection. The development of laparoendoscopic single-site surgery and its application to urothelial malignancy has not been previously evaluated.
A novel, single multichannel port and flexible laparoscopic instruments and laparoscope were used for all procedures. The eligible patients had transitional cell carcinoma that was muscle invasive or refractory to intravesical therapy. Locally advanced disease, previous abdominal or pelvic surgery or radiotherapy, or those desiring orthotopic reconstruction were excluded. No additional ports were needed, and lymphadenectomy was performed using an extended template up to the aortic bifurcation.
A total of 3 patients (2 men and 1 woman) underwent radical cystectomy with bilateral pelvic lymph node dissection. All the procedures were completed successfully. All patients underwent extracorporeal urinary diversion by way of extension of the umbilical port site. The operative time was 315 ± 40 minutes, and the blood loss was minimal (217 ± 29 mL). The pathologic evaluation revealed negative margins and negative lymph node involvement (mean number of nodes 16 ± 3). All patients were discharged within 1 week (6 ± 1 days) with minimal postoperative pain according to the visual analog pain scale (0-1 of 10). At a minimum of 2 years of follow-up (range 24-26 months), no evidence of recurrent or metastatic disease was detected.
Laparoendoscopic single-site surgery for radical cystectomy and bilateral pelvic lymph node dissection is feasible and safe for select patients. Adequate lymph node dissection was possible through a single multichannel port. The long-term oncologic evaluation of these patients awaits; however, the preliminary outcomes have been promising.
To review the current status and role of robot-assisted laparoscopic pelvic lymphadenectomy. To review the need, extent, lymph node yield, oncological feasibility, and outcome of robot-assisted pelvic lymphadenectomy for invasive bladder cancer in patients undergoing a robot-assisted laparoscopic radical cystectomy.
The National Library of Medicine and the Pub Med were extensively searched for the cases of robot-assisted laparoscopic pelvic lymphadenectomy performed in conjunction with robot-assisted laparoscopic radical cystectomy for bladder cancer using the following keywords: bladder cancer, pelvic lymphadenectomy, cystectomy, laparoscopy, robot, and robot-assisted radical cystectomy. These were reviewed and analyzed (using certain tabulated parameters) to determine the current status of robot-assisted pelvic lymphadenectomy.
The search yielded about 12 major published series (278 cases) of "robot-assisted radical cystectomy with pelvic lymphadenectomy," with an overall acceptable mean operating time(s), complication rate, blood loss, and hospital stay.
Robot-assisted laparoscopic pelvic lymphadenectomy in conjunction with robot-assisted laparoscopic radical cystectomy is an oncologically feasible and technically safe procedure with acceptable early operative outcomes that appear to be comparable to those achieved with open/laparoscopic surgery.
Cancer control outcomes after partial cystectomy (PC) are not well studied. We compared the population-based rates of overall (OS) and cause-specific survival (CSS) in patients with urothelial carcinoma of the urinary bladder (UCB) treated with PC or radical cystectomy (RC).
Within the Surveillance Epidemiology and End Results-9 database, we identified 7243 patients treated with PC (n = 1573) or RC (n = 5670), who had pathologic T(1-4)N(1-2)M(0) UCB. Matched Kaplan-Meier survival analyses compared the effect of PC vs RC on OS and CSS.
In the entire cohort, the OS and CSS estimates at 5 years were 57.2% and 76.4%, respectively, for PC patients and 50.2% and 65.8%, respectively, for RC patients (P < .001). In the cohort matched for age, race, pT stage, pN stage, tumor grade, and year of surgery, at 5 years the OS and CSS estimates were 56.0% and 73.5%, respectively, for PC patients, and 50.9% and 67.5%, respectively, for RC patients (OS, P = .03 and CSS, P < .001). When the number of removed lymph nodes was added to the matching criteria, the 5-year OS and CSS estimates were 57.2% and 70.3%, respectively, for PC patients, and 54.6% and 69.2%, respectively, for RC patients (HR 1.1, P = .3 and HR 1.1, P = .5).
Partial cystectomy does not undermine cancer control in appropriately selected patients with UCB.
Open surgery, endoscopic technique, and standard laparoscopic technique are surgical options for the management of bladder diverticuli. In this article, we report robot-assisted bladder diverticulectomy (RABD) and photoselective vaporization of prostate (PVP) in the same patient sequentially. To the best of our knowledge, this is the first case report of RABD combined with PVP.
A 63-year-old patient with benign prostatic hyperplasia and a secondary large bladder diverticulum underwent sequential PVP and RABD. Cystoscopic examination revealed obstructing prostate lobes and a large diverticulum at posterior wall of bladder. After completion of PVP procedure, a 16F urethral catheter was inserted into the diverticulum via outer sheath of optic urethrotome and another 16F urethral catheter was left in bladder for urinary drainage. A transperitoneal approach was preferred. The diverticulum was distended with saline infusion via the Foley catheter inside the diverticulum. The distended diverticulum was seen easily and dissected from the surrounding tissue. The bladder was closed in two separate layers.
Total operative time, including diverticulectomy with PVP procedure, was 230 minutes, and console time was 90 minutes. The length of stay was 7 days.
There has been always concern about the high intravesical pressures secondary to irrigant instillation that may disrupt the bladder repair. To avoid this problem we combined robotic diverticulectomy with PVP. Because of hemostatic properties of potassium-titanyl-phosphate laser, we did not encounter with bleeding after prostatectomy procedure. Moreover, we did not use irrigation, and the suture line of the bladder was kept safe. Therefore, we recommend to use greenlight laser in combined prostate and RABD operations. RABD is a feasible and safe procedure. RABD and PVP can be performed safely in the same patient sequentially.
We report our initial experience with four cases of robot-assisted laparoscopic partial cystectomy and diverticulectomy performed between June 2005 and August 2007.
The series consisted of three male patients and one female with a mean age of 64 years (range 36-77 years). In each case, a transperitoneal laparoscopic approach was used to mobilize the bladder. Next the bladder lesion was scored circumferentially cystoscopically with a Collings knife. The remainder of the excision and bladder reconstruction was performed with the da Vinci robot.
Mean operative time was 194 minutes with a mean blood loss of 35 mL. The urethral catheter was removed between 5 and 14 days following a normal cystogram. There were no significant complications. Postoperative hospital stay was 2 to 3 days.
Robot-assisted laparoscopic partial cystectomy and diverticulectomy are technically feasible and represent an alternative to open and conventional laparoscopic approaches.
Adenocarcinoma of the urinary bladder is an uncommon, often aggressive urologic cancer. In an attempt to classify and define management of this tumor, 28 patients with vesical adenocarcinoma were studied. Excluded were patients with mixed transitional cell carcinoma and adenocarcinoma. Three major classes of tumor were identified: primary vesical adenocarcinoma, urachal adenocarcinoma, and extravesical adenocarcinoma involving the bladder. Signet ring cell tumors appeared to behave more aggressively than other cell types. Radical surgery was the most effective treatment.
Bowel injury is a potential complication of any abdominal or retroperitoneal surgical procedure. We determine the incidence and assess the sequelae of laparoscopic bowel injury, and identify signs and symptoms of an unrecognized injury.
Between July 1991 and June 1998 laparoscopic urological procedures were performed in 915 patients, of whom 8 had intraoperative bowel perforation or abrasion injuries. In addition, 2 cases of unrecognized bowel perforation referred from elsewhere were reviewed. A survey of the surgical and gynecological literature revealed 266 laparoscopic bowel perforation injuries in 205,969 laparoscopic cases.
In our series laparoscopic bowel perforation occurred in 0.2% of cases (2) and bowel abrasion occurred in 0.6% (6). The 6 bowel abrasion injuries were recognized intraoperatively and 5 were repaired immediately. In 4 cases, including 2 referred from elsewhere, perforation injuries were not recognized intraoperatively and they had an unusual presentation postoperatively. These patients had severe, single trocar site pain, abdominal distention, diarrhea and leukopenia followed by acute cardiopulmonary collapse secondary to sepsis within 96 hours of surgery. The combined incidence of bowel complications in the literature was 1.3/1,000 cases. Most injuries (69%) were not recognized at surgery. Of the injuries 58% were of small bowel, 32% were of colon and 50% were caused by electrocautery. Of the patients 80% required laparotomy to repair the bowel injuries.
Bowel injury following laparoscopic surgery is a rare complication that may have an unusual presentation and devastating sequelae. Any bowel injury, including serosal abrasions, should be treated at the time of recognition. Persistent focal pain in a trocar site with abdominal distention, diarrhea and leukopenia may be the first presenting signs and symptoms of an unrecognized laparoscopic bowel injury.
Procedure-based surveys oflaparoscopic entry access injuries show a reassuringly low incidence, varying from 5 per 10,000 to 3 per 1,000, and, consequently, can provide only limited specific injury data. The current study uses existing injury-based reporting systems to access a uniquely large number of entry injuries to define the nature and outcomes of such events.
Claims arising from US and non-US entry access injuries, between 1980 and 1999, reported to the Physicians Insurers Association of America by their member and affiliate companies and entry-injury medical device reports to the US FDA, from 1995 through October 1997, were analyzed to determine operative procedures, physician specialties, entry devices, and techniques associated with specific injuries. Individual injuries were analyzed for their relative incidence and potential to cause disability and death.
Five hundred ninety-four structures or organs were injured in 506 patients, resulting in 65 deaths (13%). General surgical procedures made up at least 67% of combined medical device reports and US Physicians Insurers Association of America cases, and gynecologic procedures accounted for 63% of non-US claims. Bowel and retroperitoneal vascular injuries comprised 76% of all injuries incurred in the process of establishing a primary port. Nearly 50% of both small and large bowel injuries were unrecognized for 24 hours or longer. Delayed recognition, along with age greater than 59 years and major visceral vascular injuries, were each independent significant predictors of death.
No entry technique or device is absolutely safe. Avoidance of entry injuries depends on patient-specific anatomic orientation and control of entry axial force. Certain entry devices can be facilitating in controlling axial force. Overall, this large aggregate of entry access injuries shows them to be more serious and, along with other data, implies that they might be more common than reported in procedure-based studies.
Partial cystectomy is a bladder sparing procedure that has been used to treat invasive bladder cancer in highly selected patients. This study analyzes the outcomes of partial cystectomy in a contemporary cohort of patients to identify appropriate selection criteria for the procedure.
Records were reviewed for 58 patients with a primary bladder tumor who had undergone partial cystectomy at Memorial Sloan-Kettering Cancer Center from 1995 to 2001. Information was collected on tumor size, histology, location, presence of carcinoma in situ (CIS), multifocality, neoadjuvant treatment, clinical stage, pathological stage and disease status.
For the 58 patients analyzed, overall 5-year survival was 69% with a mean followup of 33 months (range 1 to 83). Of the patients 43 (74%) are alive with an intact bladder, 39 (67%) are currently disease-free with an intact bladder and 32 (55%) have been continuously disease-free with an intact bladder. Seven patients experienced a superficial recurrence and were treated successfully while 15 patients experienced an advanced recurrence. On univariate analysis CIS and multifocality were related to superficial recurrence, and lymph node involvement and positive surgical margin were related to advanced recurrence. On multivariate analysis concomitant CIS (odds ratio 7.05, p = 0.004) and lymph node involvement (odds ratio 4.38, p = 0.031) were predictors of advanced recurrence.
In highly selected patients with invasive bladder cancer, partial cystectomy offers acceptable outcomes. Concomitant CIS and presence of metastases to regional lymph nodes predict advanced recurrence.
Surgical options for treating urachal adenocarcinoma include radical cystectomy and en bloc partial cystectomy with excision of the urachus and umbilectomy. Recently, laparoscopy has been increasingly used to treat bladder and urachal pathologic findings efficaciously. We describe two techniques for performing laparoscopic en bloc partial cystectomy with bilateral extended pelvic lymphadenectomy.
We performed the procedure in 3 patients with established urachal adenocarcinoma. The anatomic boundaries of resection were similar to those described for open surgery. We used an inverted V-shaped, five-port configuration, with the camera port placed 3 cm supraumbilically. An antegrade approach was performed for tumors less than 5 cm in 2 cases. The steps of the procedure included an inverted V-shaped incision along the peritoneum lateral to the medial umbilical ligament on either side; urachal disconnection, dissection of the urachus using the "twist and roll technique"; anterior cystotomy, circumferential resection of the tumor-bearing bladder dome, under vision; tumor placement in a "lap-bag"; bladder reconstruction using intracorporeal suturing; bilateral extended pelvic lymphadenectomy; placement of catheter and drain; and specimen retrieval. We evolved a retrograde technique for larger size tumors (larger than 5 cm). The procedure was successfully completed in all patients, with a mean operative time of 180 minutes (range 150 to 210). No significant intraoperative or postoperative complications occurred, except for a left inferior epigastric artery injury in 1 case. The resected nodes (range 8 to 11) were free of tumor. No local or distant recurrences were observed at a mean follow-up of 6.5 months (range 4.5 to 9).
Laparoscopic en bloc partial cystectomy and bilateral extended pelvic lymphadenectomy is a safe, feasible, minimally invasive alternative to open partial cystectomy for urachal tumors.
Partial cystectomy is a surgical option for select patients diagnosed with urothelial carcinoma. We review our experience with partial cystectomy for muscle invasive urothelial carcinoma to assess local control and survival rates.
From 1982 to 2003 a total of 37 patients with muscle invasive urothelial carcinoma underwent partial cystectomy with curative intent. Reviewed data included history of superficial tumors, presence of variant histology, tumor location, clinical stage, pathological stage, presence of carcinoma in situ, adjuvant therapy and disease status.
The 5-year overall, disease specific and recurrence-free survival rates were 67%, 87% and 39%, respectively. Mean followup was 72.6 months (range 6 to 217). Of the 37 patients 19 (51%) did not have tumor recurrence, 9 (24%) had superficial recurrence in the bladder that was treated successfully and 9 (24%) had recurrence with advanced disease. A total of 24 patients (65%) had an intact bladder with no evidence of disease after a median of 53 months. There were 6 patients (16%) who died of bladder cancer, 3 of whom died of late recurrence of muscle invasive cancer (41, 44 and 138 months after partial cystectomy). On multivariate analysis higher pathological stage (HR 3.4, p = 0.04) was associated with shorter recurrence-free survival. A history of superficial tumors (p <0.01) and clinical stage (p = 0.01) was associated with advanced recurrence-free survival. The use of adjuvant chemotherapy (HR 0.18, p = 0.03) was associated with prolonged advanced recurrence-free survival, however adjuvant chemotherapy did not impact overall survival.
Partial cystectomy provides adequate local control of muscle invasive bladder cancer in select patients. Because late recurrence is not uncommon and is potentially life threatening, lifelong followup with cystoscopy is recommended.
Surgical management for bladder diverticuli includes open, endoscopic and standard laparoscopic techniques. To our knowledge we report the first series of robotic assisted laparoscopic bladder diverticulectomies.
Five patients underwent robotic assisted laparoscopic bladder diverticulectomy between December 2004 and December 2006, as performed by a single surgeon using the da Vinci robotic system for symptomatic diverticuli. The records were reviewed, the surgical technique is described and a review of the literature was performed.
All patients underwent cystoscopy, ureteral stent placement and placement of an angiographic catheter to distend the diverticulum. The diverticulum was approached transperitoneally, mobilized and transected at its neck, and the bladder was closed in 2 layers. One patient underwent ureteral reimplantation for a Hutch diverticulum. Median total operative time was 178 minutes (range 163 to 235) and robotic operative time was 83 minutes (range 63 to 143). Length of stay was 3 days (range 1 to 6). Two patients who underwent transurethral prostate resection before diverticulum resection did well. Two patients in whom medical management failed ultimately underwent transurethral prostate resection and 1 patient continued on medical therapy with regular followup.
Robotic assisted laparoscopic bladder diverticulectomy is safe and effective for patients with a large bladder diverticulum and small prostate. Perioperative surgical outcomes rival those of previously reported open, endoscopic and laparoscopic diverticulectomies.
We reviewed our experience with partial cystectomy to assess local control and survival rates, and to identify pathologic predictors for recurrence.
From 1995 to 2005, 25 patients with urothelial carcinoma underwent partial cystectomy with curative intent. As protocol, patients with primary solitary muscle-invasive bladder tumors underwent preoperative localized radiotherapy, administration of a single dose of intravesical chemotherapy at the time of partial cystectomy, and postoperative intravesical Bacillus Calmette-Guérin therapy. We reviewed clinical and pathologic data to identify variables associated with disease recurrence.
We analyzed data from 25 patient records meeting review criteria (72% male, mean age 65.1 +/- 9.8 years). At time of transurethral resection of a bladder tumor (TURBT), all had a solitary primary T2 (68%) or T1HG (32%) lesion with no evidence of carcinoma in situ. At follow-up (mean 45.3 +/- 30.7 months), 5-year recurrence-free, disease-specific, and overall survival rates were 64%, 84%, and 70%, respectively. At a mean of 18.0 +/- 15.6 months, 8% of patients experienced intravesical non-muscle-invasive tumor recurrences and were treated with TURBT and intravesical chemotherapy. Twenty percent recurred with locally advanced tumors or visceral metastasis and were treated with systemic chemotherapy, local resection or cystectomy, or both. On univariate analysis, only tumor size at time of partial cystectomy (P = .03) was significantly associated with tumor recurrence.
Partial cystectomy offers adequate control of localized invasive urothelial carcinoma in carefully selected patients with solitary primary tumors. Lifelong follow-up with cystoscopy and abdominal imaging is recommended to detect recurrence.
Guideline on muscle-invasive and metastatic bladder cancer (European Association of Urology Guideline
- M I Milowsky
- R B Rumble
- C M Booth
- T Gilligan
- L J Eapen
- R J Hauke
- MI Milowsky
Partial cystectomy after neoadjuvant chemotherapy: memorial Sloan Kettering Cancer Center Contemporary Experience
- W M Bazzi
- R P Kopp
- T F Donahue
- M Bernstein
- P Russo
- B H Bochner
- WM Bazzi
Smith’s textbook of endourology
- K H Rha
- E I Lorenzo
- C K Oh
Philadelphia: Saunders Elsevier
- E S Rovner
- Campbell-Walsh Urology
ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines
- L A Fleisher
- K E Fleischmann
- A D Auerbach
- S A Barnason
- J A Beckman
- B Bozkurt
- LA Fleisher