Laparoscopic Radical Cystectomy – one of the Enhanced Recovery After Surgery (ERAS) steps to improve cystectomy results
Hora Milan, Department of Urology, Univesity Hospital and Faculty of Medicine, Charles University, Pilsen
Objective: ERAS (Enhanced Recovery After Surgery) in Radical Cystectomy (RC) includes 22 measures, one of which is the use of mini-invasive approaches. For these reasons, we have implemented laparoscopy for RC. Pure laparoscopy versus robotic has limited possibilities for intracorporal derivation, so we combine laparoscopic ablation phase with extracorporal derivation. Only in RC with concomitant unilateral nephroureterectomy (mostly for non-functioning kidney in advanced megaureter) and ureterocutaneostomy is performed completely laparoscopically. In orthotopic neobladder, we are still performing openly.
Material and methods:
In the period 1/2010 – 5/2018, 233 RC were executed. Of which 218 for urothelial carcinoma. Since 2014, laparoscopy (LRC) has been implemented in 38 (in 8 women). Robotic system is not available. From 2015 RC formed 32.2% (37/115) of all cystectomies. For LRC were indicated patients with BMI up to 30, less advanced (not T4, N2-3), without other complications (e.g. previous extensive intra-abdominal surgery). Surgeries were performed by a specialised surgical team in oncourology and laparoscopy.
Technique of surgery (with Bricker derivation): Trendelenburg position, 5 ports, 3D camera, surgeon and 2 assistants. The Ligasure Blunt tip 5 mm® sealing device is used for both pelvic lymphadenectomy (LND) and the RC itself. Only in men is sometimes used for Santorini plexus V-Loc® 90 stitch. The peritoneum is opened, the ureters released and at the bladder discontinued, followed by LND along the external iliac vessels and the obturator bundle, are interrupted by pedicles of the bladder, in women, the front wall of the vagina is resected, the urethra is divided. From the subsequent paraumbilical minilaparotomy (about 7cm), the preparation is extracted and ureteroileostomies performed.
Results: The time of operation at 38 LRC was 239 ± 36 (198-418) min. Blood loss 588 ± 643 (120-4000) ml. Average BMI 28.5. In 26, LRC was combined with extracorporal ureteroileostomy from short laparotomy. For the remaining 12, the LRC was associated with a one-sided nephrourerectomy (which was always preceded at lateral decubitus position its own RC), followed by a laparoscopic one side ureterocutanostomy. Conversion was not necessary. Severe complications were 3, ie 7.9% (2x Clavien IIIb – wound dehiscence, reintroduction of stents and 1x V – pulmonary embolism death). In the entire 233 RC population, IIIb-V was in 57 (24.5%). Long-term oncological results have not yet been evaluated.
Conclusion: Laparoscopic RC can be used in a selected proportion of patients (BMI up to 33, less advanced tumours), at least a third. This then means a significant reduction in postoperative complications.