Laparoscopic Radical Cystectomy with Orthotopic Ileal Neobladder —— Key Steps to Success

1. Laparoscopic Radical Cystectomy with Orthotopic Ileal Neobladder——Key Steps to Success Huang Jian The 2nd Affiliated Hospital Sun Yat-Sen University, Guangzhou China

2. Introduction • Laparoscopic radical cystectomy with orthotopic neobladder (LRC-OIN) is increasingly accepted by urologists. • It is no more the issue of feasibility but the issue of improvement for this procedure. • Discuss the techniques of key steps in LRC-OIN

3. Haemostatic Instruments • Harmonic scalpel • PK system • Bipolar forceps • LigaSure vessel sealing system • Electric hook • Hem-O-Lok

4. Hem-o-lok

5. PK System

6. 图1-2-10 结扎速血管闭合系统 LigaSureTM Vessel Sealing System

7. Ultracision-Harmonic Scalpel

9. Patien’s position and trocar site

10. The Major Steps of the Procedure Step 1: Pelvic lymphadenectomy Step 2:Dissectionof seminal vesicle and Denonvelia’s fascia to expose the posterior aspect of prostate Step 3: Exposing the anterior aspect of bladder and prostate Step 4:Dividing the lateral pedicles of the bladder and the prostate Step 5: Dividing the apex of the prostate and urethra Step 6: Extracorporeal construction of Ileal neobladder Step7:Intracorporeal neobladder-urethra anastomosis

11. Step 1: Pelvic Lymphadenectomy with electric hook and LigaSure

12. Techniques of Pelvic Lymphadenectomy • Sequence: Lymphadenectomy before or after cystectomy • extent:standardor extented • Using instrument:harmonic scalpel, PK system bipolar clamp and electric scissors, or electric hook and LigaSure • Attention: blood vessel and obturator nerve injury lymphatic leakage tumor cell seeding

13. Step 2:Dissection of seminal vesicle opening Denonvelia’s fascia

14. Step 3: Exposing the anterior aspect of bladder and prostate

15. Step 4: Dividing the lateral pedicles of the bladder and the prostate • Nerve sparing • Non nerve sparing

16. How to protect the neurovalscular bundle

17. Nerve sparing techniques

18. Non nerve sparing techniques

19. Step 5: Dividing the urethra

20. Step 2 to step 5: Cystectomy Posterior aspect Anterior aspect Bilateral pedicles Prostate apex and urethra

21. How to avoid rectum injury • Correctly localized seminal vesicle • Opening the Denonvelia’s fascia and separating rectum from prostate • Dividing lateral peadicle close to the prostate • Transecting the urethra while pulling up the prostate apex

22. Different methods in dividing the lateral paedicles • LigaSure • PK Forceps • Endo-GIA • Harmonic scalpel

23. How to avoid the tumor seeding • Avoidingbladder wall perforation • Don’t transgressing the tumor boundaries, • Blocking up the bladder neck before transecting uretha

24. Step 6:Removal the spacimen and neobladder construction

25. The technique of Extracorporeal formation of neobladder • 5 cm of midline subumbilical skin incision • M shape ileal pouch • Implantation of ureters directly to the posterior wall of the pouch by means of ureteral half nipple.

26. Different techniques in formation of neobladder • Intracorporeally or extracorporeally • Reconstruction: Studer pouch, hemi-kock pouch, T pouch, M pouch, • Implantation of ureters:ileal chimney, ileal nipple, extramural serous-lined tunnels, mucosal sulcus, ureteral nipple,

27. Studer pouch T pouch Hemi-kock pouch ileal chimney extramural serous-lined tunnels ileal nipple

28. Mucosal sulcus

29. Ureteral nipple

30. Step 7: Neobladder-urethra anastomosisTwo running suturestechnique

31. Tips and tricks in Neobladder-urethra anastomosis • A traction stitch to relieve the tension • Changing to head-up position • Two running suture technique better than interrupted, or running suture technique. • Attention: the catheter out side the neobladder

32. Summary The Surgical procedures of LRC-OIN can be improved by reasonable sequence, standard maneuver and correct use of instruments.

33. Ｔhanks！