Department of Urology, Kangnam St. Mary’s Hospital The Catholic University of Korea, College of Medicine Yoo Shin Ha

1. Laparoscopic Radical Cystectomy in Catholic University Experience Department of Urology, Kangnam St. Mary’s Hospital The Catholic University of Korea, College of Medicine Yoo Shin Ha

2. Introduction Radical cystectomy : the gold standard for M. invasive or high risk bladder cancer Laparoscopic surgery : expanding now applied to treat neoplasm ofthe pelvic organ Excellent perioperative & long-term results in RCC, Prostate ca. . Encourage to explore the role of laparoscopy in bladder ca. .

3. To define the role of laparoscopic radical cystectomy ? • The main problems to solve • Technical difficulty • Urinary diversion method • intracorporeally ? or extracorporeally ? • Oncologic risk , replicating the outcome of open surgery ? . To overcoming these problems, We would like to share our experience with LRC in 36 cases, since june 2003, .

4. Pathogenesis The steps of operations Port placement Camera port Marking incision site for specimen removal 5-port fan-shaped transperitoneal approach

5. Mobilization & division of the ureters • Important landmarks • Medial umbilical lig. • Vas • Rectovesical pouch • Iliac vessels • Incision of Peritoneum • dissection down to the • UVJ • isolation of ureter • as distally as possible • Frozen biopsy . .

6. Posterior dissection • Transverse peritoneotomy • at arch of douglas pouch • Developing plane Between • SV, prostate and the rectum • Denonvilliers’ fascia • Prerectal fat . .

7. Anterior dissection • Bladder is filled with saline • starting lateral to medial • umbilical lig. • divide urachus • the prevesical space is opened . .

8. Endopelvic fascia incision & DVD control • Exposure of endopelvic fascia • Incision on line of reflection • Separation from the levator ani M. • Suture of DVC (3-0 PDS) . .

9. Lateral dissection • Retracting bladder medially • away to the ext. iliac V • Divide the vesical & prostatic • fibrovascular pedicles • Sono-surg andHem-o-lok clip . .

10. Apex dissection • divide the DVC & expose urethra • To prevent contamination , • occlude the urethra • divide the urethra & posterior • attachment . .

11. Extended PLND • Ant. to Ext. iliac artery and • medial to genitofemoral N. • along the Ext. iliac vein • and the medial side of • pelvic wall • Obturator N. • Along the common iliac A. • up to the aortic bifurcation . .

12. Extracorporeal urinary diversion • through incision for speciemen • removal • GIA stappler • ileal conduit or ileal neobladder • is made in the usual manner • 4th port expanded for stoma . .

14. Result • June 2003 – MAY 2008 • LRC : 36 patients • Male 32, Female 4 • Mean age (SD) : 67.35 (± 10.1) • Mean BMI (SD) : 23.2 (± 2.4)

15. Perioperative characteristics • Mean total operative time (SD) : 573.9 (± 108.0) • Ileal conduit group : 557.7 (± 98.9) • Neobladder group : 698.8 (± 104.3) • Mean estimated blood loss (SD) : 709.5 (± 496.1) • Days to ambulation : 4.1 days (3-5) • Days to oral intake : 4.5 days (2-6) • Post-op hospital stay : 12.8 days (7-26) • Urethrectomy : 17 cases

16. Perioperative complications • Cystectomy and PLND could be completed laparoscopically • without conversion & complications • no rectal injury • no major vessel injury

17. Urinary diversion Constructed extracorporeally through the same incision Diversion : Ileal conduit 32 patients W-neobladder 3 (open conversion 2) Y-neobladdr 1 (open conversion 1) Ileal conduit W-neobladder Y-neobladder opening opening caudal cranial

18. Urethrectomy • Indications : carcinomatous involvement of the urethra, typically prostatic urethra • High risk of urethral recurrence Campbell-Walsh urology 9th ed. involvement of the prostatic urethra multifocal disease the presence of carcinoma in situ (CIS) involvement of the bladder neck upper tract TCC Urol Clin North Am 2005;32:199-206

19. Urethrectomy in catholic experience • Of total 36 patients, 17 cases of total urethrectomy was done • In 17 cases Positive margin of urethra : 4 cases involvement of the bladder neck : 9 cases the presence of carcinoma in situ (CIS) : 1 cases involvement of the prostatic urethra : 3 cases

20. Pathological outcomes Among total 36 cases, distant metastasis - 7 cases Local recurrence – 2 cases

21. Standard PLND vs Extended PLND • lymphatic tissue of • common iliac V and • up to aortic bifurcation • More accurate staging • Therapeutic benefit Urol Steven K, Poulsen AL J Urol 2007 Mills et al ; Surg Oncol Clin N Am 2007

22. Extended PLND in catholic experienceafter 25th case Standard PLND – 12.8 (4 - 22) Extended PLND – 16.9 (12 - 26)

23. Oncological outcomes • In catholic experience • oncological efficacy comparable to other reports of LRC • possible to replicate oncologic results of ORC Long term (over 5 yrs) oncologic survey Large scale survey

24. CONCLUSION ; The main problems to define the role LRC • Technical difficulty • Urinary diversion method Laparoscopic radical cystectomy is technically feasible . • Extracorporeal urinary diversion with small incision • maintains the benefits of laparoscopy • safe and effective method • providing comparable perioperative and functional outcomes • as open suregery Oncologic risk , replicating the outcome of open surgery ? . Need for technical advance for orthotopic neobladder !!

25. Oncologic risk , replicating the outcome of open surgery ? Not yet !! • Oncological outcomes from several centers’ experiences • including catholic university may suggest the possiblity of • replicating oncological outcomes of ORC • Large number and long-term oncologic data is required to • document long term cancer control with LRC . .

26. Thanks for your attention . .