Laparoscopic cystoprostatectomy for bladder cancer

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Laparoscopic   cystoprostatectomy   for   bladder   cancer

Authors
R Van Velthoven
Media type
Duration
17'54''
Publication
2006-11
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Nov 2006;6(11).
URL: http://www.websurg.com/doi-vd01en2001.htm

Laparoscopic   cystoprostatectomy   for   bladder   cancer

2. Dissection of ureter 01'35''
Once the tunnelization has been completed, the lateral incision of the posterior peritoneum begins midway at the level of iliac vessels. It is then extended caudally towards the internal inguinal ring and cranially towards the vascular crossover of ureters. Progressive skeletonization of the main vascular elements is performed in order to isolate all of the lymph node groups. Hence extensive lymphadenectomy is carried out, extending well beyond the limits of conventional ilio-obturator lymph node dissection. Here we can see the internal surface of the external iliac vein. The pelvic wall along with the fascia of the internal obturator muscle and lymph node groups are progressively isolated medially. Dissection is continued cranially along the internal border of the iliac vessels. A thorough control and hemostasis of the main lymphatic elements encountered will be achieved. Here we can see the use of a 10 mm LigaSure™, or vessel-sealing device. Nowadays, it is understood that dissection may be extended to the external surface of the same vessels in order to include the lymph node group located between these elements and the genitofemoral nerve. Here we can see the origin of the hypogastric artery. Dissection is continued anteriorly finding the crossing of the ureter. The distal portion of the ureter should be totally dissected while preserving its vascular supply. Lateral incisions merge with the posterior incision already completed. Lymph node dissection is progressively continued anteriorly. The ureter is followed towards the entrance of its intramural course which should not be dissected. The landmark to be identified is the crossing with the umbilical artery that is clearly visible laterally here at present. As for any hollow organ involved in transitional cell carcinoma, the ureter is secured by clips placed before division and its distal portion is orientated in order to facilitate a frozen section to screen for severe dysplasia whose presence, if proven, would require further anterior division.
3. Steps and further dissection 04'30''
Once excluded from the operative field, the ureter is left behind until urinary reconstruction is achieved and lymphatic dissection is continued towards the presacral region. The median structures, here the vascular ilio-obturator pedicle along with the nerve, are easily identified at the internal edge of the conventional ilio-obturator triangle that is crossed. The anterior vascular structures of the hypogastric vessels are progressively identified and secured by clips or other hemostatic devices, in this case by using the 10 mm vessel-sealing system. Here, the illustration summarizes the different steps already achieved; the same operative steps are repeated on the left side: freeing of the internal border of the external iliac vein, identification of the pelvic wall, progressive medialization of all lymph node groups, caudal dissection towards the inguinal ligament cephalad towards the emergence of the hypogastric artery anteriorly, merging of posterior and lateral incisions allowing isolation and dissection of the hypogastric artery and ureter, progressive control of the main lymphatic branches, identification of the anterior vascular network of the hypogastric artery whose superior structures will be secured. Here we can see the division of the superior vesical branch. The ureter is clipped and a division through orientation of the distal segment to be sent to pathology for frozen section. Hemostasis is continued from cranially to caudally along the superior and medial pedicles of the bladder, while keeping as a landmark the lateral surface of the seminal vesicle in order to clearly identify the junction between the bladder and the prostate as well as the emergence of the superior prostatic pedicles. Antegrade hemostasis should not be performed blindly to avoid damaging the paraprostatic neurovascular bundle in its emergence from the pararectal region. Once the superior pedicles are totally controlled, the bladder remains attached only by its superior peritoneal surface and by prostatic ligaments. The umbilical ligament is identified proximal to the umbilicus. It is divided as cranially as possible to respect the oncologic principles of radical cystectomy. The peritoneal layer is opened cranially to caudally at the lower margins of the lateral incisions.
4. Freeing of the prostate 09'20''
The Retzius’ space is progressively opened; its areolar tissue is easily identified. Progression of the dissection to the left is clearly visible here towards the lower extremity of the previous lateral incision. Once the Retzius’ space is completely opened, the dissection will carry on to the prostatic complex, with liberation of the endopelvic fascias, detachment of the lateral aspects of the prostate and retraction of the levator ani muscle fibers until we have clearly identified the puboprostatic ligaments. Here it’s the right puboprostatic ligament and the ipsilateral aspect of the prostate. Control of those structures, along with accompanying vessels can be done by any means including the 10 mm vessel sealing device, whilst making sure not to use too high frequency currents. Once the size of the prostate’s anterior commissure is reduced, the same hemostatic step may be applied “en bloc” at the level of the Santorini’s plexus as an alternative to its ligature, well-known in the context of a radical prostatectomy. The liberation of the prostatic apex without division of the urethra will allow an easier lateral mobilization of the prostate, particularly important here in the context of nervous preservation, when you take into account the absence of a dissection of the bladder neck and the importance of the operative specimen that includes altogether the bladder and the prostate. Dissection is continued at the level of the superior pedicles and left prostatic base where the prostatic branches are grasped using the antegrade approach. Dissection and progressive division of prostatic pedicles help to retract the neurovascular bundle laterally. Here we have the same view as the one obtained on the right: when searching for a correct identification of the vascular landmark, the main landmark to find is the base of the seminal vesicle.
5. End of the procedure 12'04''
Once the prostate is freed, its lateral aspect may be mobilized in order to expose the distal elements that are to be dissected. Dissection is continued at the level of the urethra which, contrary to prostatectomy, is totally freed circumferentially in order to be isolated. The catheter is removed and the urethra is secured by one clip applied before division to avoid any cell spillage. The preserved distal stump of the urethra will be sent to pathology for frozen section.It is to be observed that tissues lying posterior to the urethra are larger than found conventionally in radical prostatectomy. The final preservation of neurovascular bundles is not completed at the level of the apex. It will be carried out once the prostatic complex has been fully mobilized. Here to the right we can see clearly the retraction of the nerve that has already been dissected and the division of the apical pedicle that stops in the proximity of the pillar of the urethra. Following the logics of antegrade dissection, dissection is continued towards the midline. The same technique will be applied caudally along the left nerve. Hemostasis of the small apical branch will be achieved once the specimen will be removed entirely. The specimen is extracted through a median incision which helps to create an ileal reservoir in the present case. Here we have a Studer ileal bladder whose anterior closure has formed a kind of large bladder neck which is anastomosed to the residual urethral stump. A U-shaped stitch fixes the posterior limb of the new neobladder neck at 6 o’clock. Then, a suspended suture is applied to perform the anastomosis between the urethral stump and the new bladder shown in the video. The posterior layer between the urethra and the neobladder is sutured; this is a running suture. And the procedure finishes with the suturing of the anterior layer as shown. To avoid stenosis between the urethra and the neobladder, we use a 22 French catheter to catheterise the urethra. Once the anastomosis is completed, its patency is checked by rinsing the orthotopic reservoir. Double drainage is used in the case of cystectomy to control the anastomosis and the reservoir sutures to ensure digestive continuity.