96

Robotic and Laparoscopic Bladder

Surgery

Lee Richstone; Douglas S. Scherr

Questions

1.Laparoscopic ureteral reimplantation can be performed:

a.with a cross-trigonal approach.

b.with a Boari flap or bladder advancement flap.

c.with a psoas hitch.

d.via a traditional laparoscopic or robotic approach.

e.all of the above.

2.All of the following are essential surgical aspects of the Boari flap or bladder advancement flap EXCEPT:

a.an adequate-sized bladder must be present (200 to 300 mL).

b.the contralateral vesical pedicle may be transected if necessary.

c.the bladder flap should be slightly shorter than anticipated because bladder tissue can be easily stretched.

d.a tension-free anastomosis is important.

e.typically, a refluxing ureteral anastomosis is created.

3.Principles of open, laparoscopic, or robotic vesicovaginal fistula (VVF) repair include all of the following EXCEPT:

a.good exposure of the fistulous tract.

b.wide excision of the fibrous and scar tissue.

c.tension-free repair of the vagina and bladder.

d.interposition of a flap of peritoneum or omentum.

e.adequate drainage.

4.Contraindications for laparoscopic enterocystoplasty include all of the following EXCEPT:

a.diverticulosis.

b.inflammatory bowel disease.

c.renal failure.

d.noncompliance.

e.ulcerative colitis.

5.Which of the following statements is NOT correct regarding laparoscopic enterocystoplasty?

a.Subtotal cystectomy is not always mandatory.

b.Mesenteric pedicle of the selected bowel segment is wide and broadbased.

c.Mesenteric window is closed.

d.Reestablishment of bowel continuity is a critical step of the operation and may be performed extracorporeally for added security, if necessary.

e.Bowel-to-bladder anastomosis is optimally performed with interrupted serosa-to-serosa sutures.

6.Partial cystectomy can be performed in all of the following circumstances EXCEPT:

a.tumor at the bladder dome.

b.tumor in the bladder diverticulum.

c.solitary invasive bladder tumor located at a distance from the ureteric orifices.

d.history of multiple tumors or carcinoma in situ (CIS).

e.good bladder capacity.

7.Which of the following statements is TRUE regarding partial cystectomy?

a.Thirty percent to 40% of patients with bladder cancer are candidates for a partial cystectomy.

b.Five-year survival rates range from 80% to 90%.

c.Laparoscopic partial cystectomy is now an established procedure.

d.All of the above.

e.None of the above.

8.Which of the following is a contraindication for laparoscopic radical cystectomy today?

a.Multiple bladder tumors

b.Nonbulky, invasive bladder cancer

c.T4 disease

d.Moderate obesity

e.Open pelvic surgery

9.As regards radical cystectomy, all of the following have been performed laparoscopically EXCEPT:

a.extended pelvic lymph node dissection.

b.uterus-and vagina-sparing radical cystectomy.

c.anterior pelvic exenteration in the female.

d.orthotopic neobladder.

e.Indiana pouch, constructed intracorporeally.

.Anatomic boundaries of extended pelvic lymph node dissection include all of the following EXCEPT:

a.external iliac artery (lateral).

b.obturator nerve (posterior).

c.aortic bifurcation area (proximal).

d.internal inguinal ring (distal).

e.bladder (medial).

.Future directions for laparoscopic/robotic radical cystectomy are likely to include which of the following?

a.Careful, prospective, long-term evaluation of oncologic and functional outcomes

b.Evaluation of the potential advantages of intracorporeal bowel work

c.Elimination of bowel through use of novel bladder substitutes

d.International collaboration

e.All of the above

Answers

1.e. All of the above. All of the included answers are correct regarding laparoscopic ureteral reimplantation. Minimally invasive ureteral reimplant can be performed in a refluxing or nonrefluxing fashion, and with a crosstrigonal or tunneled approach if so desired. In cases with larger ureteral loss, a Boari flap or bladder advancement flap can be utilized, or a psoas hitch can be performed replicating open techniques. Finally, both a laparoscopic and robotic approach to ureteral reimplantation has been described.

2.c. The bladder flap should be slightly shorter than anticipated because bladder tissue can be easily stretched. A tension-free anastomosis of the anterolateral bladder flap based on the ipsilateral vesical pedicle is critical.

The bladder flap should be somewhat longer and wider than anticipated because the nondistended bladder shrinks in size, thus placing tension on

the anastomosis. Ideally, a flap length-to-breadth ratio of 3:1 ensures good vascularity of its apex.

3.b. Wide excision of the fibrous and scar tissue. Wide circumferential excision of the fistula and associated scar tissue is not necessary and may not even be feasible. Only the fibrotic VVF tract and its edges need to be excised. Adequate mobilization of the anterior vaginal wall and posterior bladder wall is performed to achieve a tension-free repair. Care is taken not to compromise the ureteral orifices. An interposition graft of omentum is anchored between the vagina and the bladder with a stitch.

4.a. Diverticulosis. The presence of bowel pathology such as diverticulitis or ulcerative colitis requires the use of alternative, nondiseased bowel segments. Similar to open surgery, laparoscopic enterocystoplasty should not be performed in the presence of advanced renal or liver failure, inflammatory bowel disease, or short gut syndrome, or in a patient who is unable to perform or noncompliant in performing intermittent catheterization reliably. Diverticulosis is not a contraindication for performing enterocystoplasty.

5.e. Bowel-to-bladder anastomosis is optimally performed with interrupted serosa-to-serosa sutures. The technical principles of enterocystoplasty are identical between open surgical and laparoscopic techniques. Generous mobilization of the bladder allows creation of an adequate anteroposterior cystotomy. Subtotal cystectomy is necessary only in patients with severely symptomatic interstitial cystitis. An optimal segment of bowel based on a broad, well-vascularized mesenteric pedicle is selected that will reach the pelvis without tension. The bowel segment is isolated and bowel continuity reestablished by either intracorporeal or extracorporeal techniques, and the mesenteric window is closed. The isolated bowel segment is detubularized, and a bowel plate is created appropriately. A tension-free, watertight, fullthickness, circumferential, running anastomosis of the bowel segment to the bladder is created. Adequate urinary drainage is established.

6.d. History of multiple tumors or carcinoma in situ (CIS). Contraindications to partial cystectomy include multiple bladder tumors, tumors involving the bladder neck or posterior urethra or trigone, and concomitant CIS. History or current evidence of multifocal transitional cell carcinoma (TCC) with or without CIS is a contraindication for partial cystectomy. The ideal patient for partial cystectomy is one who has a solitary, organ-confined invasive bladder tumor located at the dome of a good-capacity bladder, without any concomitant multifocality or CIS.

7.e. None of the above. In large series of patients with bladder cancer, fewer than 10% of the patients are candidates for a partial cystectomy. In the properly selected patient, 5-year survival rate ranges from 50% to 70%. Laparoscopic partial cystectomy has only been performed in a few selected cases and is currently a controversial procedure.

8.c. T4 disease. Laparoscopic radical cystectomy is an emerging procedure performed at centers of laparoscopic expertise. At this writing, laparoscopic radical cystectomy should be offered to nonobese patients with nonbulky, organ-confined bladder cancer without pelvic lymphadenopathy on preoperative computed tomography (CT). Various conditions such as morbid obesity, prior radiotherapy, or pelvic surgery are relative contraindications because of the increase in laparoscopic technical complexity. Locally advanced T4 disease should not be approached laparoscopically.

9.e. Indiana pouch, constructed intracorporeally. Since the initial report of laparoscopic cystectomy in 1992 by Parra and colleagues, more than 300 laparoscopic radical cystectomies have been performed worldwide. In the female, laparoscopic anterior pelvic exenteration and uterus, fallopian tube, vagina-sparing radical cystectomy have been performed. In the male, conventional radical cystectomy and prostate-sparing radical cystectomy have been performed. Bilateral extended pelvic lymph node dissection with mean nodal yields of 21 lymph nodes has been reported. With regard to urinary drainage, ileal conduit, Mainz pouch, Indiana pouch (extracorporeally constructed), and orthotopic neobladder have all been performed laparoscopically. However, long-term follow-up outcomes are still lacking.

.a. External iliac artery (lateral). Laterally, the dissection is extended up to the genitofemoral nerve. At the conclusion of an extended bilateral pelvic lymph node dissection, the external and internal iliac artery and vein, the

common iliac artery, the obturator nerve, the pelvic side wall, and the perivesical area should be bilaterally devoid of lymphatic fatty tissue.

.e. All of the above. Laparoscopic radical cystectomy is an evolving treatment modality with increasing experience being reported from multiple centers worldwide. With earlier detection of bladder cancer, careful application of laparoscopic techniques, and meticulous long-term follow-up, laparoscopic radical cystectomy is likely to emerge as a viable treatment option for the selected patient with bladder cancer.

Chapter review

1.Bladder surgery and the associated urinary diversion are associated with some of the highest rates of complications in urologic surgery.

2.Bladder diverticulectomy may be indicated in those of considerable size in which there is incomplete emptying, chronic or repeated urinary tract infection, bladder calculi, pain, or malignancy.

3.Any outlet obstruction must be addressed before the time of diverticulectomy.

4.In constructing a Boari flap, it is critical to ensure that the base of the flap is wide enough to provide for adequate vascularity. The base should be at least twice as wide at the apex as it is long to prevent contracture. Some recommend a 3:1 ratio.

5.Any patient considered for augmentation cystoplasty should be capable of self-intermittent catheterization.

6.In a partial cystectomy, a 2-cm margin should be outlined endoscopically with the electrocautery before opening the bladder because a decompressed bladder may distort the adequacy of the resection margin.