Blackwell Science, LtdOxford, UK IJU International Journal of Urology 0919-81722002 Blackwell Science Asia Pty Ltd 101January 2003 560 Antegrade extraperitoneal approach to radical cystectomy TA Serel et al. 10.1046/j.0919-8172.2002.00560.x Original Article2528BEES SGML
International Journal of Urology (2003) 10, 25–28
Original Article
Antegrade extraperitoneal approach to radical cystectomy and ileal neobladder TEKIN AHMET SEREL, GÜVEN SEVI˙N, HAKKI˙ PERK, ALIM KO S¸AR AND SEDAT SOYUPEK Department of Urology, Süleyman Demirel University, School of Medicine, Isparta, Turkey Abstract
Background: We describe a new operative technique for the surgical treatment of bladder cancer. Methods: Male patients with invasive bladder cancer were managed by radical cystoprostatectomy using a technically different approach than the conventional method. The main feature of this method includes a small vertical incision between pubis and umbilicus, keeping the abdominal peritoneum closed during the surgery. Reperitonealization is done at completion to isolate the urinary anastomoses from the bowel anastomoses. Results: Seventy-six consecutive patients with bladder cancer underwent this operation. The mean operation time was 4 h 30 min and the mean hospital stay was 11 days. No mortality was seen in the early postoperative period. Only one patient developed serious bowel distension. Two patients developed pneumonia. Wound infection was seen in two patients. Two patients experienced hydronephrosis in the late period of follow-up. Four patients developed pelvic lymphocele. There was no evidence of postoperative electrolyte loss in any of the patients. Three patients developed abdominal hernia and this was corrected with surgical treatment. Urodynamic evaluation of 15 patients showed a low capacity reservoir. All patients were continent during the daytime. Conclusion: This technique keeps the abdominal peritoneum closed during radical cystoprostatectomy, preventing the patients from complications, such as infection, water and electrolyte imbalances. The technique also decreases the recovery time.
Key words
bladder neoplasm, cystectomy, ileal neobladder.
Introduction Orthotopic bladder operations are becoming one of the main solutions of invasive bladder cancer after radical cystectomy. The old types of urinary diversion might be avoided by orthotopic neobladder substitution to maintain continence and also body image. In the broadest sense, the goal of urinary diversion should be the preservation of renal function in a manner that is psychologically and socially acceptable to the patient.1,2 The ileal form of urinary diversion would approximate
Correspondence: Tekin Ahmet Serel MD, Çelebiler mh 137. Cd 12/2 32040 Süleyman Demirel University, Isparta, Turkiye. Email:
[email protected] Received 25 July 2001; accepted 23 May 2002.
normal bladder function and provide continent nonrefluxing low-pressure storage of sterile urine and allow complete and convenient emptying.3–5 Nowadays, there has been tremendous interest in alternate forms of urinary diversion.6 The effort has been to develop the wellknown procedures rather than to create new types of operative techniques. The goal of these efforts aims to minimize the risk of infection, blood, water and electrolyte loss and to gain time during the procedure. The conventional methods involve a midline supra- and infra-umblical incision that causes an increase in the duration of bowel exposure to the atmosphere. It often carries a risk of water and electrolyte imbalance and infection. We describe a modified approach for orthotopic bladder substitution that keeps the peritoneum closed during radical cystectomy, obturatory lymphadenectomy and urethral replacement.
26
TA Serel et al.
Methods Seventy-six men with invasive bladder cancer underwent the extraperitoneal antegrade method at Vakıf Gureba Hospital in Istanbul and Süleyman Demirel University in Isparta, Turkey. All patients were staged preoperatively with spiral abdominopelvic computed tomography (CT) and transrectal ultrasonography. We applied transurethral electro resection of bladder tumor extending to the deep bladder wall in the patients. Postoperative tumor specimens were graded histopathologically with the Mostoffi grading system. The patients with invasive tumor in the posterior wall and bladder dome were excluded from the study. Their age ranged 46–70 years (mean, 55 years) and mean follow-up time was 11 months (range, 5–35 months). The patients were followed up at three-month intervals. All patients were evaluated with routine biochemical analysis, urodynamic studies and radiological examination in followup.
The endopelvic fascia was incised laterally on either side of the prostate. After the lateral lobes were separated from the levators the apex of the prostate was identified. The puboprostatic ligaments were divided. The dorsal venous complex was transected and oversewn or ligated and cut between sutures with care taken to avoid bunching the striated urethral sphincter. The anterior urethral wall was incised along the striated sphincter to expose the urethral catheter. After closely passing a long, right-angled clamp behind, the posterior urethral wall was incised distal to the verumontanum to expose Denonvilliers’ fascia. The neurovascular bundles were mobilized from the level of the bladder neck to the urethra and then proximal by clipping the small branches to the prostate and bladder neck. Care was taken to include the striated sphincter in these stitches to prevent urethral retraction. With sharp and blunt dissection the prostate was mobilized cephalad by gentle traction on the Foley catheter. The lateral pedicles are divided close to the seminal vesicles, avoiding injury to the neurovascular
Surgical procedure (a)
The patients were placed supine under general anesthesia and a small midline infraumblical incision was done. If simultaneous urethrectomy was planned, the low lithotomy position was preferred. The incision was deepened through the subcutaneous tissues and anterior rectus sheath. The rectus abdominis muscles are separated in the midline. The underlying transversalis fascia was incised and a plane was developed on either side, remaining just superficial to the peritoneum, to avoid injury to the inferior epigastric vessels. Inferiorly, the space of Retzius was entered. Operability was assessed by palpating the bladder tumor and its mobility in the pelvis. The whole pelvic peritoneum was gently pushed cephalad at the level of the vasa deferentia on either side to visualize the common iliac vessels. Bilateral ilioobturator nodal dissection was carried out for frozen section examination. Cystectomy was started by cutting the urachus at the level of the umbilicus. The hypogastric artery was divided between ligatures at its origin from the internal iliac artery. The superior vesical vessels were identified and cut, opening up the paravesical planes. The bladder was further separated from the rectum cranially to identify the ureters until it was 2.5 cm away from the ureterovesical junction (Fig. 1a). At this level the ureters and then the vasa were divided. All fibrofatty tissue carrying the vascular supply from the inferior and middle vesical vessels was divided on both sides running from either side of the rectum to the bladder (Fig. 1b). Preprostatic fat was teased away to expose the puboprostatic ligaments and dorsal venous complex.
Bladder
Peritoneum
Rectum
(b)
Fig. 1 Schematic illustration of the surgical stages. (a) Bladder is separated from the rectum. (b) Rectovesical plane of dissection is developed.
Antegrade extraperitoneal approach to radical cystectomy
bundles. The attachment of Denonvilliers’ fascia to the rectum was released, maintaining all of its layers on the seminal vesicles. From here the developing plane led to a thin layer of pearly white peritoneum reflecting the anterior surface of the rectum. We constructed a Hautmann type of ileal bladder substitution for 60 patients and a Studer type of ileal neobladder for the other 16 patients.4,7 From a small hole in the peritoneum, we could easily pull out 40–60 cm of ileum to construct either a Hautmann or Studer type of ileal pouch. The ureters stayed in their proper places and were implanted directly and extraperitoneally to our new pouch after being liberated by a small distal dissection. The Le Duc or extramural subserous (Hassan) methods were used for the implantation of the ureter to the Hautmann type of neobladder.8,9 For all Studer types of ileal bladder we used the Wallace method to implant the ureter. During this method, distal ureters needed a little further dissection. After the ureters were re-implanted, the opened peritoneal cavity was isolated from the neobladder by suturing the free edges of retained peritoneum flaps together around the mesenteric pedicle.
Results The mean operation time was 4 h 30 min. The mean hospital stay was 11 days (range, 7–19 days). There was no mortality preoperatively or in the early postoperative period. Table 1 summarizes the outcomes of the patients and neobladders. Only one patient developed serious bowel distension that dissolved in 3 days postoperatively. Two patients developed pneumonia that was managed successfully with antimicrobials. Two patients who developed wound infection also responded well to medical treatment. Two patients experienced hydronephrosis in the late period of follow-up (> 6 months after surgery). One of these patients underwent an ureteroneocystostomy and the other had to be managed with percutaneous nephrostomy due to a serious cardiopulmonary insufficiency. Four patients developed Table 1 Complications of the procedure Complications
No. patients (n)
Percentage
Occurrence
1 2 4 2 4 3
1.4 2.8 5.6 2.8 5.6 4.2
Early Early Early Late Late Late
27
pelvic lymphocele but there was no need for any treatment. There was no evidence of electrolyte loss in the patients postoperatively. Three patients developed abdominal hernia and this was corrected with surgical treatment. The preoperative clinical stage and postoperative pathological stages are shown in Table 2. Six patients who had T2a clinical tumor preoperatively were found to have a greater pathological stage postoperatively. Four of them had T2b and two of them had T3 disease. The tumor was grade I in three patients, grade II in 22 and grade III in 45. Three patients had a positive lymph node involvement. Eleven patients had nocturnal enuresis after the surgery. Urodynamic evaluation of 15 patients showed a low capacity reservoir (mean, 120 cm3; range, 50–170 cm3). All patients were continent during the day.
Discussion The peritoneum protects the abdominal organs. Conventional cystectomy and urinary diversion involve transperitoneal mobilization of the bladder. It often carries a risk of urinary leakage that may affect the intestinal system directly resulting in infection and leading to gut adherents and deterioration of ileal anastomosis.10 Preservation of the striated sphincter is very important whenever a neobladder is planned. Notably in the conventional procedure the important rhabdosphincter is dealt with last. In our series, we describe a new modified management of bladder cancer to standard surgery for radical cystectomy. A small infraumblical incision and extraperitoneal dissection provide the most undisturbed operative field during cystectomy and obviate any need to pack the bowels into the upper abdomen. Completely antegrade extraperitoneal dissection of the rectovesical plane increases the safety of the procedure. Preserving the peritoneal flaps helps during repeat peritonealization to isolate the urinary anastomosis from the bowel anastomosis as in normal anatomy. This technique protects the urinary anastomoses from the septic complication of bowel anastomosis. The duration of bowel exposure to the atmosphere is also decreased. Additionally, when the decision is made to abandon the procedure due to
Table 2 Operative stages Bowel distension Pneumonia Wound infection Ureteral stricture Lymphocele Abdominal hernia
Preoperative clinical stages (n) Postoperative pathological stages (n) n, Number of patients.
T2a
T2b
T3
28 22
33 37
5 7
28
TA Serel et al.
significant metastatic nodes, the wound may be closed without having violated the peritoneal cavity. The causes of the ureteropouch anastomotic strictures are: (i) some technical errors; (ii) devitalization of ureters while mobilized; and (iii) intraperitoneal transformation of ureters.8 After the closure of the abdominal peritoneum during the intact peritoneal procedure, the surgeon can easily anastomose the ureters, which have stayed retroperitoneally in their proper places, and very little mobilization of the ureteral tips are sufficient for the anastomosis. In our technique, the peritoneal cavity is opened at the end of cystectomy. It does not allow examination of the intraperitoneal viscera to evaluate retroperitoneal nodal disease, and the liver and bowel. However, in practice, the incidental detection of intra-abdominal metastases at surgery is extremely rare in this era of modern imaging with CT and magnetic resonance imaging. A patient with orthotopic bladder substitution urinates with abdominal strain. A large incision line may deteriorate the rectus muscle and may cause incisional postoperative hernias or wound dehiscence. Studer et al. reported a 10% early reoperation rate in the patients who underwent transperitoneal cystectomy.11 Using the Camey procedure, Lilien and Camey reported a 12% reoperative rate in 93 patients (4 ileus and 8 abdominal wall repair).12 A comprehensive study by Frazier et al. of 675 transperitoneal cystectomy cases found wound dehiscence in 22 cases, ileal obstruction in 20 cases, bowel cutaneous fistula in 16 cases, rectal injury in 15 cases, ureteroenteric fistula in nine cases, urinoma in five cases.10 In our extraperitoneal technique, there was a lower incidence of these disadvantages (Table 1). In conclusion, most of our patients who underwent cystectomy had muscle invasion of bladder carcinoma in which case going wide on the peritoneum may be needless. Much of the peritoneum may be preserved for repeat peritonealization that serves to iso-
late the urinary anastomosis from occasional leakage from the bowel anastomosis. Our technique facilitates urinary diversion operations with its various modifications.
References 1 McDougal WS, Koch MO. Accurate determination of renal function in patients with intestinal urinary diversion. J. Urol. 1986; 135: 1175. 2 Arai Y, Taki Y, Kawase N et al. Orthotopic ileal neobladder in male patients: functional outcomes of 66 cases. Int. J. Urol. 1999; 8: 388–92. 3 William RF. The ileal neobladder. Urol. Clin. North Am. 1991; 3: 140–7. 4 Hautmann RE, Miller K, Steiner U, Wenderoth U. The ileal neobladder: Six years of experience with more than 200 patients. J. Urol. 1993; 150: 40–5. 5 Studer UE, Zingg EJ. Ileal orthotopic bladder substitutes. Urol. Clin. North Am. 1997; 24: 781–93. 6 Jagdeesh NK, Ramesh IG, Hemnt BT, Bhalachandra DK, Ketan BJ. Radical cystoprostatectomy: An extraperitoneal retrograde approach. J. Urol. 1999; 161: 545–8. 7 Studer UE, Gerber E, Springer J, Zingg EJ. Bladder reconstruction with bowel after radical cystectomy. World J. Urol. 1992; 10: 11–9. 8 LeDuc A, Camey M, Teillac P. Original antireflux uretero-ileal implantation technique long-term follow-up. J. Urol. 1987; 137: 1156–8. 9 Abol-Enein H, Ghoneim MA. A novel uretero-ileal reimplantation technique: the serous lined extramural tunnel. A preliminary report. J. Urol. 1994; 151: 1193–7. 10 Frazier HA, Robertson JE, Poulson DF. Complications of radical cystectomy and urinary diversion. A retrospective review of 675 cases in 2 decades. J. Urol. 1992; 148: 1041–5. 11 Studer UE, Danuser H, Merz VW, Springer JP, Zingg EJ. Experience in 100 patients with an ileal low-pressure bladder substitute combine with an afferent tubular isoperistaltic segment. J. Urol. 1995; 154: 49. 12 Lilien OM, Camey M. 25 years experience with replacement of the human bladder (Camey procedure). J. Urol. 1984; 132: 886–91.
[email protected]
