Laparoscopic Radical Cystectomy Paolo Puppo, MD and Angelo Naselli, MD*
Address *Urology Unit, Department of Surgical Oncology, National Institute for Cancer Research, Largo Rosanna Benzi 10, Genoa 16100, Italy. E-mail:
[email protected] Current Urology Reports 2005, 6:106–108 Current Science Inc. ISSN 1527-2737 Copyright © 2005 by Current Science Inc.
Laparoscopic radical cystectomy is an emerging technique. It has been proposed as an alternative to open radical cystectomy, which is the gold standard treatment of muscleinvasive or high-risk superficial bladder cancer. The experience in laparoscopic radical cystectomy reported in peer-reviewed journals account for approximately 100 cases, with a median longest follow-up of 11.5 months. Safety of the technique and cancer control need to be confirmed by a larger cohort of patients; however, after an initial analysis, it seems to be equivalent to open radical cystectomy. Equivalent does not mean better. Long-term results will determine if supposed benefits of laparoscopy overweigh the true increment of cost and time.
Introduction Open radical cystectomy (ORC) is the standard procedure for the treatment of muscle-invasive bladder cancer. After the pioneeristic reports of Parra et al. [1], Sanchez de Badajoz et al. [2], and Puppo et al. [3], the laparoscopic procedure has been proposed as an alternative technique. Approximately 100 cases of laparoscopic radical cystectomy (LRC) are reported in peer-reviewed papers; 86 men and 21 women underwent LRC over a period of approximately 10 years. Thus, the follow-up times that have been reported are very limited and the main issue of oncologic surgery, the cancer control, has to be verified.
Surgical Standards Optimal standard of ORC is well defined. Intra- and postoperative mortality and morbidity, surgical margin status, and the number of lymph nodes retrieved are the main indicators of quality. Mortality is lower than 4% in the largest series in the literature. Knap et al. [4] reported a mortality of 2% among 268 patients, who underwent radical cystectomy, at a median age of 65 years from 1992 to 1998. The surgical re-exploration rate was 17%. In 1999, the European Organization for Research and Treatment of Cancer published a paper about 976 patients and the mor-
tality rate was 3.7% [5]. Ghoneim et al. [6] performed 1026 radical cystectomies between 1969 and 1990 and experienced a mortality of 4%. Stein et al. [7] showed a 2.5% mortality among 1054 patients between 1971 and 1997. In the same series, early morbidity was approximately 30%. The patients with stage–pT3-pT4 cancer experienced approximately 50% mortality (80% in the series by Ghoneim et al. [6]) and the lymph nodes retrieved were positive in approximately 20%. Herr et al. [8] fixed standards of radical cystectomy in a paper published in 2004. They reported on 1091 radical cystectomies performed in four institutions from 2000 to 2002 by 16 surgeons. A positive surgical margin rate is considered acceptable when it is lower than 10% overall and 15% among patients with stage–pT3-pT4 cancer. The median number of pelvic lymph nodes retrieved during surgery should be 10 to 14. The lowest number of procedure per center considered enough to reach this standard is 10 each year [8]. Data of the reports concerning LRC have published in peer-reviewed papers [9–15,16••,17–19,20•,21,22•,23–26] (in order by date of publication). Surprisingly, among 107 cases, there is only one death related to surgery [25]. The number of cases is very limited; therefore, a low death rate could be serendipitous. In addition, the procedure is performed only in leading urologic units and by experienced surgeons. On the other hand, age and comorbidities should not have influenced operative mortality significantly. Together with series of well-selected patients [12,13], there are series with a high percentage of elderly patients, American Society of Anesthesiologists grade of 3 or more, and advanced-stage bladder cancer [10,11,14,20•,25]. Denewer et al. [25], who reported the only perioperative death, had seven patients of 10 who underwent laparoscopic salvage radical cystectomy. The rate of patients with an advanced local stage, pT3-pT4, or with positive lymph nodes is lower than what has been reported by major series of ORC and is respectively 33% (27/82) and 9.6% (7/73). Even more surprisingly, only three cases of positive surgical margin are reported [9,11,14]. In each case, the prostate was involved by cancer, from bladder neoplasm or primary tumor. The overall low rate of positive surgical margin, even in advanced local stages, could be caused by the magnification during dissection, but also, and more likely, by patient selection. On the other hand, dissection of the prostate apex or pedicles is technically difficult in the case of cancer infiltration. Overall, 27 complications related to surgery are reported. Morbidity rate, 25%, is the same in the major series of ORC. Complications caused
Laparoscopic Radical Cystectomy • Puppo and Naselli
conversion to open surgery in five cases (4.6%). Only three papers [12,14,20•] report the number of lymph nodes retrieved. The number varies from three to 21. Blood loss rarely exceeds 400 mL as it occurs in contemporary series of ORC. Transfusions rarely are needed in open radical cystectomy and in LRC. Hospital stay does not differ greatly between LRC and ORC performed in experienced urologic units. This is easily explained because the time of discharge is linked first to bowel function recovery and then to the chance of discharging the patient with an indwelling catheter (in orthotopic diversions), much less to the operative technique and consequent stress. None of the series of LRC published reached the number of 10 procedures per years. Therefore, it seems to be advisable to concentrate this kind of surgery in few centers to collect an adequate number of cases per year.
Technical Aspects The procedures usually are performed with five or six ports. Operative time is extremely dependent from the learning curve and from the type of diversion. Intracorporeal urinary diversion takes much more time then the extracorporeal, especially when an orthotopic reservoir is created. Total time of surgery ranges from 260 minutes to 12 hours. Only nine patients underwent hand-assisted LRC [11,18] and 18 patients, robot-assisted LRC [12,13,16••]. Vascular pedicles were secured with a stapler in seven of 18 series. Some papers reported excellent vascular control mean harmonic scalpel [17,21]. Extreme attention is paid to avoid tumor spillage during dissection because tumor seeding is common for transitional cell cancer. The specimen weighs approximately 200 to 400 G and has a correspondent volume. Therefore, it can be extracted from a compliant wound of the abdomen, vagina, or anus. The incision of the abdomen is commonly used to pull out the gut to configure the urinary diversion. The length of the incision ranges from 3.5 to 15 cm [9], but it usually is approximately 5 to 7 cm. It can be obtained with a new incision or by extending a port site. During handassisted LRC, the specimen is extracted through the hand port. Because the ORC can be performed easily through a 12to 15-cm umbilical-pubic incision, it can be debated what real advantage the chance of sparing 5 to 10 cm of incision offers. Vaginal extraction, originally described by Puppo and Ricciotti [26], is not always carried out in the woman, even if access through the anterior vaginal wall allows the surgeon to complete the cystectomy easily and to perform, if necessary, a total urethrectomy. Only Turk et al. [23] extracted the specimen transanally. This was the natural way to carry out the specimen while performing an ureterosigmoidostomy. Urinary diversion was cutaneous ureterostomy in three patients, sigmoid ureterostomy in 17, ileal conduit in 38, and continent ileal pouch in one. In the other 48 patients, an orthotopic ileal neobladder was performed. One case of robot-assisted LRC and intracorporeal creation of orthotopic
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neobladder has been reported [16••]. As in ORC, the diversion of choice is the orthotopic neobladder, but it usually is configured and sutured extracorporeally. Some authors proceed to anatomize the ureters and urethra after re-establishing pneumoperitoneum. Only one author reported a complete intracorporeal ileal neobladder [16••]. Executing LRC and orthotopic neobladder remains time-consuming. It takes between 380 and 720 minutes, much more then the time required for the open procedure, which is approximately 180 minutes.
Follow-up and Cancer Control Radical cystectomy is the gold standard of the treatment of muscle-invasive and high-risk superficial bladder cancer. The largest monocentric series of ORC are from Mansoura [6], Los Angeles [5], and Padova [27]. Approximately 80% of the patients were in stage pT3-pT4 in the series by Ghoneim et al. [6]; 50% were in this stage in the other two series [5,27]. The rate of positive lymph nodes at pathologic examination is approximately 20% [6,7,9]. The overall 5-year survival rate is 48% [6], 66% [7], and 56% [27], respectively. The series of LRC, considered together, consist of more selected patients. The rate of stage pT3-pT4 is 33% (27/82) and 9.6% (7/73) for pN+. Follow-up is reported in 50% of the papers published on LRC. Among 18 papers, the highest length of follow-up reached 48 months and the median maximal length was 11.5 months. A total of 42 patients underwent a reported follow-up; 32 of them were disease-free (76%). Of these 42 patients, 32 had pathologic examination reported: 14 pT3pT4 (44%) and two pN+ (6%). Short follow-up and a limited number of patients does not allow a definite evaluation of the oncologic safety of LRC. However, at a first superficial analysis, LRC does not appear to have a negative impact on cancer control.
Conclusions Laparoscopic radical cystectomy still is in its pioneeristic era. Its indications are increasing, but only in centers extremely committed to laparoscopy. The first 100 cases demonstrated that LRC is feasible and probably capable of having the same results of ORC. Morbidity and mortality have been relatively similar in the major series of ORC. Blood loss and length of hospital stay in LRC do not differ much from ORC. The surgical margins rate is surprisingly low and always involves the prostate. Recent series of ORC and orthotopic neobladder do the same. There is a lack of information regarding the number of lymph nodes retrieved during the procedure. The urinary diversion of choice is orthotopic neobladder. However, once demonstrated that a new technique is feasible, this does not mean that it should replace the older one. Most papers published on LRC are devoted mainly to the description of the operative technique; followup and survival rate data generally are missing. However, by
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pulling all of the reports together, an idea about cancer control can be obtained empirically. The population undergoing LRC is better selected overall than that of major series of ORC and the survival rate of 76% at follow-up (median maximal length of follow-up, 11.5 months) appears to be similar to that of the major series of ORC. Obviously, more homogeneous and greater cohorts of patients are necessary with longer follow-up to definitively judge this procedure in terms of surgical safety and cancer control. Laparoscopic radical cystectomy is still money- and time-consuming and needs a long learning curve and dedicated surgeons. In the meantime, ORC is becoming less invasive because blood loss and operative time are progressively reduced. A comparative prospective study is absolutely needed to assess the degree of invasiveness of LRC compared with ORC, both performed by experienced surgeons, before advocating the introduction of LRC in clinical practice. The reduction in length of the skin incision by a few centimeters cannot be enough to justify such a great change in urologic surgery. Benefits with regard to reduction of blood loss, analgesic consumption, and hospitalization theoretically may overcome the higher cost in terms of instruments, time in operating room, and a dedicated team of surgeons, but it still is to be demonstrated. LRC should be considered as a mere experimental procedure and, in this capacity, should be proposed to patients.
References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.
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