Laparoscopic radical cystectomy
Laparoscopic radical cystectomy is considered one of the most demanding laparoscopic procedures, entailing not only removal but also reconstruction of certain organs. The surgery entails the removal of the entire urine bladder – along with the uterus and ovaries in women, or prostate and seminal glands in men – and the reconstructive part requires the formation of a certain sort of urinary diversion. It is done via a transperitoneal approach, and performed only in medical centers with extensive experience in radical surgery and laparoscopy.
When is it needed?
Laparoscopic radical cystectomy is the surgical treatment of muscle-invasive bladder cancer, and sometimes other aggressive forms of cancer that do not react to other sorts of treatment.
How is it performed?
In order to perform laparoscopic radical cystectomy, we require 5 trocars inserted at the bottom part of the abdominal wall. The ablation (organ removal) consists of disconnecting both ureters near the urine bladder and detaching the bladder itself (alongside the uterus, ovaries, and parts of the vagina in women, or the prostate and seminal vesicals in men). Then, we remove the detached organs in their entirety. One of the key parts of the procedure is pelvic lymphadenectomy – also known as PLND, or pelvic lymph node dissection.
The reconstructive part of the surgery entails finding a new way of passing urine. One of the most commonly used methods is ileal conduit urostomy: connecting a section of the small intestine to the ureters on one end, and making a small incision in the abdominal wall to connect the other end to the skin, in order to redirect urine (Bricker bladder). A long, isolated part of the small intestine can be used to form an “artificial bladder” (neobladder or neovesica), a reservoir connected to the ureters on one end and the urethra on the other.
There is a third, albeit much more rarely applied method: ureterocutaneostomy. The urinary diversion can be performed both entirely laparoscopically, or using the open surgical approach. The surgery wraps up by placing drainage tube in order to monitor and control possible bleeding, as well as urine secretion. The endoscopic bag containing the tissue is removed through an extended incision made at the most convenient place to avoid cutting into muscle, or via the vagina in women. The remaining trocars are removed, and the incisions are stitched up.
What are the possible complications?
In the hands of an experienced surgical team, complications in laparoscopic radical cystectomies are relatively rare, beyond the general risks involved in laparoscopic surgeries. The most common possible complication is bleeding that might require a blood transfusion. The already established complications with laparoscopic radical cystectomies, such as damages to the large intestine, the rectum, and blood vessels, are minimal and occur in less than 0.5% of all patients. Approximately 5% of laparoscopic radical cystectomies require a conversion to the open surgical approach.