Laparoscopic Radical Cystectomy with Orthotopic Ileal Neobladder ——Key Steps to Success Huang Jian The 2 nd Affiliated Hospital Sun Yat-Sen University, Guangzhou China
Introduction Laparoscopic radical cystectomy with orthotopic neobladder (LRC-OIN) is increasingly accepted by urologists. n It is no more the issue of feasibility but the issue of improvement for this procedure. n Discuss the techniques of key steps in LRC-OIN n
Haemostatic Instruments n n n Harmonic scalpel PK system Bipolar forceps Liga. Sure vessel sealing system Electric hook Hem-O-Lok
Hem-o-lok
PK System
Liga. Sure. TM Vessel Sealing System 图 1 -2 -10 结扎速血管闭合系统
Ultracision-Harmonic Scalpel
Patien’s position and trocar site
The Major Steps of the Procedure Step 1: Pelvic lymphadenectomy Step 2: Dissection of seminal vesicle and Denonvelia’s fascia to expose the posterior aspect of prostate Step 3: Exposing the anterior aspect of bladder and prostate Step 4: Dividing the lateral pedicles of the bladder and the prostate Step 5: Dividing the apex of the prostate and urethra Step 6: Extracorporeal construction of Ileal neobladder Step 7: Intracorporeal neobladder-urethra anastomosis
Step 1: Pelvic Lymphadenectomy with electric hook and Liga. Sure
Techniques of Pelvic Lymphadenectomy n n Sequence: Lymphadenectomy before or after cystectomy extent: standard or extented Using instrument: harmonic scalpel, PK system bipolar clamp and electric scissors, or electric hook and Liga. Sure Attention: blood vessel and obturator nerve injury lymphatic leakage tumor cell seeding
Step 2: Dissection of seminal vesicle opening Denonvelia’s fascia
Step 3: Exposing the anterior aspect of bladder and prostate
Step 4: Dividing the lateral pedicles of the bladder and the prostate Ø Nerve sparing Ø Non nerve sparing
How to protect the neurovalscular bundle
Nerve sparing techniques
Non nerve sparing techniques
Step 5: Dividing the urethra
Step 2 to step 5: Cystectomy Posterior aspect Anterior aspect Bilateral pedicles Prostate apex and urethra
How to avoid rectum injury Correctly localized seminal vesicle n Opening the Denonvelia’s fascia and separating rectum from prostate n Dividing lateral peadicle close to the prostate n Transecting the urethra while pulling up the prostate apex n
Different methods in dividing the lateral paedicles Ø Ø Liga. Sure PK Forceps Endo-GIA Harmonic scalpel
How to avoid the tumor seeding Ø Avoidingbladder wall perforation Ø Don’t transgressing the tumor boundaries, Ø Blocking up the bladder neck before transecting uretha
Step 6: Removal the spacimen and neobladder construction
The technique of Extracorporeal formation of neobladder 5 cm of midline subumbilical skin incision n M shape ileal pouch n Implantation of ureters directly to the posterior wall of the pouch by means of ureteral half nipple. n
Different techniques in formation of neobladder n n n Intracorporeally or extracorporeally Reconstruction: Studer pouch, hemi-kock pouch, T pouch, M pouch, Implantation of ureters: ileal chimney, ileal nipple, extramural serous-lined tunnels, mucosal sulcus, ureteral nipple,
Studer pouch T pouch ileal chimney extramural serouslined tunnels Hemi-kock pouch ileal nipple
Mucosal sulcus
Ureteral nipple
Step 7: Neobladder- urethra anastomosis Two running sutures technique
Tips and tricks in Neobladder- urethra anastomosis A traction stitch to relieve the tension n Changing to head-up position n Two running suture technique better than interrupted, or running suture technique. n Attention: the catheter out side the neobladder n
Summary The Surgical procedures of LRCOIN can be improved by reasonable sequence, standard maneuver and correct use of instruments.
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