Laparoscopicradical cystectomy in the female: surgical tips and techniques

Abstract

Objective To discuss surgical tips and techniques of laparoscopic radical cystectomy in the female. Methods We retrospectively reviewed 29 females who underwent laparoscopic radical cystectomy between Feb. 2008 and Mar. 2017. The median age was 64 years (range 37-83 years), and the median BMI was 24.7 kg/m2 (range 12.1-31.2 kg/m2), and the median CCI was 3 (range 2-9). No distant metastasis was identified by bone scans, chest X-ray and sonography. Preoperative pathology were non-muscular infiltrating bladder cancer in 19 patients and muscular infiltrating bladder cancer in 10 patients by cystoscopic biopsy. Surgical method: under general anesthesia, the patients were placed in lithotomy position. A 5-port transperitoneal approach was used. Under laparoscopy, the suspensorium ligament of ovary was dissected and cut at lateral to the fimbriae of uterine tube, then the ureter was divided and umbilical artery was managed. The broad ligament of uterus was divided. Afterwards, the Douglas' pouch was opened and the fornix of vagina was cut transversely. Then, the endopelvic fascia was divided. The bladder was excised with the female reproductive organs together. If the female reproductive organs were decided to preserve, the dissection was performed along the space between bladder and uterus or vagina. Frozen section of urethra end andthe distal ureter were then obtained. The resected tissues were removed through the vagina, and then vagina was closed. Urinary diversion consisted of orthotopic ileal neobladder in 9 patients, ileal conduit in 14 patients, ureterostomy in 4 patients. All urinary tracts were removed for two cases due to renal function loss before surgery. Results Mean total operative time was 315mins (ranged from180 mins to 420 mins). Estimated blood loss was 299 ml (ranged from 10 ml to 1 500 ml). Complications occurred in 2 cases. One patient had both vaginal infection and incomplete intestinal obstructionand the other had vaginal infection alone. No patients died in perioperative period. At a median follow up of 36.8 months (ranged from 2 to 110 months), 24 patients (82.8%)were alive without recurrences, 1 (3.4%) had metastasis in lymph nodes and 4 (13.8%) died. Conclusions Laparoscopic radical cystectomy in the female is technically feasible. Knowing female pelvic anatomy and grasping the techniques conduce to optimize the tips of the surgery and reduce complications. Key words: Female; Laparoscopic radical cystectomy; Surgical technique