Simultaneous Laparoscopic Management of 3 Urological Malignancies

Abstract

A 65-year-old male smoker presented with gross hematuria. Transurethral resection of the bladder revealed urothelial cell carcinoma, pT1 grade 3. Despite instillation of intravesical bacillus Calmette-Guerin and a repeat endoscopic resection, muscle invasive bladder cancer subsequently developed with involvement of the prostatic urethra. Computerized tomography also demonstrated a 4 cm. central right renal mass (fig. 1). There was no evidence of metastatic disease or lymphadenopathy. Serum prostate specific antigen and creatinine were 2.9 ng./ml. and 1.5 mg./dl. (normal 0.6 to 1.1), respectively. After a discussion of treatment options the patient underwent laparoscopic nephroureterectomy with en bloc laparoscopic radical cystoprostatectomy. He did not desire a continent urinary diversion. Nephrectomy was performed via a 4-port transperitoneal approach, and the ureter was mobilized below the iliac vessels without division. Three additional ports were placed to facilitate cystoprostatectomy, performed as described previously.3 Vascular pedicles and dorsal vein complex were controlled using a combination of an endovascular gastrointestinal anastomosis stapler and laparoscopic coagulating shears. After apical prostate identification the urethra was transected with an endovascular gastrointestinal anastomosis stapler immediately after removal of the Foley catheter. The specimen was removed intact from the extended infraumbilical trocar site (fig. 2). Lymphadenectomy and ileal conduit construction were performed through the minilaparotomy. Estimated blood loss was 800 ml., and operative time was 11 hours. No intraoperative or postoperative complications were encountered, and the patient resumed oral intake at 4 days and was discharged home at 6 days postoperatively. Pathological examination confirmed 3 separate urological malignancies—clear cell renal cell carcinoma, pT1N0 Fuhrman grade 3; bladder urothelial cell carcinoma, pT2bN0 grade 3; and prostate cancer, Gleason score 3 4 pT2bN0—as well as low grade dysplasia throughout the right ureter. All surgical margins were negative.