The clinical anatomy and operation skill of laparoscopic pelvic lymphadenectomy for invasive bladder cancer

Abstract

Objective To summarize the anatomy,operation skill and experience of laparoscopic pelvic lymphadenectomy for the treatment of invasive bladder cancer.Methods From June 2008 to July 2011,43 patients including 29 males and 14 females; aged 40-77 years-old with 58.9±10.0 on average,who underwent laparoscopic radical cystectomy and pelvic lymphadenectomy were analyzed retrospectively.Among those patients,tumor recurrence 19 cases; there were 11 cases of multiple tumors,and the others were single tumor,including 9 cases on triangle,8 cases on right wall,6 cases on left wall,7 cases on bottom,2 cases on dome.The size of the tumors is between 1.0～7.5 cm with (3.0±1.4) cm on average.Preoperative staging showed 28 cases of T2,10 cases of T3 and 5 cases of T4.Biopsy pathological examination showed 22 cases of high-grade papillary urothelial carcinoma,20 cases of low-grade papillary urothelial carcinoma,and 1 case of carcinoma in situ.Results Laparoscopic pelvic lymphadenectomy can be performed through three different interfaces.Lateral surface follows the genitocrural nerve at the surface of psoas major muscle,and the far end is at the plain of the external iliac artery emerging out the pelvic cavity.Medial surface begins with the cleidoic umbilical artery,or circular cord-shape medial umbilical ligament in the lateral side of the bladder,extending to upper bladder artery which is the branch of the internal illiac artery.Anterior basal surface is pubic bone converged by the medial surface and the lateral surface,along with the pelvic wall to the pelvic bottom fascia.The operation time was 180-510 min with (320±88) min on average.The EBL was 50-1 500 ml with (342±291) ml on average,and 12 cases need blood transfusion with volume of 200-1 000 ml and (567±187) ml on average.All cutting edges were negative and average 5.6 lymph nodes were removed during the operation with lymph node positive rate of 7.0％ (3/43).Postoperative pathological examination showed 12 cases of low-grade papillary urothelial carcinoma,9 cases of high-grade papillary urothelial carcinoma,and 22 case of invasive urothelial carcinoma.There was no death during the perioperatire period,but 4 patients had postoperative complications.Thirty-six patients were followed up with average of (15.4±9.5) months.One patient died and 8 patients developed complications during the follow-up period,and the relapse free survival rate was 94.4％ (34/36).Conclusions Following the principles of open surgery and the 3 anatomical surface,laparoscopic pelvic lymphadenectomy for the treatment of invasive bladder cancer is technically safe and effective,and the clinical effectiveness was satisfied,with the advantages of minimal invasiveness,clear surgical field,less blood loss,and shorten operation time. Key words: Bladder cancer; Radical cystectomy; Laparoscopy; Pelvic lymphadenectomy