腹腔镜下膀胱前列腺切除术在男性膀胱癌患者（图文演示）

中文版：腹腔镜下膀胱前列腺切除术在男性膀胱癌患者（中文图文演示）

LAPAROSCOPIC   CYSTOPROSTATECTOMY   FOR   BLADDER   CANCER   IN   A   MALE   PATIENT
Authors
R Van Velthoven
Abstract
Radical cystectomy remains the gold standard for muscle invasive bladder cancer and high-risk superficial tumors resistant to intravesical treatment. Nevertheless, the laparoscopic cystoprostatectomy has rarely been well codified and illustrated.
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1. Introduction
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Radical cystectomy remains the gold standard for muscle invasive bladder cancer and high-risk superficial tumors resistant to intravesical treatment (Dalbagni et al., 2001); moreover, open cystoprostatectomy with urinary diversion remains a major procedure, which may be demanding for patients.
Although cystectomy performed through a laparoscopic approach was firstly described in 1992 (Parra et al.), this indication remained very controversial and was still considered recently as experimental for the treatment of bladder cancer (Breda et al., 2001). During the last decade, the greatest impact of the laparoscopic approach in urology was undoubtedly shown on patients with genitourinary malignancies. When only pelvic lymph node dissection and occasionally nephrectomies were initially considered as oncologically feasible, presently, several other approaches such as laparoscopic adrenalectomy and radical nephrectomy are today considered as standards of care, not only at centers of excellence but even in the general community. Maturing data with laparoscopic radical prostatectomy suggest excellent continence rates and equivalent oncologic results based on pathological surrogates of cure (Guillonneau and Valancien, 2000).
Laparoscopic approach for advanced disease such as cytoreductive nephrectomy has also been found to be feasible for selected patients with metastatic renal cell carcinoma. Other novel therapies, such as laparoscopic radical cystectomy with urinary diversion and laparoscopic retroperitoneal lymph node dissection, hold great promise of benefit for patients with urologic malignancies (Matin, 2003).
Beyond initial reports on feasibility, controversy persisted regarding the risk of cell spillage or port metastases in transitional cell carcinoma; yet the strict observation of oncological safety rules as the respect of closed urinary cavities has increased the acceptance of laparoscopic nephro-ureterectomy (Matin, 2003); hence, radical cystectomy should become increasingly accepted if the same rules are carefully observed (Tsivian and Sidi, 2003). Moreover, animal and clinical experimental work has demonstrated that laparoscopy may be less immunodepressant than its open counterpart (Miyake et al., 2002); this additional theoretical advantage could play a positive role in favor of radical cystectomy performed laparoscopically.
Although laparoscopic cystectomy with different urinary diversions has already been described, it has shown to provide intraoperative and postoperative advantages when compared to open surgery (Paz et al., 2003; Matin and Gill, 2002; Wood, 2002). Nevertheless, the laparoscopic cystoprostatectomy has rarely been well codified and illustrated (Simonato et al., 2003). Having set up an experience in radical prostatectomy since 1999, our groups started to perform laparoscopic radical cystectomy one year later, in spring 2000; from then and until June 2004, 30 patients were operated in Brussels and 8 in Heilbronn.
As elegantly shown in another recent review (Moinzadeh and Gill, 2004), all technical steps of an open surgical radical cystectomy with urinary diversion have been translated into equivalent laparoscopic maneuvers.
The potential advantages of doing the procedure laparoscopically are the smaller incisions, hence decreased pain and quicker recovery time implying shortened hospital stay, decreased blood loss and fluids imbalance compared with the open technique. If transfusion is usual during open surgery, it is uncommon with laparoscopy. A stepwise protocol is actually established, with minor alternative variations between centers (Matin and Gill, 2002; Simonato et al., 2003; Moinzadeh and Gill, 2004; van Velthoven et al., 2003).

2. Anatomy

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The anatomical relationships of the prostate and the bladder are complex. Situated deep at the base of the pelvis, it is in contact with the following:
- muscular and aponeurotic structures (levator ani muscles, endopelvic fascia, Denonvilliers' fascia/rectoprostatic fascia);
- visceral structures (rectum);
- vascular structures (prostatic venous plexus);
- neurovascular structures (neurovascular bundles leading to ischiocavernous muscle);
- lower urinary apparatus (bladder neck, striated urethral sphincter).
The prostate is joined to the bladder. They are removed en bloc.

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Blood supply to the bladder largely depends on the anterior branches of the hypogastric artery: the superior vesical artery, the inferior vesical artery, and the vesicoprostatic artery.
The branches are encountered successively at the root of the hypogastric artery. The superior vesical artery runs under the peritoneal cover of the superior lateral aspect of the bladder; it gives two to five branches to the bladder and generally the funicular artery of the ductus deferens.
The inferior vesical artery runs medially to reach the bladder base, supplying the bladder, the prostate and the ampulla of the ductus deferens.
The vesicoprostatic arteries generally originate from the inferior vesical artery and supply the seminal vesicle and the prostate.

3. Indications/Contraindications
Radical cystectomy is the gold standard treatment for:
- muscle-invasive (>= pT2a) bladder cancer;
- high-risk (pT1G3, pTis) disease resistant to conservative treatment.

4. Preoperative management
Preoperatively, the bowel is prepared by oral self-administration of 2 liters of electrolyte lavage solution during two days before the surgical procedure. Prophylaxis with a cephalosporin antibiotic is performed from day 1 to 5 and low-molecular-weight heparin (4000 Units) is administered preoperatively and until postoperative day 15. Compression stockings are applied as the patient is placed in the supine position with the legs apart to allow free access to the perineal space. The table is set to a 30° Trendelenburg position. A Foley catheter (18 French) is inserted to drain the bladder and a nasogastric tube is positioned. As the lower limbs are carefully strapped to the table without compressions, no shoulder pads are necessary.

5. Operating room set-up

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The technique is challenging, requiring considerable laparoscopic infrastructure and expertise. Using a five- or six-port transperitoneal approach, the radical cystectomy and pelvic lymph node dissection are performed first. Standard laparoscopic surgical equipment with few special instruments is required. The patient is placed in a supine position with the legs apart for easy access to the perineal space.
The table is set to a Trendelenburg position (30° tilt).
The patient’s lower limbs are carefully strapped to the table.

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1. The surgeon is on the patient’s left side, if right-handed.
2. The assistant is on the patient’s right side.
3. A second assistant stands next to the first assistant and can help pass the instruments and can also handle one of the trocars.

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1. The laparoscopic unit and the monitor are placed at the patient’s feet, between the legs.
2. The operating table must permit a 30° Trendelenburg position.

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The patient is in a supine position, with the lower limbs slightly abducted (15°). A 30° flexion is given to the knees to define the value of Trendelenburg position accordingly. Extension of the hips should be avoided to prevent any backache.
A 5-port diamond or fan-shaped transperitoneal approach is used. The first 10 mm trocar is placed 1 cm above the umbilicus; an open technique through a mini-laparotomy is optional at this level. This trocar is reserved for the 0° laparoscope. The remaining 4 ports are placed under endoscopic control after classical establishment of the pneumoperitoneum (12-14 mm Hg) with or without the use of a Veress needle.
At the left McBurney’s point, a 12 mm trocar is placed; this diameter is chosen to ease the retrieval of pelvic lymph nodes after dissection. At the true McBurney’s point, a 10 mm trocar is placed to accommodate a 10 mm instrument if necessary.
On the midline, a 5 mm trocar is placed, one span below the umbilical trocar. A fifth 5 mm trocar is placed horizontally to the umbilicus, on the vertical line of the right lateral trocar.
The abdomen and pelvis are inspected; adhesions of the sigmoid loop in the left fossa, when present are released by blunt and sharp dissection.

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The basic instrumentation is common to all laparoscopic procedures:
1. 0° laparoscope
2. Fine dissecting scissors
3. Ultrasonic dissectors (optional)
4. Fine grasping forceps
5. 2 fenestrated grasping forceps
6. Bipolar cauterizing grasper
7. Needle holder
8. Suction-irrigation device
9. 5 mm clip applier
10. Retrieval bag
- urinary catheter
- 2.0 braided suture, 26 mm needle
- 3.0 absorbable monofilament suture, 26 mm needle

8. Operative protocol
1. Dissection of prerectal space (seminal vesicles left intact)
2. High peritoneal incision from along the ureters until internal inguinal ring
3. Division of ductus deferens, using a medial retractor
4. Extended pelvic lymph node dissection (ilio-obturator, internal iliac/medial external iliac): both the extent of node dissection and the number of lymph nodes removed has a direct impact on survival for both negative and positive node patients)
5. Division of ureter (once clamped)
6. Merging of peritoneal incisions; division of superior, inferior vesical artery, vesicular arteries
7. Late division of urachus and umbilical ligaments
8. Dissection of Retzius’ space
9. Complete dissection of the endopelvic fascia
10. Dissection along the prostate for preservation of neurovascular bundles (intrafascial: Aphrodite’s veil)
11. Complete dissection of urethra
12. Retrieval of the closed specimen “en bloc”
Laparoscopic anastomosis to the urethra in orthotopic bladder replacement

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The procedure begins with dissection of the plane posterior to the seminal vesicles. Dissection is started at the level of the rectovesical pouch (Douglas’ pouch). The posterior wall of the bladder is lifted vertically using a fenestrated forceps held by the second assistant. A horizontal 6-8 cm incision is carried out on the peritoneum two fingerbreadths above the bottom of the Douglas’ pouch.
Ampullae and seminal vesicles are exposed but not dissected from the bladder to which they remain attached throughout the procedure. If necessary, the posterior aspect of Denonvilliers’ fascia is exposed and incised horizontally to open the perirectal fatty space. When started high enough, the dissection is able to leave the Denonvilliers’ posterior sheet covering the seminal vesicles.
The dissection is continued bluntly on each side and on the anterior aspect of the rectum towards the apical area of the prostate.
The vascular supplies of the vesicles are identified laterally, but not divided so far.
A tunnel between the rectum and the prostate with the vesical and prostatic fibrovascular pedicles is created laterally.