腹腔镜下膀胱前列腺切除术在男性膀胱癌患者（图文演示）

10. Lateral dissection of bladder

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The umbilical arteries are identified close to the abdominal inguinal ring and the peritoneum is incised just laterally to them. From the internal inguinal ring caudally, a vertical incision of the peritoneum follows the medial aspect of the external iliac artery until the crossing of the ipsilateral ureter. The ductus deferens is divided at the level of the inguinal ring and retracted medially to open the space medial to the external iliac vessels.

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The classical or extended ilio-obturator lymph node dissection (Stone et al., 1997; Lieskowsky and Skinner, 1984) may be carried out at this moment; sampling of the nodes in view of frozen sections can be extended to external and/or internal node groups.

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The peritoneal incision is then extended cranially, at the anterior aspect of the ureter, beyond the crossing of iliac vessels; this allows preparation of an adequate length of free ureter in view of their ulterior re-implantation. Careful hemostasis of the arteriolar supply to the iliac portion of ureters should be ensured to avoid potentially neglected bleedings.
The superior vesical artery is divided at its origin. This can be accomplished by means of a 10 mm vessel sealing device or by division between laparoscopic clips.
The ureter is then further followed, completely dissected and divided between clips, close to its intramural portion. The last centimetre is resected and properly oriented for frozen section to exclude dysplasia of the lower ureter.

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The lymph node dissection is extended to the common iliac lymph nodes, then to the presacral and para-aortic lymph nodes.

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The inferior vesical artery and vesiculo-prostatic artery are then divided as described above. Their division is carried out in close vision of the lateral aspect of the seminal vesicle to which they provide arterial supply. The division of the successive pedicles is temporarily interrupted at the upper lateral edge of the prostate, on each side, in order to preserve temporarily the emergence of the neurovascular bundles.
So far, the bladder remains suspended through its anterior attachments and the Retzius’ space is kept closed except for its lateral aspects.

11. Anterior dissection of bladder

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When the antegrade dissection and division of the bladder’s upper vascular elements are achieved, the umbilical ligaments are divided and the Retzius’ space is then opened. The high division of umbilical ligaments is enabled by the supraumbilical position of the telescope, by the working position of the scissors in the upper right trocar, and by a hemostatic forceps working through the left lateral trocar.
At this point, the anterior peritoneum is incised laterally to the umbilical arteries from the umbilicus to the inguinal ring. The prevesical space is entirely opened and the bladder is dissected from the anterior abdominal wall. With a combination of sharp and blunt dissection, the space between the lateral wall of the bladder and the pelvic side wall is developed until reaching the endopelvic fascia on both sides.

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The superficial dorsal vein is then divided on the anterior aspect of the prostate and the endopelvic fascia is opened on its line of reflexion; the lateral surface of the prostate is separated from the levator ani muscle to carefully isolate the dorsal vein complex and the prostatic apex.

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At this time, the lateral aspect of the prostate is exposed by the first assistant exerting traction on the vesico-prostatic junction in the opposite direction. This maneuver exposes the superior vesiculo-prostatic pedicle left intact so far. In the meantime, the rectum is pushed downwards with the suction cannula in order to expose the medial aspect of the vesico-prostatic pedicle.

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Nerve-sparing dissection of vesicoprostatic complex:
Marching down the pelvis, the visceral fascia is opened on the lateral aspect of the prostate and the branches of the ipsilateral neurovascular bundle to the prostate are divided successively towards the apex of the prostate, on each side, using either an ultrasonic scalpel, a 5-10 mm vessel sealing device or a bipolar forceps.

12. Apical dissection

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At this point, the vesico-prostatic complex is still attached to the pelvic floor by the deep dorsal vein complex and the urethra. The plexus of Santorini is divided after ligation or using a vessel sealing device.

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Division of urethra:
The anterior aspect of the urethra is exposed as proximal as possible to the prostatic parenchyma in order to maintain the puboprostatic ligaments intact as well as an adequate urethral stump, if an orthotopic neobladder reconstruction is planned.
From the points reached by the division of the visceral fascia, the lateral and posterior aspects of the urethra are then dissected with a 5 or 10 mm right-angled Maryland forceps. When free, the urethra is ligated with an intracorporeal knot or clamped by a 10 mm Hem-o-Lock® clip and divided after removal of the indwelling catheter.
The urinary lumen is never opened by this means in order to avoid any cell spillage.

Releasing the specimen:
The terminal plate and the distal insertions of Denonvilliers’ fascia are incised, releasing the specimen completely.

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If the available length of both ureters is considered too short by the surgeon, the former dissection is continued cranially. The left ureter is tunnelized behind the sigmoid loop to join the right ureter in the retroperitoneal space; a fenestrated atraumatic forceps is passed through the upper right trocar, lifting the posterior peritoneum caudally towards the aortoiliac bifurcation, and bluntly dissecting the sigmoid mesentery to allow the passage of the left ureter to the opposite side.

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After a last overview of main hemostatic controls, the pneumoperitoneum is temporarily deflated; lateral trocars remain as they are placed.
In case of an orthotopic bladder replacement, a midline laparotomy incision is made, unifying the two medial trocar holes; these trocars are temporarily removed.
The vesicoprostatic specimen is removed ‘en bloc’ through the incision; its entrapment into a bag is optional.

15. Orthotopic bladder replacement

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The orthotopic neobladder pouch is created by suturing opened small bowel together to form a new bladder. As usual, a 55 to 60cm segment of ileum located 15cm away from the ileocecal junction is isolated and detubularized, leaving intact a proximal 10cm isoperistaltic afferent Studer limb segment. Depending on the surgeon’s skills or preferences, a Hautmann’s ileal bladder can be built as well and the bowel prepared accordingly. The continuity of the small bowel is restored outside the body through the incision made for specimen retrieval; a spherical neobladder is constructed extracorporeally as well. A termino-terminal uretero-ileal anastomosis is then performed through the same incision, according to Wallace or to Bricker.

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Ureters are intubated with 8 French smooth catheters temporarily attached to the posterior wall of the pouch with rapidly absorbable sutures (Vicryl rapid® 2.0).
Both catheters are exteriorized through the anterior wall of the pouch, and subsequently, will be passed through the abdominal wall thereafter.
The anterior wall of the reservoir is closed by a running Connel-Mayo PGA 3.0 suture; the caudal part of this closure is left open in view of the vesicourethral anastomosis.
When the pouch is ready, it is placed into the abdomen and the mini-laparotomy is closed classically. The 10mm trocar is replaced for the lens, in an infraumbilical position and the pneumoperitoneum re-insufflated.

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After appropriate positioning of the ileal neobladder in its orthotopic position, a vesicourethral anastomosis is started between the ileal orifice left open and the urethral stump.
This technique is now widely adopted for the reconstructive part of radical prostatectomy. Briefly, the suture is started at six o’clock on the ileal edge of the suture; two 6-7 inches of 2.0 PGA monolayer threads knotted together are used; two hemi-running sutures are then built until twelve o’clock where the only knot tied intracorporeally is done.

When this suture is completed, a Jackson-Pratt drain is placed into the pelvis; the tube is exteriorized through a trocar hole in the right fossa. Fascial incisions of 10 mm are closed with interrupted 0 sutures. The skin is closed with surgical staples.

17. Postoperative management
In the first night, all patients were monitored on the intensive care unit for monitoring of vital parameters and adequate pain management. Parenteral nutrition was continued until complete oral feeding. The drains are removed after reduction of secretion below 50 ml. On day 10 the ureteral stents are removed without cystogram. The urethral catheter of neobladders is removed on postoperative day 18, after 48 hours of intermittent clamping every 2 hours.

18. Conclusion
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◀▶
Challenging procedure
Technically feasible in experienced hands
Expected benefits:
- minimize blood loss;
- minimize analgesic requirement;
- minimize hospital stay.
Lower morbidity
- standardization of the procedure mandatory
Selected indications for TCC

Oncologically complying with the rules of surgery for transitional cell carcinoma (TCC) of the bladder:
- Transperitoneal route;
- Urachal and peritoneal resection;
- Extended pelvic lymph node dissection;
- Hollow organs remain closed.

It may become a standard of care even in the elderly:
Neurogenic bladder, interstitial cystitis.

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