David A. Rebuck and Robert B. Nadler
Laparoscopic and Robotic Bladder Diverticulectomy
The first to describe a minimally invasive technique for the treatment of bladder diverticulae using the laparoscopic approach was Parra et al1 and Das in 1992.2 This group successfully resected a large, incompletely emptying, and colonized diverticulum in an 87-year-old man. Since then, multiple variations on this surgery have evolved and include both transperitoneal and extraperitoneal approaches. Today, robotic-assisted laparoscopic diverticulectomy represents the most recent major modification to this approach. Herein, we describe the role of laparoscopic and robotic-assisted laparoscopic techniques in the treatment of bladder diverticulae.
Anatomy, Physiology, and Pathophysiology
Bladder diverticulae represent a herniation of the bladder urothelium through the muscularis propria of the bladder wall. They are located adjacent to and connect with the bladder lumen through a narrow neck or ostium.3 On histologic examination, the diverticular wall is composed of mucosa, lamina propria, scattered thin muscle fibers, an adventitial layer, and, in some cases, a fibrous capsule or pseudocapsule.4,5 Because diverticulae contain only scattered thin muscle fibers, they do not empty their contents effectively during bladder emptying, leaving residual urine within the bladder which results in their characteristic findings on both endoscopic and radiologic examination. Bladder diverticulae may be classified as either congenital or acquired.
Congenital diverticulae present during childhood, usually in those less than 10 years of age, and are almost exclusively seen in boys.6,7 Congenital diverticulae can be further classified by whether they are associated with functional urinary tract pathology. Among children without associated functional pathology, the cause appears to be a congenital weakness at the level of the ureterovesical junction.8, 9 Diverticulae in these children tend to be solitary, large, located lateral and posterior to the ureterovesical junction, and are associated with normal urodynamics.9, 10 Cystoscopically, these diverticulae are seen in smooth-walled bladders without significant trabeculation.8 Among children with associated functional pathology, the cause appears to be associated with bladder outlet obstruction (as with posterior urethral valves), neuropathic bladder, or prune belly syndrome. Diverticulae in these children tend to be multiple, smaller, located at the bladder dome, and associated with abnormal urodynamics. Cystoscopically, these diverticulae are associated with significant trabeculation.3
Acquired diverticulae may be iatrogenic in nature and due to inadequate bladder closure after cystotomy or ureteral reimplantation which results in out-pouching of mucosa at the location of the suture line.11, 12 The most common association of acquired diverticulae, however, is bladder outlet obstruction due to benign prostatic hyperplasia (BPH), urethral stricture, or dysfunctional voiding.3 Such diverticulae are most commonly seen in men after 60 years of age and are uncommon in women.13 They are usually multiple, can occur anywhere in the bladder, and cystoscopically, are associated with significant bladder trabeculation.14 Acquired diverticulae in adults comprise the focus of the discussion in this chapter.
Most bladder diverticulae are asymptomatic in and of themselves. Rather, symptoms are often attributable to the commonly associated bladder outlet obstruction. As a result, most diverticulae are found during investigation of lower urinary tract symptoms or incidentally on radiographic or cystoscopic examination. Historically, the classic presentation of clinically significant diverticulae is of recurrent urinary tract infection. That such diverticulae result in inadequately drained urine predisposes them to infection. As such, a comprehensive approach to the diagnosis of bladder diverticulae relies on both cystoscopic and radiographic investigations. The former to visualize the location (especially in relation to the ureteral orifices and bladder neck), number, size (of the diverticulum itself as well as the size of its ostium) and content (which may include stone or tumor) of the diverticulae, and the latter to confirm the incomplete emptying of the diverticulae after micturition. Voiding cystourethrography (VCUG) is an appropriate modality for diagnosis as it also provides information about anatomy, location, size, and associated vesicoureteral reflux. Identification of VUR is important as a diverticulum that encompasses the ureteral orifice may create a functionally shortened intramural ureteral segment. In these patients, excision of the bladder diverticulum with ureteroneocystotomy may be necessary. Finally, as bladder outlet obstruction, impaired compliance, and neuropathic bladder conditions may result in the formation of bladder diverticulae, a urodynamic study may be of value in identifying and treating associated conditions when such an investigation will influence clinical management.
Treatment of bladder diverticulae depends primarily on first identifying and treating the cause of the diverticulum which is most commonly bladder outlet obstruction due to BPH, urethral stricture, voiding dysfunction, or neurogenic bladder.3 This may be performed prior to management of the diverticulum or concurrently with treatment of diverticulum. If the former approach is pursued and results in improved emptying of the diverticulum with corresponding resolution of symptoms and complications, then treatment of the diverticulum itself may not be required. As such, indications to treat bladder diverticulae include persistent symptoms, infections, obstruction (of the ureter or the bladder neck), vesicoureteral reflux, stones or malignant disease within the diverticulum. If an indication to treat is present, treatment options include observation, endoscopic management, or surgical excision using either the open or laparoscopic approaches.
Observation or expectant management may be the preferred approach in patients who are unlikely to improve their bladder emptying, or in those who continue to exhibit poor bladder emptying, after surgical treatment of their bladder outlet obstruction. As well, those unfit or unwilling to pursue surgical treatment are also candidates for observation. In these patients, treatment with clean intermittent catheterization or an indwelling catheter is appropriate. Endoscopic management of bladder diverticulae has also been described.15, 16 Such an approach may be appropriate for those with small diverticulae who are undergoing an endoscopic treatment of their bladder outlet obstruction, and who are poor candidates for an extirpative approach. This approach involves resection using a resectoscope loop or Collins knife down to the muscle fibers at the level of the diverticular ostium, thus disrupting the sphincter-like properties of the diverticular neck and allowing for improved diverticular emptying. Resection of the bladder neck may also be combined with fulguration of urothelium of the diverticulum which may result in its obliteration or a reduction of size.17
For most urologists, surgical excision by way of the open approach remains the most familiar treatment option. Open bladder diverticulectomy may be performed via an extravesical, intravesical, or combination approach.17 Laparoscopic bladder diverticulectomy represents a minimally invasive alternative to the open approach and can be performed either transperitoneally or extraperitoneally.18 Laparoscopic diverticulectomy employs the same principles of the open approach which include: 1.) Complete mobilization of the diverticular sac and neck; 2.) Excision of the diverticulum; and 3.) Precise double-layer bladder closure.19 Treatment of bladder outlet obstruction, if not already achieved, can be performed either immediately before or after diverticulectomy.20 It should be noted, however, that case series suggest that a staged approach of endoscopic outlet management followed by laparoscopic diverticulectomy results in faster recovery, lower blood loss, and comparable outcomes compared with the combined open approach.20 Robotic-assisted laparoscopic diverticulectomy also adheres to these treatment principles and represents the most recent major modification to the laparoscopic approach (Videos 1,2,3).
Laparoscopic Bladder Diverticulectomy: Transperitoneal Approach
As outlined by Gill,19 the transperitoneal technique of laparoscopic bladder diverticulectomy involves ten steps: 1.) Individual cystoscopic catheterization of the ureters, the bladder, and the diverticulum itself; 2.) Insufflation of the peritoneal cavity; 3.) Insertion of four or five transperitoneal laparoscopic ports; 4.) Selective distension of the diverticulum; 5.) Incision of the peritoneum over the diverticulum; 6.) Identification and preservation of the ureters; 7.) Circumscription of the neck and excision of the diverticulum at its ostium; 8.) Double-layer bladder closure; 9.) Distension of the bladder to confirm closure; and 10.) Placement of a perivesical drain and urethral (or suprapubic) catheter.
The first descriptions of laparoscopic bladder diverticulectomy,1,2 and most of the literature since then, report on outcomes that have utilized the transperitoneal approach. Porpiglia et al. compared the safety and effectiveness of laparoscopic transperitoneal bladder diverticulectomy to open bladder diverticulectomy.21 They performed a retrospective study comparing 12 consecutive patients who underwent sequential transurethral resection of the prostate (TURP) and transperitoneal laparoscopic diverticulectomy to 13 consecutive patients who underwent suprapubic prostatectomy and open diverticulectomy. There were no differences between the groups in prostate volume, diverticular size, or diverticular position. The laparoscopic group had a longer operative time (4 hours vs. 2 hours and 16 minutes) than the open group, but was superior in terms of blood loss (18% vs. 27% drop in hemoglobin), post-operative analgesic requirements, and hospital stay (3.2 vs. 9.6 days). There were no complications reported in either group, and no difference in post-operative follow-up uroflow rates. The authors concluded that the transperitoneal laparoscopic approach is safe and effective.
Since the original descriptions of this approach, several other authors have published similar reports in both children and adults.20,22-29 The largest series using the transperitoneal approach followed 13 patients.28 At the start of the procedure, the surgeons placed three individual catheters: First, a ureteral catheter was inserted into the ipsilateral orifice to aid in intra-operative identification of the ureter. Second, a 14 Fr. council-tip Foley catheter was placed with its balloon within the diverticulum to aid with intra-operative identification of the diverticulum during laparoscopy. Third, a 10 Fr. straight catheter was also inserted into the lumen of the bladder. A five-port configuration was used: a 10 mm umbilical port at the umbilicus for the laparoscope, two additional 10 mm ports below the level of the umbilicus at the lateral margin of the rectus muscle, and two 5 mm ports inferior and lateral to the ipsilateral 10 mm port. Laparoscopic diverticulectomy was then performed in accordance with the principles and steps of diverticulectomy described above.19 The mean operative time was 4 hours and 25 minutes. Operative time reported in the literature ranges from 120-460 minutes. The second largest series of transperitoneal laparoscopic bladder diverticulectomy described a mean operative time of 247 minutes in 10 patients.20 Operative time has decreased as surgeon experience with laparoscopy has evolved. Operative time for the laparoscopic approach, however, is still approximately twice as long as that of contemporary open surgery, which ranges from 80 minutes to 2.6 hours.20, 21
Laparoscopic Bladder Diverticulectomy: Extraperitoneal Approach
Compared to transperitoneal laparoscopic diverticulectomy, there have been few reports on the outcomes after the extraperitoneal approach. Proponents of the latter argue that this approach mimics open surgery, avoids manipulation or mobilization of intraperitoneal structures, eliminates the risk of intraperitoneal urine leak, and possibly reduces the chances of postoperative port site complications such as hernia formation.18
The extraperitoneal technique of laparoscopic bladder diverticulectomy was first described by Nadler et al. in a patient with a 300 mL diverticulum and an elevated International Prostate Symptom Score (IPSS) of 28.18 Their approach utilized the same principles of bladder diverticulectomy, described above. The case was initiated with a transurethral incision of the patient’s small (20 g) prostate followed by the diverticulectomy. A self-made balloon over a 5 Fr. angiocatheter was inserted into the diverticulum and distended with normal saline. The diverticulectomy technique utilized a 2 cm incision below the umbilicus, which was used to introduce the surgeon’s finger and a self-made dilating balloon catheter to develop the retroperitoneal space. The dilating balloon was inflated with 1000 mL of normal saline to accomplish this. They then placed four laparoscopic ports, a 12 mm port at the level of the incision, a 12 mm port in the midline between the pubic symphysis and umbilicus, and a third 12 mm port in the right lower quadrant. A 5 mm port was also placed in the left lower quadrant. They dissected the diverticulum emanating just lateral the right ureteral orifice. The diverticulectomy time was lengthy (6 hours and 20 minutes), but this represented their initial experience with this technique. The estimated blood loss was only 100 mL. The surgical drain and the patient were discharged home on the second post-operative day. A cystogram performed on post-operative day 15 was normal except for a 1.5 cm out-pouching at the level of the diverticulectomy site. At two-months post-operatively, his bladder capacity was 450 mL, his post-void residual was 60 mL, his IPSS score was 9, and there was no evidence of recurrence of the diverticulectomy. Since then, only a few other cases using this technique have been reported.30-32
Notably, Shah et al.31 reported on three patients who underwent holmium laser enucleation of the prostate followed by laparoscopic extraperitoneal bladder diverticulectomy. At the conclusion of the enucleation, a 14 Fr. council-tip Foley catheter was placed into the diverticulum over a guidewire. A ureteral catheter was also placed into the ipsilateral orifice, and a 10 Fr. feeding tube was placed into the bladder. The diverticular catheter was inflated and its position in the diverticulum was confirmed fluoroscopically. This catheter was then put on traction such that the diverticulum could be distended to aid identification during laparoscopy. A 10 mm incision was made below the umbilicus and a self-made balloon dilator, similar to that described by Nadler et al.18 was used to develop the extraperitoneal space. A Hasson port was placed in this location and with pneumopreperitoneum, two additional 5 mm ports were placed lateral to the border of the rectus muscles. Bladder diverticulectomy was carried out and bladder closure was accomplished in a single layer. They reported no complications, no blood transfusions, a mean diverticulectomy operative time of 4 hours and 6 minutes, and a mean discharge time of 2.8 days. At 1 month post-operatively, post-void residuals and IPSS scores had significantly improved. Finally, Flasko et al.32 also reported on laparoscopic extraperitoneal bladder diverticulectomy in a 26 year-old male using a similar technique with a self-made balloon catheter to distend the diverticulum Intraoperatively. Their operative times were 2 hours and 20 minutes and they too reported excellent outcomes.
Robotic-assisted Bladder Diverticulectomy
The first report of robotic-assisted diverticulectomy was described by Berger and Stifelman in 2006 and the first series by Myer and Wagner in 2007.33,34 In the latter, five patients underwent transperitoneal diverticulectomy. A triple catheter arrangement similar to that described by Nadler et al18 was used to distend the diverticulum, intra-operatively identify the ureters, and drain the bladder. A five-port configuration was used to perform the diverticulectomy. A 12 mm port was placed at the umbilicus for the laparoscope, two 8 mm robot ports were placed 10 cm inferolateral the camera port, a 12 mm assistant port was placed 2 fingerbreadths medial to the right anterior superior iliac spine, and a 5 mm assistant port was placed at the level of the umbilicus and between the camera and the right robotic port. Diverticulectomy was then performed. The median operative time was just under 3 hours and included cystoscopy, port placement, robot docking, and incision closure. Median console time was 83 minutes. One patient underwent a ureteral reimplantation for a Hutch diverticulum. Drain removal was done at a median of 2 days and the median length of stay was 3 days. One patient had urine leakage on cystogram at 14 days post-operatively, which resolved by 28 days. The operative time was less compared to the larger transperitoneal pure laparoscopic series described above,20,28 while the post-operative hospital stay was comparable.
A recent case report by Kural et al.35 describe a transperitoneal robotic-assisted laparoscopic diverticulectomy followed by photo-vaporization of the prostate (PVP). Total operative time, including diverticulectomy with PVP procedure, was 230 minutes, and console time was 90 minutes. The length of stay was 7 days. They concluded that PVP is the best approach among patients who require simultaneous bladder outlet surgery with repair of bladder diverticulae as it is associated with less blood loss and a decreased need for post-operative bladder irrigation which may interfere with or disrupt bladder closure during laparoscopic diverticulectomy which followed it. Other reports of robotic-assisted laparoscopic diverticulectomy have been published and report similar results.36-38 Many of these authors comment that the lack of tactile and haptic feedback with the da Vinci robot® (Intuitive Surgical, Inc., Sunnyvale, CA) is compensated for by the 3-dimensional visualization, the ability to see the diverticulum from all angles, the magnification afforded by the camera, the 7 degrees-of-freedom of the instruments, and the motion scaling of the surgeon’s movements, all of which are well utilized when working in the tight space of the pelvis, especially during intracorporeal suturing during bladder closure34. These advantages may be manifested by the decreased operative times when compared to those laparoscopic cases described without the use of robotic-assistance.
Techniques of Intra-Operative Identification of the Diverticulum
Successful treatment of bladder diverticulae depends on complete identification and mobilization of the diverticular sac and its excision that incorporates the diverticular neck at the level of its ostium. During laparoscopy, however, pneumoperitoneum will have the effect of compressing the catheterized (and therefore empty) bladder into the pelvis. As a result, a bladder diverticulum will also be empty and therefore difficult, if not impossible, to identify. This challenge is overcome by incorporating one of several maneuvers that allows the surgeon to visualize the diverticulum despite an empty bladder and compressing effects of the pneumoperitoneum.
1. Catheterization of the Diverticulum with Fluid Distension
In their large series, Abdel-Hakim et al.28 were able to identify the diverticulum during laparoscopy by catheterizing it with a 14 Fr. council-tip Foley catheter. At the start of the procedure and under cystoscopy, a ureteral catheter was first placed into the ipsilateral orifice. This was followed by insertion of a second 4 Fr. ureteral catheter into the lumen of the diverticulum itself. The council-tip Foley was then placed on top of the ureteral catheter and its position was monitored with fluoroscopy as its balloon was inflated with 30 mL of saline. The bladder was then also catheterized with a smaller 10 Fr. straight catheter which was placed alongside the diverticular catheter. With the patient in Trendelenburg position, the diverticular catheter is placed on gentle traction so that its balloon occludes the diverticular neck. The diverticulum is then distended with saline without distending the bladder. By this means, the diverticulum can be distended and emptied as needed, making its recognition and dissection easy from the beginning of the procedure. Transection of the diverticulum was then carried out over the balloon, which was then deflated and removed.
The advantages of this technique include the use of instruments familiar to urologists. The disadvantages include the possibility that multiple catheters placed through the urethra may be cumbersome. As well, there is a risk that diverticulae with wider necks may not be adequately occluded by the balloon of a council-tip Foley catheter or that the balloon may be dislodged thus precluding the ability to selectively distend the diverticulum. Despite this concern, such balloons may easily be inflated with more than 30 mL and the authors did not report any difficulty with this technique.
2. Catheterization of the Diverticulum with Balloon Distension
In the series reported by Myer and Wagner,34 the authors were able to identify the diverticulum during laparoscopy by pre-operatively catheterizing it with a large angiographic occlusion Equalizer™ balloon catheter. At the start of the procedure and under cystoscopy, a double-J® ureteral stent was first inserted. This was followed by insertion of the angiographic catheter into the lumen of the diverticulum itself. A urethral catheter is also inserted to drain the bladder. The balloon of the angiographic catheter was then inflated. The authors noted that in all cases the diverticulae were adequately distended and easy to identify from surrounding tissue and that it was not necessary to distend the diverticulum itself with saline. A similar technique was used by Nadler et al.18 in which a self-made balloon was created using the cut finger of a latex glove over a 5 Fr. angiocatheter, which was inserted cystoscopically into the diverticulum and distended with 180 mL of normal saline.
The advantages of this technique include the use of fewer instruments (as the angiographic catheter can be placed directly into the diverticulum under cystoscopy without the need of a guidewire), no need to place the angiographic balloon on traction, and no need to distend the diverticulum itself with saline. The disadvantages of this technique include less familiarity of angiographic catheters among urologists, the risk of angiographic catheter dislodgement, and the possibility the natural shape of the diverticulum, and therefore the shape and location of its neck, may be distorted in diverticulae that have a volume much larger than the volume of the angiographic balloon. Despite this, the authors did not report any difficulty in their cohort of patients with diverticulae as large as 15.8 cm in greatest dimension.
3. Cystoscopic-Assisted Identification of the Diverticulum (Video 1)
In the report by Macejko et al.,36 the authors were able to identify the diverticulum by using a combination of bladder distension via the urethral catheter and cystoscopic illumination of the diverticular lumen. At the start of the procedure and under cystoscopy, ureteral stents were inserted. A urethral catheter was then inserted as well. During laparoscopy, the bladder was distended with saline until the bladder margins were clearly identified. The urethral catheter was then removed and a flexible cystoscope was inserted. With the laparoscopic lights dimmed, the cystoscope was inserted into the diverticular lumen and illuminated it to aid dissection. Once the dissection was complete, the cystoscope was retracted into the bladder lumen and the diverticulum was transected at its base. A similar approach was also described by Parra et al.1
The advantages of this technique include the familiarity of these instruments among urologists, its simplicity to perform, the cost savings by using fewer disposable instruments, and the ability of immediate assessment of the margin of resection around the ostium as determined by real-time cystoscopy by the bedside assistant. The disadvantages include the increased time required to perform a separate intra-operative cystoscopic procedure.
Complications and Rescue Strategies: Laparoscopic and Robotic Bladder Diverticulectomy
Early complications associated with laparoscopic and robotic bladder diverticulectomy include those associated with laparoscopy, in general, such as infection, bleeding, problems related to insufflation and port placement, as well as injury to surrounding organs, such as bowel. Complications unique to bladder diverticulectomy are described below:
1. Failure to identify the diverticulum during laparoscopy:
Failure to adequately identify the diverticulum during laparoscopy can be a frustrating and time-consuming complication, which may lead to incomplete or partial excision of the diverticulum. Best management of this problem is avoidance by comprehensive pre-operative assessment with cystoscopy and VCUG to accurately document the location, number and size of the diverticulae, including the size of the diverticular neck. Techniques for intra-operative identification of the diverticulum are described above. There is no evidence to support which of these described techniques is the best. Knowledge of the patient’s diverticular anatomy, however, is important. Those with very large diverticulae or those with wide diverticular necks may best be approached with a technique that relies on fluid rather than balloon distension as certain balloons may insufficiently dilate the diverticulum. Furthermore, use of a council-tip Foley with a balloon of sufficient size to occlude the diverticular neck will also be helpful. Pre-operative sizing of these instruments will avoid delays in the operating room while the patient is under general anesthetic.
2. Ureteral injury:
There is a significant risk of ureteral injury when performing laparoscopic bladder diverticulectomy as the most common location of diverticulae is lateral to the ureteral orifice. This risk, however, can be avoided by careful attention to technique and knowledge of ureteral anatomy. Pre-operative placement of ureteral stents are of benefit in identifying the ureters intra-operatively. If a partial non-thermal transection occurs, it may be repaired primarily and stented. Complete ureteral transection or thermal-related injuries usually require ureteral reimplantation or ureteroureterostomy with or without a psoas hitch depending on the location and nature of the injury. Conversion to an open approach may be prudent.
3. Post-operative urine leak:
Post-operative urine leaks are usually self-limiting and are due to inadequate cystotomy closure. This may be prevented by more extensive mobilization of the bladder to facilitate a tension-free closure. Successful management of this complication usually requires continued bladder and perivesical drainage with the urethral catheter and closed-suction drain, respectively. Larger urinary leaks may require antibiotic prophylaxis to prevent urinoma infection.
Late complications are rare and have been sparsely reported.
1. Prolonged urine leak and urinary fistula
The sequelae of a prolonged urine leak from cystotomy closure will depend on whether the diverticulectomy was approached from a transperitoneal or extraperitoneal technique. Urine leaks involving the peritoneal contents will have deleterious metabolic and gastrointestinal effects. Failure of a urine leak to resolve and subsequent fistula formation (to the skin incision, for example) may be due to the effects of a foreign body within the cystotomy closure, previous radiation treatment to the pelvis, infection, unrecognized malignancy, or bladder outlet obstruction. Management of prolonged urine leak or urinary fistula mandates an investigation to rule-out each of these causes.
2. Recurrence of bladder diverticulae:
Most bladder diverticulae are acquired secondary to bladder outlet obstruction. Failure to adequately treat the cause will lead to recurrence. Patients receiving medical therapy for BPH may require surgery and patients already managed surgically, in whom a hypotonic detrusor is suspected, may require clean intermittent catheterization or an indwelling catheter.
Laparoscopic and Robotic Partial Cystectomy
Partial cystectomy is a bladder-preserving treatment that involves full-thickness surgical excision of a bladder lesion and the surrounding bladder wall.39 Partial cystectomy has been used for both benign and malignant diseases. Open partial cystectomy has been performed since the 19th century. Laparoscopic partial cystectomy was first described in 1993 by Nezhat and Nezhat40 for infiltrating bladder endometriosis. Since then, most of the literature on laparoscopic partial cystectomy involves patients with isolated benign tumors of the bladder, however, increasing data documents the use of this procedure for transitional cell carcinoma (TCC). For example, the first series describing the use of laparoscopic partial cystectomy for TCC was reported by Mariano and Tefilli in 2004,41 who described this procedure among six patients with a mean follow-up of 30 months.
Anatomy, Physiology, Pathophysiology, and Disease
Laparoscopic partial cystectomy, like its open counterpart, may be indicated in certain circumstances. These include isolated benign diseases of the bladder including bladder endometrioma, pheochromocytoma and placenta percreta. It may also be used in select cases of malignant disease such as TCC. Cases of TCC for which partial cystectomy may be appropriate include solitary tumors, or those contained within a diverticulum, that are distant from the ureteral orifices, trigone, bladder neck, and posterior urethra (to allow a 1.5-2 cm resection margin) with no history or current evidence of multiple tumors or carcinoma in-situ. As bladder volume is decreased with partial cystectomy, candidates should have good pre-operative bladder capacity to allow for a decrement in volume without impairing bladder storage functions. Still, fewer than 10% of patients with TCC are candidates for partial cystectomy.19
Laparoscopic and Robotic Partial Cystectomy
As described by Gill19 and Mariano and Tefilli,41 the technique of laparoscopic partial cystectomy involves 9 steps: 1.) Selective catheterization of the ureters (if required for lesions close to the ureteral orifices) and insertion of a bladder catheter; 2.) Placement of 5 transperitoneal ports, similar to that described for laparoscopic radical prostatectomy;42, 43 3.) Pelvic lymph node dissection, if required for TCC; 4.) Mobilization of the bladder, both posteriorly and anteriorly, to maximize the bladder wall diameter which facilitates acquisition of tumor-free margins and allows for a tension-free bladder closure; 5.) Intra-operative identification of the bladder lesion; 6.) Excision of the bladder lesion and its removal via an impermeable laparoscopic sac; 7.) Double-layer closure of the cystotomy; and 8.) Placement of a perivesical drain and urethral catheter.
A large series reporting the outcomes among 15 patients undergoing laparoscopic partial cystectomy for benign disease was performed by Nezhat et al in 2002.44 All patients had bladder endometriosis and the lesions were in the bladder dome in eight and posterior bladder wall in seven. Chapron and Dubuisson45 also described laparoscopic partial cystectomy in 8 patients who also had endometriosis the mean volume of which was 9.5 cm.3 They described no intra- or post-operative complications and after 31 months of follow-up, all patients recovered completely. Kozlowski et al.46 in 2001 described a laparoscopic partial cystectomy in a patient with a 3 x 3 cm bladder pheochromocytoma. After pre-operative and anesthetic preparation, the tumor was cystoscopically scored around its margin with a Collin’s knife. The tumor was then excised laparoscopically and there were no complications.
Mariano and Tefilli41 were the first to report the outcomes among patients undergoing laparoscopic partial cystectomy for malignant disease. Each of their 6 patients had a solitary, high-grade, invasive, organ-confined bladder tumor. They used a transperitoneal approach with 5 laparoscopic ports: An 11 mm port at the umbilicus for the laparoscope, 2 additional 10 mm ports at lateral and inferior to the laparoscope port for the working forceps and ultrasounic scalpel, and two 5 mm ports anterior and superior to the anterior-superior iliac spine. The mean operative time was 3.4 hours and the mean blood loss was 200 mL. Post-operatively, 2 patients had spontaneously resolving urine leaks. The mean hospital stay was 4 days. There were no other intra- or post-operative complications, however, one of their patients developed locoregional disease and metastases 9 months later and ultimately received chemotherapy.
Recently, robotic-assisted partial cystectomy was described by Spiess and Correa47 in 2009. They performed a robotic-assisted laparoscopic partial cystectomy and urachal resection for a case of urachal adenocarcinoma. They used a 6-port technique and dissected the bladder anteriorly to level of the umbilicus while simultaneously transilluminating the bladder cystoscopically to define the bladder boundaries of the mass.
Techniques of Intra-Operative Identification of the Bladder Lesion
Complete excision of bladder pathology is critical to the success of partial cystectomy whether performed via the open or laparoscopic approach. The transperitoneal or extraperitoneal approaches do not allow the surgeon to directly view the lesion of interest located within the bladder lumen. This challenge is overcome by one of two general approaches that direct the laparoscopic surgeon where to begin his bladder resection.
1. Intravesical approach:
In their series, Mariano and Tefilli41 first catheterized and emptied their patients’ bladders. After they performed lymphadenectomy, the bladder was then completely mobilized. A small cystotomy on the bladder dome was made. With the Foley catheter clamped, the pneumoperitoneum entered the bladder and rapidly distended it. The laparoscope and instruments could then be advanced into the distended bladder. Excision of the bladder lesion was then performed under direct vision through the cystotomy.
The advantage of this technique is its simplicity. The disadvantages, however, include the notion that the initial cystotomy is still performed blindly and its success is dependent on accurate pre-operative knowledge of the tumor location so as to avoid the risk of performing the cystotomy too close to the lesion (or even through the lesion). Ideal lesions for this approach may be those not located directly at the bladder dome, but more laterally to avoid this risk. Furthermore, as several instruments must traverse the cystotomy to perform the excision, the cystotomy itself must be large enough to accommodate them. This may result in a larger cystotomy defect to close and thus a higher risk or post-operative urine leakage. Finally, as a separate cystotomy is made in addition to the partial cystectomy, two separate bladder closures must be made, rather than just one (see below).
2. Extravesical approach (cystoscopic-guided laparoscopic partial cystectomy):
Nerli et al.48 described a technique, which avoided the need to make a separate cystotomy incision to inspect the bladder lumen. During laparoscopy, a cystoscope was inserted into the bladder and the lesion was identified on a monitor adjacent to the laparoscopic monitor. Using the guidance of the cystoscopic image, the laparoscopic cautery device was then used to score the extravesical surface to mark the site of the incision on the bladder. This was then performed with cautery markings placed circumferentially around the lesion with a 1.5-2 cm margin. The cautery was then used to make a full-thickness bladder incision and the lesion with the healthy margin of bladder wall was then excised.
The advantages of this technique include the lack of a second cystotomy site thus requiring fewer bladder closures and less risk of post-operative urinary leak. It also provides the surgeon with a cystoscopic image that closely matches the perspective he will use when examining the bladder during cystoscopic follow-up. Disadvantages include the additional equipment required and therefore increased cost.
Complications and Rescue Strategies: Laparoscopic and Robotic Partial Cystectomy
Many of the complications associated with bladder diverticulectomy (described above) are also seen with partial cystectomy. Complications unique to laparoscopic and robotic partial cystectomy are described. Local recurrence represents a significant risk among those undergoing laparoscopic partial cystectomy for TCC. There is limited data regarding the risk of local recurrence among those undergoing laparoscopic partial cystectomy, however, the risk among open series ranges from 40-78%.49 Key elements in minimizing this risk is strict selection of patients thought to be appropriate for partial cystectomy. Still, one review of the open partial cystectomy literature concluded that only 5.8% to 18.9% of patients with muscle-invasive bladder cancer would be suitable candidates.50 As well, adequate intra-operative identification of the lesion to incorporate a 1.5-2 cm margin of healthy appearing tissue around the tumor is critical to ensure a negative surgical margin. A positive intra-operative frozen-section margin should be re-resected during the same anesthetic. An inability to obtain a negative frozen-section margin should mandate either conversion to open partial cystectomy or radical cystectomy.
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