INTRODUCTION AND OBJECTIVES: Pelvic lymph node dis- ... artery cranially, external iliac vein laterally, bladder wall medially and internal iliac vessels ...
e654
THE JOURNAL OF UROLOGY姞
V1692 ILEAL NEOBLADDER WITH SUBTITUTION OF THE URETHRAL MUCOSA AND SPHINCTER PRESERVATION IN FEMALE MULTIFOCAL BLADDER CANCER Joan Palou*, Jorge Caffaratti, Josep Maria Santillana, Josep Maria Gaya, Humberto Villavicencio, Barcelona, Spain INTRODUCTION AND OBJECTIVES: Multifocal bladder cancer and involvement of the bladder neck are a contraindication for neobladder replacement in women due to the high risk of urethral involvement and future recurrence. We present a technique of removal of the urethral mucosa and submucosa and its substitution by intestinal mucosa. With this technique it is possible to preserve the sphincter, therefore continence, and to perform an orthotopic neobladder in patients with multifocal high grade non-muscle invasive disease or involvement of the bladder neck. METHODS: A 47 year-old female with multifocal disease underwent cystectomy and histeroanexectomy. She was initially placed in the dorsal lithotomy position and the mucosa and submucosa of the urethra was dissected from the outer layers. A radical cystectomy, including hystero-adnexectomy, was then performed through a Pfanenstiel incision. Care was taken to transect the urethra very close to the bladder neck and the urethral mucosa, previously dissected, was removed. Extended lymphadenectomy was performed. A 45 cm ileal segment was used to build a Studer Neobladder. A 8 cm segment of the distal ileum was not detubularized. The serosa and muscularis of this segment were removed leaving a segment of 6-8 cm of pure mucosa and submucosa. This segment segment was passed through the native urethra and anastomosed to the external urethral meatus. RESULTS: There were no postoperative complications. The ureteral stents were removed at 9 days and cystostomy at 10 days postop. A voiding cystogram was done at 21 days and the urethral catheter removed since there was not any leakage; postvoid residual urine less than 50 ml. At one month followup the patient is continent day and night, with a frequency of every 1-2 hours per day and 3 times at night. CONCLUSIONS: This innovative technique offers the possibility to perform a neobladder in patients who, otherwise, would have been offered other intestinal diversions due to the necessity to resect the urethra. Source of Funding: None
V1693 EXTENDED PELVIC LYMPH NODE DISSECTION DURING ROBOTIC PROSTATECTOMY James Porter*, Dhiren Dave, Seattle, WA INTRODUCTION AND OBJECTIVES: Pelvic lymph node dissection (PLND) at the time of radical retropubic prostatectomy (RRP) provides staging information and a potential therapeutic advantage. The value and extent of PLND remains controversial with little data evaluating outcomes of PLND during robotic RRP. We present the results of PLND performed during robotic RRP by a single surgeon. METHODS: 750 patients underwent robotic RRP between July, 2005 and August, 2009 by a single surgeon (JRP). Patients underwent extended PLND if they had Gleason score of 7 or greater, PSA greater than 10 or if their risk of lymph node involvement was 4% or greater based on the MSKCC pre-operative nomogram. Boundaries of PLND included Cooper’s ligament caudally, bifurcation of the common iliac artery cranially, external iliac vein laterally, bladder wall medially and internal iliac vessels posteriorly. Rate of PLND was assessed. The rate of positive nodes and nodal yield were determined. Complications of PLND were also assessed. RESULTS: Of 750 patients undergoing robotic RRP, 272 (36.2%) received PLND. 122 patients underwent a standard PLND while 150 underwent extended PLND. Overall, positive nodes were found in 27(10%) patients. Nine patients (7.4%) in the standard dissection grioup and 18 (12%) had positive nodes. The node count for the
Vol. 183, No. 4, Supplement, Tuesday, June 1, 2010
standard group was on average 9.8 while the node count was 12.1 for the extended group. PLND had a longer length of surgery compared to robotic prostatectomy without PLND (203 ⫾ 41 min. vs. 181 ⫾ 40 min.; p⬍0.01). Complications included pelvic lymphoceles in three patients, and obturator neuropathy in two others. CONCLUSIONS: Extended pelvic lymph node dissection can be performed robotically when indicated with minimal complications. The lymph node yield and rate of positive nodes is greater with extended PLND as compared to standard. More experience is needed with extended PLND to determine which patients will benefit from this procedure. Source of Funding: None
V1694 THE T-POUCH ORTHOTOPIC ILEAL NEOBLADDER Hugh Perkin*, Philip Kim, Georg Bartsch, Eila Skinner, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Orthotopic neobladders are a common form of urinary diversion for patients undergoing radical cystectomy for bladder cancer. The T-pouch is one technique that may be used to prevent reflux from the pouch to the kidneys. METHODS: Here we demonstrate and describe the major steps in the reconstruction of an anti-refluxing orthotopic ileal neobladder. RESULTS: The T-pouch utilizes an extraserosal tunneled afferent limb which prevents urinary reflux to the kidneys. CONCLUSIONS: The T-pouch is a viable option for patients requiring an anti-refluxing orthotopic neobladder. The extraserosal tunneling technique may also be applied to the efferent limb of a continent cutaneous diversion. Source of Funding: None
V1695 POST-CHEMOTHERAPY ROBOT-ASSISTED LAPAROSCOPIC RESECTION OF A RESIDUAL RETROPERITONEAL TUMOR IN TESTICULAR CANCER Georg Schoen*, Nina Harke, Tobias Egner, Frank Schiefelbein, Wuerzburg, Germany INTRODUCTION AND OBJECTIVES: Definitive indications for post-chemotherapy retroperitoneal lymph node dissection (RPLND) in non-seminoma are residual tumors bigger than 1 cm and a teratoma component in the primary tumor indicating a possible future teratoma residual tumor. The laparoscipic RPLND is an alternative minimally invasive procedure to the open operation. The robot-assisted technique shows the advantages over the laparoscopic technique in this video. METHODS: A 40 year old male patient with testicular cancer, tumormarkers elevated (-HCG 34.200, AFP 4470 kIU/). The result of the pathology after orchiectomy showed: Teratoma- and EmbryonalGerm-Cell-Carcinoma. 4 cycles of chemotherapy (PEP) followed. Tumor markers were negative, in the computed tomography large residual tumors were found. In this video we show the robot-assisted RPLND step by step: full flank position with attached arm, application of four trocars close to the midline, docking of the robot. Detaching of the colon and the left flexure to expose the renal hilum and the pancreas. Loop of the ureter and excision of the spermatic vein. Split and roll-technique, isolation of the main retroperitoneal structures. Lymph node dissection, removal of the specimen using a laparoscopic bag. RESULTS: The operation could be performed without complications. Bloodloss was 120 ml. Operation time was 4 hours. Pathology after RPLND showed 6 lymph nodes in total: 75% necrosis, 25 % mature and immature teratoma. Re-staging 3 and 6 months postop showed no evidence for a relapse 6 months postoperatively. CONCLUSIONS: Robot-assisted RPLND showed advantages compared to the laparoscopic RPLND: Three-dimensional view 360°, flexibility of the instruments, accessibility of the retroperitoneum from the renal vessels to the external inguinal ring without repositioning, imitation of the open resection of residual tumors. Good outcomes of
