Bladder carcinoma is the most common malignant urological tumor in China, with a male-female ratio of 3:1.1 So the number of female patients with invasive bladder carcinoma is considerable. Although multiple reports of laparoscopic radical cystectomy (LRC) are available in the literature, most of them focus on male patients.2–6 LRC in female has not been well illustrated except Moinzadeh et al7 presented the technique of complete intracorporeal LRC in 11 female patients. In this paper we report our preliminary experience with LRC with orthotopic ileal neobladder in 14 female patients.
From February 2003 to February 2008, 14 female patients with invasive bladder carcinoma, aged 42 to 75 years (mean 57.8 years), were subjected to LRC with orthotopic ileal neobladder at our institution. Nine of these patients underwent hysterectomy and ovariectomy, and the remaining 5 had the uterus and ovarian appendage preserved. Preoperative cystoscopy proved that the tumor was more than 2 cm away from the bladder neck and no urethrostenosis existed. None of the patients had urinary incontinence and abdominal muscle chalasia. Nor distant metastasis was identified by bone scans, chest X-ray and sonography. Intravenous pyelography indicated normal renal functions, and the 2002 TNM staging revealed T2a in 6 patients, T2b in 7, and T3b in 1. Preoperative histological characteristics demonstrated grade II in 9 patients, and grade III in 5. Lymph node metastasis with enlarged lymph node in obstructed packets was detected in 1 patient by CT.
General anesthesia with endotracheal intubation was used for all patients. The patients were placed in Trendelenburg position with head downward 15°, upper leg abduced and knee joint flexed (Figure 1). After vaginal irrigation, iodoform gauze was inserted into the vagina. A Foley catheter was inserted from the sterile field. A 5-port trans-peritoneal approach was applied and ports were placed in a semicircular fan array. The first 12 mm trocar was placed at superior creases of the umbilicus for the 30° laparoscope after establishment of the pneumo-peritoneum. The remaining 4 trocars for the working instruments were placed under the laparoscope. The second and third 12 mm trocars were at 2 cm below the umbilicus on the midclavicular line in both sides. The fourth and fifth 5 mm trocars were at 2–3 cm superior and medial to anterior superior iliac spines in both sides.
The peritoneum was incised at the level of common iliac artery bifurcation, and the ureter was mobilized distally to the ureterovesical junction. The infundibulopelvic suspensory ligaments containing the ovarian vessels are transected with LigasureTM (Valleylab, USA). The round ligaments of the uterus were cut around the inner ring aperture. The fallopian tubes, ovaries and broad ligaments of the uterus were dissected along the pelvic wall. The vessel sheath was opened along the external iliac artery and pelvic lymphadenectomy was done as described previously.5 Adipose tissue and lymph nodes around the external iliac vessel, internal iliac vessel and obturator nerve were removed. While pushing the uterus anteriorly, the recto-uterine pouch was exposed and the peritoneum was incised (Figure 2). The posterior wall of the cervix and the anterior wall of the rectus were separated. After drawing the uterus to the opposite side, the cardinal ligaments and the distal ends of the uterus as well as the lateral vessel pedicles of the bladder were transected by LigaSure (Figure 3). The uterus was retracted anteriorly, and the sacro-uterine ligament were transected. The fornix of the vagina was opened along the bilateralis of the cervix. The vagina had been plugged with one or two wet gauzes before operation to help identify the vagina, prevent CO2 leakage and maintain the pneumo-peritoneum. The bladder was filled with 200 ml saline and inverted U-shaped peritoneotomy was performed from the urachus extending lateral to the medial umbilical ligaments and peritoneum reflection by electric hook, and also connected to the incision line of the bilateral peritoneum. The retropubic space was exposed and endopelvic fascia was visualized. The dorsal vein complex of the clitoris was secured with LigaSure or bipolar electrocoagulation, and the bladder neck was exposed. The Foleys catheter was ligated and transected outside the urethral orifice. The anterior urethra wall was cut 5 mm distal to the neck of the bladder to preserve the functional urethra for orthotopic neobladder procedure. The Foleys catheter was then pulled into the abdominal cavity and the posterior wall of the urethra was divided. The Foleys catheter was retracted to turn over the bladder neck upwardly, the posterior wall of the bladder was exposed and divided (Figure 4). The vagina was circumcised at the fornix of the vagina, and the vaginal stump was sutured with 2-0 absorbable stitches.
In the selected, sexually active, younger woman with low-volume organ-confined disease without perivesical extension, the nerve-sparing technique of laparoscopic radical cystectomy with preservation of fallopian tubes, ovaries, uterus, and vagina can be employed. The suspensary ligaments of the ovary were free from the external iliac vessel, but not divided to reserve the ovarian blood supply. After pushing the broad ligaments of the uterus inside, the performance of pelvic lymphadenectomy was followed by incision of the peritoneum along the vesicouterine pouch and dissection of the bladder from the anterior aspect of the uterus and vagina until the bladder neck. The other steps were as same as the non-genital sparing procedure.
The tumor was removed by a midline incision at the 4–5 cm lower abdomen. The ureteric ends were pulled out of the incision and ureter stents were placed. Through the same incision the ileum was extracted out from the peritoneal cavity and 50 cm of the ileum was isolated 15 cm proximal to the ileocecal junction. The isolated ileal segment was cleaned, detubularized, shaped as a“M”, and sutured with 3-0 dexon. One cm of the distal ureter was opened and formed a half-nipple and then implanted into the posterior wall of the pouch and fixed by 6 stitches with 4-0 dexon. A 22-Fr Foley catheter was inserted into the urethra and pulled out from the skin incision and a small opening was made at the bottom of the pouch. A traction stitch was sutured between the lower margin of the opening of the pouch and the tip of the Foley catheter. The pouch was put into the peritoneal cavity, the skin incision was closed and a pneumo-peritoneum was established again. After drawing the Foley catheter, the pouch was closed to the urethral stump and the opening of the pouch was identified. Urethral anastomosis of the pouch was made by two running sutures with Vicryl 3/0/26 (Syneture USA). After the hemostasis was confirmed, the 2 pelvic drainages were placed. The trocars were removed and the ports were closed.
In all patients, no conversion to open surgery was necessary. The mean operation time was (350.2±41.3) minutes (range 250–480) and the mean blood loss was (349.8±76.4) ml (range 100–1000), with blood transfusions of 400 ml only in 1 patient intraoperatively. None of the patients experienced intraoperative complications such as pneumothorax and injury of great pelvic vessels.
The postoperative complications included uretero-pouch anastomotic stricture (1 patient) which was successfully treated by percutaneous nephrostomy and antegrade double-J stent indwelling at 3 months and pouch-vaginal fistula (1 patient) which was treated by repairing through the vagina at 3 weeks. The postoperative complication rate was 14.3% (2/14). There were no other postoperative complications.
Follow-up time ranged from 3 to 60 months, and more than 6 months for 12 patients, all of whom achieved micturition in half a year. One patient had occasional day-time incontinence and 2 had night-time incontinence. Two patients who had undergone hystectomy and ovariectomy had voiding difficulties after one year; however micturition was achieved by adjusting position and increasing abdominal pressure. The clean intermittent self-catherization was needed in these 2 patients. Six months after the operation, the volume of the neobladder was (333.6±40.4) ml (range 270–550), and the residual urine volume was (31.2 ± 18.1) ml (range 0-83).
Histopathological examination of these tumors demonstrated TCC with the following stages: pT2aN0M0 (4 patients); pT2bN0M0 (7); pT2bN1M0 (1); pT3N1M0 (1); pT4N0M0 (1). Examination of tumor grade demonstrated grade II (8 patients); grade III (6). The surgical margins of the bladder specimen were tumor free for all the patients. The median number of removed lymph nodes was 12 (range 7–18), and 2 patients who had positive lymph nodes were given adjuvant chemotherapy after recovery. One patient with T2bN1, grade III had bone metastasis at 8 months and died at 11 months postoperatively. No trocar seeding was found.
Orthotopic bladder substitution is now feasible. The procedure has gained an increasing popularity in men for whom cystectomy is indicated,8–11 but the use of such procedures in women with invasive bladder carcinoma remains controversial. The first clinical attempt was made by Tscholl et al12 in 1987 in a female patient who became continent after orthotopic bladder substitution. After that, investigations13–15 showed that the rates of incontinence and over-continence in females are comparable to those in males who have been similarly treated with orthotopic bladder substitution. Because of self-micturition and high quality of life after operation, orthotopic bladder substitution has increasingly been accepted by female patients with invasive bladder cancer. The application of orthotopic bladder substitution in women is due to the deep understanding of the urethral sphincter muscle system and innervation. The female continence depends on the striated rhabdosphincter fibers, most of which were found in the middle and distal thirds of the urethra. Thus, in patients undergoing removal of the bladder neck and part of the proximal portion of the urethra, urine continence and spontaneous micturition can be maintained by preservation of the urethral sphincter system.16 The sphincter of the urethra in females is innervated both by the autonomic pelvic plexus and the pudendal nerves. These findings are supported by Strasser et al17 by the results of animal experiments that the autonomic nerves predominantly innervate and regulate the upper part of the urethra, whereas stimulation of the pudendal nerves leads to a contraction of the lower part of the sheep urethra. The pudendal nerves are not disturbed during the pelvic surgery in females because the branches of the pudendal nerves are outside of the pelvic cavity.
To protect the urinary continence mechanism, it is necessary to preserve the intact external urethral sphincter. Bejany et al18 recommended that the cutting edge of the urethra of females should be adjacent to the pubourethral ligament in the distal end of the bladder neck; Hautmann et al13 considered that cutting 1 cm of the proximal urethra or 1/5 of the urethra could preserve sufficient external urethral sphincter without postoperative over-continence.
LRC with orthotopic neobladder in male patients with invasive bladder carcinoma is as safe, feasible as radical tumor resection, and offers less invasion but quick recovery.2–6 With the improvement of laparoscopic technics and renovation of equipments, LRC with an orthotopic neobladder is maturing. In our 14 female patients with invasive bladder cancer but without metastasis, LRC with orthotopic ileal neobladder was performed successfully with a mean operative time of 344.5 minutes. Compared to open procedure, LRC with an orthotopic neobladder in females has 3 advantage. First, clearer operative view facilitates meticulous dissection and less injury of the pelvic floor structure improves the postoperative continent effect. Second, each dissection is performed with good haemostasis, blood loss is little during the operation, and the pneumo-peritoneal pressure could also decrease the veinlet hemorrhage. Third, the bowel was only exposed when the ileal pouch is formed extracorporeally. Less exposure and manipulation of the bowel may associate with quicker functional recovery of the intestinal tract and lower the incidence of related complications after the operation.
In our series, 2 of the 9 patients who had undergone hysterectomy, salpingo-oophorectomy and partial vaginectomy had hypercontinence, but none of 5 patients who had received uterine and ovary-sparing procedure had this voiding dysfunction. The study of Ali-El-Dein et al19 showed that retention appeared to be mechanical in nature due to the pouch's falling back in the wide pelvic cavity, resulting in acute angulation of the posterior pouch-urethral junction after removal of uterine and appendage. So preservation of the uterus and ovarian appendage not only maintains sexual function, but also prevents retension after operation. But indications must be strictly selected, patients with locally advanced tumors should be excluded.
In summary, LRC with orthotopic ileal neobladder in female patients is a technically feasible, safe and mini-invasive procedure with a low morbidity and acceptable neobladder function. Long-term follow-up is required to confirm the neobladder function and oncological outcomes.
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