Introduction & Objectives
Laparoscopic Radical Cystectomy (LRC) is a technically high-demanding procedure requiring advanced laparoscopic skills. LRC offers a complete minimally invasive alternative with equivalent oncologic outcomes compared to open surgery. One of the time-consuming steps in LRC is the transection of the vascular pedicle from the bladder (and prostate). In this study we investigated the use of an endoscopic stapling device for this step, looking at the peri- and postoperative outcome.
Material & Methods
From December 2015 till October 2016, 21 patients underwent LRC using the new stapling technique: the vascular bladder (and prostate) pedicle was transected using a laparoscopic stapling device (Echelon® 60mm). The same stapling device was used later in the procedure for the side-to-side anastomosis of the small intestine, creating the Bricker-loop or neobladder. We compared this group with our control-group of 122 patients who underwent LRC from January 2005 till October 2014. In the previous procedures we used Hemolock® clips and ultrasonic sealing (Ultracision®) for the transection of the vascular bladder (and prostate) pedicle. The indication for surgery in both groups was Muscle Invasive Bladder Carcinoma (MIBC) or BCG-resistant high-risk non-MIBC. All procedures were performed by the same urologist. Patient characteristics and peri-operative data are reported. All data were prospectively collected.
|Variables||LRC (n=122)||LRC stapling (n=21)|
|Gender||Male - n (%)||96 (78,7%)||8 (38,1%)|
|Female - n (%)||26 (21,3%)||13 (61,9%)|
- n (%)
|CIS, BCG-resistant||7 (5,7%)|
|pTa-1 GrIII, BCG-resistant||22 (18,0%)||6 (28,6%)|
|pT2||82 (67,2%)||12 (57,1%)|
|cT3||4 (3,3%)||3 (14,3%)|
In our study we found that LRC + stapling compared to LRC without stapling showed a highly significant decrease in operation time and a decrease in blood loss. The postoperative hospital stay in the LRC + stapling group was significantly decreased with six days on average. The transfer to the ICU was also lower in the LRC+stapling group.
|Variables||LRC (n=122)||LRC stapling (n=21)||P-value|
|Urinary derivations||Bricker||111 (90,1%)||18 (85,7%)|
|Neobladder||9 (7,3%)||3 (14,3%)|
|Indiana Pouch||2 (1,6%)|
|Operation time (min)||Mean||358||290||<0,001|
|Blood loss (ml)||Mean||630||432||0,065|
|Hospital stay (days)||Mean||17||11||<0,001|
|MC||18 (14,9%)||2 (9,5%)||0,523|
|Ward||84 (69,4%)||19 (90,5%)||0,010|
This study shows promising results in the use of a stapling device in LRC: lower perioperative blood loss, reduction in operating time and admission stay. The biases in this study were the small series in LRC + stapling, a difference in experience of the surgeon and a difference in gender between the both groups. Despite of these biases we think we have proved the feasibility of this new technique with this study. Future research and data analysis is necessary to further investigate this subject, looking at cost-effectiveness and long-term follow-up.