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Laparoscopic Radical Cystectomy with Orthotopic Ileal Neobladder —— Key Steps to Success. Huang Jian The 2nd Affiliated Hospital Sun Yat-Sen University, Guangzhou China. Introduction.
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Laparoscopic Radical Cystectomy with Orthotopic Ileal Neobladder——Key Steps to Success Huang Jian The 2nd Affiliated Hospital Sun Yat-Sen University, Guangzhou China
Introduction • Laparoscopic radical cystectomy with orthotopic neobladder (LRC-OIN) is increasingly accepted by urologists. • It is no more the issue of feasibility but the issue of improvement for this procedure. • Discuss the techniques of key steps in LRC-OIN
Haemostatic Instruments • Harmonic scalpel • PK system • Bipolar forceps • LigaSure vessel sealing system • Electric hook • Hem-O-Lok
图1-2-10 结扎速血管闭合系统 LigaSureTM Vessel Sealing System
The Major Steps of the Procedure Step 1: Pelvic lymphadenectomy Step 2:Dissectionof seminal vesicle and Denonvelia’s fascia to expose the posterior aspect of prostate Step 3: Exposing the anterior aspect of bladder and prostate Step 4:Dividing the lateral pedicles of the bladder and the prostate Step 5: Dividing the apex of the prostate and urethra Step 6: Extracorporeal construction of Ileal neobladder Step7:Intracorporeal neobladder-urethra anastomosis
Step 1: Pelvic Lymphadenectomy with electric hook and LigaSure
Techniques of Pelvic Lymphadenectomy • Sequence: Lymphadenectomy before or after cystectomy • extent:standardor extented • Using instrument:harmonic scalpel, PK system bipolar clamp and electric scissors, or electric hook and LigaSure • Attention: blood vessel and obturator nerve injury lymphatic leakage tumor cell seeding
Step 2:Dissection of seminal vesicle opening Denonvelia’s fascia
Step 3: Exposing the anterior aspect of bladder and prostate
Step 4: Dividing the lateral pedicles of the bladder and the prostate • Nerve sparing • Non nerve sparing
Step 2 to step 5: Cystectomy Posterior aspect Anterior aspect Bilateral pedicles Prostate apex and urethra
How to avoid rectum injury • Correctly localized seminal vesicle • Opening the Denonvelia’s fascia and separating rectum from prostate • Dividing lateral peadicle close to the prostate • Transecting the urethra while pulling up the prostate apex
Different methods in dividing the lateral paedicles • LigaSure • PK Forceps • Endo-GIA • Harmonic scalpel
How to avoid the tumor seeding • Avoidingbladder wall perforation • Don’t transgressing the tumor boundaries, • Blocking up the bladder neck before transecting uretha
Step 6:Removal the spacimen and neobladder construction
The technique of Extracorporeal formation of neobladder • 5 cm of midline subumbilical skin incision • M shape ileal pouch • Implantation of ureters directly to the posterior wall of the pouch by means of ureteral half nipple.
Different techniques in formation of neobladder • Intracorporeally or extracorporeally • Reconstruction: Studer pouch, hemi-kock pouch, T pouch, M pouch, • Implantation of ureters:ileal chimney, ileal nipple, extramural serous-lined tunnels, mucosal sulcus, ureteral nipple,
Studer pouch T pouch Hemi-kock pouch ileal chimney extramural serous-lined tunnels ileal nipple
Step 7: Neobladder-urethra anastomosisTwo running suturestechnique
Tips and tricks in Neobladder-urethra anastomosis • A traction stitch to relieve the tension • Changing to head-up position • Two running suture technique better than interrupted, or running suture technique. • Attention: the catheter out side the neobladder
Summary The Surgical procedures of LRC-OIN can be improved by reasonable sequence, standard maneuver and correct use of instruments.