© 1990 S. Karger AG, Basel 0302-2 8 38/90/0184-02 53$ 2.7 5/0
Eur Urol 1990; 18;253-257
Transprostatic Selective Cystectomy with an Ileal Bladder 1608206
Albrecht Schilling, Alexander Friesen Department of Urology, Städtisches Krankenhaus Bogenhausen, Munich, FRG
Key Words. Bladder cancer • Diagnostic TUR-P • Transprostatic cystectomy • Ileal bladder Abstract. Since 1987 we have changed our surgical approach to radical cystectomy and ileal neobladder in order to maintain erectile function and urinary continence. The routine diagnostic work-up includes a staging transurethral resection of the prostate in order not to miss any ductal involvement. The selective cystovesiculectomy is performed by cutting through the apex of the prostate, thus leaving a wide, funnel-shaped tunnel of the prostatic urethra for the anastamosis with the M- or W-shaped ileal reservoir. The preliminary results of 27 patients show excellent results concerning erectile function and continence, as requested by our predictive criteria. Especially the continence achieved after a training period of 3 months is reliable. Further observation will show whether the functional improvements and advantages in the operative technique are achieved at the cost of a higher relapse rate of urethral tumors.
Methods and Clinical Material Besides the routine examinations to exclude métastasés (X-ray of the chest, computed tomography of the pelvis and abdomen and bone scintiscan), we also thoroughly investigate whether there is any local tumor dissemination. The following system was used to gain material for the cytologic and histologic assessment during the transurethral removal of the bladder tumor followed by laser coag ulation of the tumor site. The cytology of the bladder washout is followed by bladder mapping. Samples are taken from all parts of the vesical walls and several specimens are collected in the area of the bladdemeck and also from the pars prostaticae urethrae. The
collected samples are cold biopsy specimens. Finally, a transurethral resection of the prostatic urethra is undertaken. We perform radical selective cystectomy and a neobladder oper ation under the following circumstances: (1) the biopsy specimens from the area of the bladdemeck and the pars prostaticae are tumor free; (2) no carcinoma can be located in the resected specimens of the prostate; (3) the immediate sections of the pelvic lymphadenectomy are free of métastasés. The development of the bladder is begun cranially by cutting around the pars affixa of the peritoneum. The bladder is mobilized in the usual way. In the area of the tumor, the dissection has to be done at the greatest possible distance. To avoid any damage to the erectile nerve fibers, the dissection has to be done close to the walls of the vesical cervix. The bladder is removed transprostatically, cra nially to the colliculus seminalis after severing the puboprostatic ligaments (fig. 1). We use a segment of the terminal ileum approximately 55 cm long for the neobladder. The aboral part is chosen at a distance of 20 cm from the cecum (fig. 2). According to the anatomical varia tions of the mesenteric attachment, the ileal segment is adjusted Mor W-shaped to ensure a tension-free anastomosis (fig. 3). The intes tinal plate is formed according to the method suggested by Kock et al. [4]. We sew the sutures with 0000 PDS (fig. 4). For the implan tation of the ureter, we follow the method of Carney and Le Duc [ 1, Downloaded by: University of Exeter 144.173.6.94 - 5/3/2020 3:44:35 AM
Since 1983, 62 neobladder operations have been per formed at our department [8, 9], a technique meant to replace ureterostoma in order to ameliorate these pa tients’ quality of life. But continence, and especially noc turnal continence, could not be reliably maintained after removal of the prostate. Also, to be honest, erectility was only achieved in very few cases and even then not to a satisfactory degree. For these reasons, we have been applying a new strategy since 1987 concerning radical cystectomy and replacement by an ileal bladder.
254
Schilling/Friesen
\ -J.
V Ï ' ■ i. ■■ t I m?
WMgS. Site
7
/
Fig. 2. W-shaped, antiperistaltic order of the ileum and antimesenteric incision.
Fig. 3. A bowel plate is formed by continuous suture of the wound lips.
Fig. 4. After implantation of a ureter a dome is formed by a continuous suture (PDS 00000). Downloaded by: University of Exeter 144.173.6.94 - 5/3/2020 3:44:35 AM
Fig. 1. The black outline schematically shows the operative method of the transprostatic cystovesiculectomy. Structures near the apex which are important for closure or for erection are carefully spared.
Transprostatic Selective Cystectomy with an Ileal Bladder
255
6
5] and Tumer-Warwick and Ashken [11], After forming the intesti nal plate like a dome (fig. 5), the neobladder is anastomosed with the funnel-shaped resected remains of the prostatic urethra (fig. 6). Beginning at 6 o’clock, two semicircular 1CT1 dexon sutures are sewn and a knot is tied at 12 o’clock. Then the ventral occlusion of the bladder is done. The anastomosis is then splinted with a Charrière 22 silicone catheter. Further urinal drainage runs via two Charrière 8 PVC splints, which are inserted transneovesically over the abdominal wall. After 12 days, the ureter splints and after 21 days the catheter are removed. The patient is led to train his bladder and also his voiding according to a voiding scheme. The voiding scheme requests empty ing of the bladder every 2 h. During the night, the patient should empty his bladder twice. As a final filling volume, a maximum capacity of 450 ml - not more - is desirable. This means that after the training period, the bladder should be emptied every 4 h.
Results Since 1987, we have performed 27 transprostatic selective cystectomies with our new method using an ileal M- or W-shaped neobladder. The average age of the patients was 61.3 (47-68) years. The average period of
observation lasted 8 months (2-27 months). Twenty-five patients suffered from a urothelial bladder carcinoma, 2 cases showed a sarcoma (table 1). The operations took between 3.5 and 6 h. None of the patients required a blood transfusion during the operation. Complications (table 2) In 1 case there was a venous insufficiency of the seg ment after the dissection from the ileum during the oper ation. We were forced to resect this part and again dis sect a new segment of the ileum. The further course was without complications. After the operation, 1 patient died because of septic complications. Three patients had dislocations of splints which made a transitory percutaneous nephrostomy nec essary. To dry up a leak in the anastomosis region in another case, a double-sided percutaneous nephrostomy and a percutaneous neocystostomy were necessary. Early Complications. After removing the splints, an obstruction was discovered in 2 cases at the ureteral pas sage, at the site of reimplantation. In 1 case an anteroDownloaded by: University of Exeter 144.173.6.94 - 5/3/2020 3:44:35 AM
5
Fig. 5. Anastomosis of the urethral stump with the broad base of the bowel plate by two semicircular sutures. Fig. 6. The funnel-shaped urethra is ideally fit for anastomoses with the ileal bladder. The anastomosis is begun with two sutures at 6 o’clock and than continued with a running semicircular suture until 12 o’clock where it ends.
256
Schilling/Friesen
Tumor
pTiSN0Mo G3 pT I N(jM0 G2
Particularities
n
Adjuvant cytostasic treatment
2 lymphangiosis carcinomatosa of the superficial stroma 2 5 3
pT2 N0M0 G2 pT2 N0M0 G3 pT3a pNiMo G2 pT3a pNoMo G2 pT3b pNoMo G2 pT3b pNoMo G3 pT3 N0M0 rhabdomyosarcoma pT3 N0M0 leiomyosarcoma
1
+
6 3 3
+
+
1 +
Table 2. Complications During the operation Venous insufficiency of the ileal segment
1
Early complications Percutaneous nephrostomy - Caused by dislocation of splints - To dry up a leak in the region of the anastomosis DJ insert - With dilatation of an obstruction in the region of the ureter implantation - With resection of scar tissue near urethral orifice
1 1 1 1
Late complications Vesicorenal reflux Stricture in the urethra Stricture in the region of the anastomosis Adhesion of the ileus Métastasés Overstretching of the bladder Feverish infection of the urinary tract
0 0 0 l l 1 2
Table 3. Urodynamic parameters (4 months after the operation) (n = 19) Continence complete
day, n night, n
19 19
Frequency of miction
day, n night, n
3-5 0-1 350-500 0-28 14-30 45-60
Eur Urol 1990; 18;253-257
Transprostatic Selective Cystectomy with an Ileal Bladder 1608206
Albrecht Schilling, Alexander Friesen Department of Urology, Städtisches Krankenhaus Bogenhausen, Munich, FRG
Key Words. Bladder cancer • Diagnostic TUR-P • Transprostatic cystectomy • Ileal bladder Abstract. Since 1987 we have changed our surgical approach to radical cystectomy and ileal neobladder in order to maintain erectile function and urinary continence. The routine diagnostic work-up includes a staging transurethral resection of the prostate in order not to miss any ductal involvement. The selective cystovesiculectomy is performed by cutting through the apex of the prostate, thus leaving a wide, funnel-shaped tunnel of the prostatic urethra for the anastamosis with the M- or W-shaped ileal reservoir. The preliminary results of 27 patients show excellent results concerning erectile function and continence, as requested by our predictive criteria. Especially the continence achieved after a training period of 3 months is reliable. Further observation will show whether the functional improvements and advantages in the operative technique are achieved at the cost of a higher relapse rate of urethral tumors.
Methods and Clinical Material Besides the routine examinations to exclude métastasés (X-ray of the chest, computed tomography of the pelvis and abdomen and bone scintiscan), we also thoroughly investigate whether there is any local tumor dissemination. The following system was used to gain material for the cytologic and histologic assessment during the transurethral removal of the bladder tumor followed by laser coag ulation of the tumor site. The cytology of the bladder washout is followed by bladder mapping. Samples are taken from all parts of the vesical walls and several specimens are collected in the area of the bladdemeck and also from the pars prostaticae urethrae. The
collected samples are cold biopsy specimens. Finally, a transurethral resection of the prostatic urethra is undertaken. We perform radical selective cystectomy and a neobladder oper ation under the following circumstances: (1) the biopsy specimens from the area of the bladdemeck and the pars prostaticae are tumor free; (2) no carcinoma can be located in the resected specimens of the prostate; (3) the immediate sections of the pelvic lymphadenectomy are free of métastasés. The development of the bladder is begun cranially by cutting around the pars affixa of the peritoneum. The bladder is mobilized in the usual way. In the area of the tumor, the dissection has to be done at the greatest possible distance. To avoid any damage to the erectile nerve fibers, the dissection has to be done close to the walls of the vesical cervix. The bladder is removed transprostatically, cra nially to the colliculus seminalis after severing the puboprostatic ligaments (fig. 1). We use a segment of the terminal ileum approximately 55 cm long for the neobladder. The aboral part is chosen at a distance of 20 cm from the cecum (fig. 2). According to the anatomical varia tions of the mesenteric attachment, the ileal segment is adjusted Mor W-shaped to ensure a tension-free anastomosis (fig. 3). The intes tinal plate is formed according to the method suggested by Kock et al. [4]. We sew the sutures with 0000 PDS (fig. 4). For the implan tation of the ureter, we follow the method of Carney and Le Duc [ 1, Downloaded by: University of Exeter 144.173.6.94 - 5/3/2020 3:44:35 AM
Since 1983, 62 neobladder operations have been per formed at our department [8, 9], a technique meant to replace ureterostoma in order to ameliorate these pa tients’ quality of life. But continence, and especially noc turnal continence, could not be reliably maintained after removal of the prostate. Also, to be honest, erectility was only achieved in very few cases and even then not to a satisfactory degree. For these reasons, we have been applying a new strategy since 1987 concerning radical cystectomy and replacement by an ileal bladder.
254
Schilling/Friesen
\ -J.
V Ï ' ■ i. ■■ t I m?
WMgS. Site
7
/
Fig. 2. W-shaped, antiperistaltic order of the ileum and antimesenteric incision.
Fig. 3. A bowel plate is formed by continuous suture of the wound lips.
Fig. 4. After implantation of a ureter a dome is formed by a continuous suture (PDS 00000). Downloaded by: University of Exeter 144.173.6.94 - 5/3/2020 3:44:35 AM
Fig. 1. The black outline schematically shows the operative method of the transprostatic cystovesiculectomy. Structures near the apex which are important for closure or for erection are carefully spared.
Transprostatic Selective Cystectomy with an Ileal Bladder
255
6
5] and Tumer-Warwick and Ashken [11], After forming the intesti nal plate like a dome (fig. 5), the neobladder is anastomosed with the funnel-shaped resected remains of the prostatic urethra (fig. 6). Beginning at 6 o’clock, two semicircular 1CT1 dexon sutures are sewn and a knot is tied at 12 o’clock. Then the ventral occlusion of the bladder is done. The anastomosis is then splinted with a Charrière 22 silicone catheter. Further urinal drainage runs via two Charrière 8 PVC splints, which are inserted transneovesically over the abdominal wall. After 12 days, the ureter splints and after 21 days the catheter are removed. The patient is led to train his bladder and also his voiding according to a voiding scheme. The voiding scheme requests empty ing of the bladder every 2 h. During the night, the patient should empty his bladder twice. As a final filling volume, a maximum capacity of 450 ml - not more - is desirable. This means that after the training period, the bladder should be emptied every 4 h.
Results Since 1987, we have performed 27 transprostatic selective cystectomies with our new method using an ileal M- or W-shaped neobladder. The average age of the patients was 61.3 (47-68) years. The average period of
observation lasted 8 months (2-27 months). Twenty-five patients suffered from a urothelial bladder carcinoma, 2 cases showed a sarcoma (table 1). The operations took between 3.5 and 6 h. None of the patients required a blood transfusion during the operation. Complications (table 2) In 1 case there was a venous insufficiency of the seg ment after the dissection from the ileum during the oper ation. We were forced to resect this part and again dis sect a new segment of the ileum. The further course was without complications. After the operation, 1 patient died because of septic complications. Three patients had dislocations of splints which made a transitory percutaneous nephrostomy nec essary. To dry up a leak in the anastomosis region in another case, a double-sided percutaneous nephrostomy and a percutaneous neocystostomy were necessary. Early Complications. After removing the splints, an obstruction was discovered in 2 cases at the ureteral pas sage, at the site of reimplantation. In 1 case an anteroDownloaded by: University of Exeter 144.173.6.94 - 5/3/2020 3:44:35 AM
5
Fig. 5. Anastomosis of the urethral stump with the broad base of the bowel plate by two semicircular sutures. Fig. 6. The funnel-shaped urethra is ideally fit for anastomoses with the ileal bladder. The anastomosis is begun with two sutures at 6 o’clock and than continued with a running semicircular suture until 12 o’clock where it ends.
256
Schilling/Friesen
Tumor
pTiSN0Mo G3 pT I N(jM0 G2
Particularities
n
Adjuvant cytostasic treatment
2 lymphangiosis carcinomatosa of the superficial stroma 2 5 3
pT2 N0M0 G2 pT2 N0M0 G3 pT3a pNiMo G2 pT3a pNoMo G2 pT3b pNoMo G2 pT3b pNoMo G3 pT3 N0M0 rhabdomyosarcoma pT3 N0M0 leiomyosarcoma
1
+
6 3 3
+
+
1 +
Table 2. Complications During the operation Venous insufficiency of the ileal segment
1
Early complications Percutaneous nephrostomy - Caused by dislocation of splints - To dry up a leak in the region of the anastomosis DJ insert - With dilatation of an obstruction in the region of the ureter implantation - With resection of scar tissue near urethral orifice
1 1 1 1
Late complications Vesicorenal reflux Stricture in the urethra Stricture in the region of the anastomosis Adhesion of the ileus Métastasés Overstretching of the bladder Feverish infection of the urinary tract
0 0 0 l l 1 2
Table 3. Urodynamic parameters (4 months after the operation) (n = 19) Continence complete
day, n night, n
19 19
Frequency of miction
day, n night, n
3-5 0-1 350-500 0-28 14-30 45-60
