LAPAROSCOPIC ASSISTED RADICAL CYSTOPROSTATECTOMY WITH Y-SHAPED ORTHOTOPIC ILEAL NEOBLADDER CONSTRUCTED WITH NON-ABSORBABLE TITANIUM STAPLES THROUGH A 5 CM PFANNENSTEIL INCISION

Introduction: We performed a laparoscopic radical cystoprostatectomy followed by constructing a Y-shaped reservoir extra-corporeally with titanium staples through a 5-cm muscle-splitting Pfannenstiel incision. Surgical technique: Upon completion of the extirpative part of the operation, the surgical specimen was entrapped and removed intact through a 5-cm Pfannenstiel incision. Through the extraction incision, the distal ileum was identified and a 40 cm segment isolated. With the aid of the laparoscope, the ureters were brought outside the abdominal cavity and freshened and spatulated for approximately 1.5-cm. Bilateral double J ureteral stents were then inserted up to the renal pelvis and the ureters were directly anastomosed to the open ends of the limbs of the neobladder. Following this, the isolated intestinal segment was arranged in a Y shape with two central segments of 14 cm and two limbs of 6 cm. The two central segments were brought together and detubularized, with two sequential firings of 80 x 3.5 mm and 60 x 3.5 mm non-absorbable mechanical stapler (Multifire GIA US Surgical) inserted through an opening made at the lowest point of the neobladder on its anti-mesenteric border. The neobladder was reinserted inside the abdominal cavity and anastomosed to the urethra with intracorporeal laparoscopic free-hand suturing. Conclusion: Although this procedure is feasible and the preliminary results encouraging, continued surveillance is necessary to determine the lithiasis-inducing potential of these titanium staples within the urinary tract.


INTRODUCTION
Initially restricted to a few centers of excellence, the worldwide experience with laparoscopic radical cystectomy is clearly on the increase (1).Nowadays, the extirpative portion of the procedure does not represent a limiting factor and pure laparoscopic techniques are employed to expeditiously perform radical cystectomy and pelvic lymphadenectomy (2,3).Nonetheless, there is a trend to perform the reconstructive procedures necessary to create the urinary diversion extracorporeally, using conventional open surgical technique in an attempt to reduce the overall surgical time (1).Recently, the Italian group from Piedmont has described an "easy, fast and reliable" technique to create an orthotopic Y-shaped ileal neobladder open surgically using nonabsorbable titanium staples (4).Based on these promising results, we sought to perform a laparoscopic radical cystoprostatectomy followed by the construction of a Y-shaped reservoir extracorporeally through a 5 cm muscle-splitting Pfannenstiel incision.Therefore maximizing the benefits of a minimally invasive approach including, decreased postoperative pain, shorter hospital stay, quicker recovery, better cosmesis without a significant increase in the operative time.
Herein, we describe the surgical technique and present our preliminary results with laparoscopic assisted radical cystoprostatectomy with Y-shaped orthotopic ileal neobladder using non-absorbable titanium staples.

SURGICAL TECHNIQUE
Laparoscopic radical cystoprostatectomy was performed using a 5-port transperitoneal approach, which has been described in detail elsewhere (1)(2)(3).Upon completion of this extirpative part of the operation, the surgical specimen was entrapped in a Lapsac and removed intact through a 5-cm muscle-splitting Pfannenstiel incision (Figure -1).Through the extraction incision, the distal ileum was identified and brought outside the abdominal cavity.Using conventional open surgical techniques, a 40 cm ileal segment was isolated 15 to 20 cm proximal to the ileocecal valve and a side-to-side entero-entero anastomosis was performed to re-establish bowel continuity.Through the laparoscope, the ureters, which were previously anchored to the anterior abdominal wall with a stay stitch, were identified and also brought outside the abdominal cavity.Laparoscopic viewing was used to ensure the ureters were not twisted or rotated.Subsequently, the ureters were freshened and spatulated for approximately 1.5-cm.Bilateral, 6F double J ureteral stents were then inserted up to the renal pelvis and the ureters were directly anastomosed to the open ends of the limbs of the neobladder using running sutures of 4-0 PDS (Fig- ure-2).Following this, the isolated intestinal segment was arranged in a Y shape with 2 central segments of 14 cm and two limbs of 6 cm.The 2 central segments

A B
were brought together and detubularized with 2 sequential firings of a 80 x 3.5 mm and 60 x 3.5 mm nonabsorbable mechanical stapler (Multifire GIA -US Surgical) inserted through an opening made at the lowest point of the neobladder on its anti-mesenteric border (Figure -3).The recently created neobladder was reinserted inside the abdominal cavity and the 5-cm Pfannenstiel incision was closed.Pneumoperitoneum was re-established and the Y-neobladder was anastomosed to the urethra with four interrupted 2-0 monocryl sutures over a 22F Foley catheter, using intracorporeal laparoscopic free-hand suturing.The 2 limbs of the neobladder were then fixed to the psoas muscles.A suction drain was left in the deep pelvis.

PATIENTS AND RESULTS
Two male patients diagnosed with muscle invasive transitional cell carcinoma of the bladder consented and were scheduled to a laparoscopic assisted radical cystoprostatectomy with orthotopic Yshaped ileal neobladder.Metastatic workouts with chest x-rays and abdominal CTs were negative in both patients.There were no signs of enlarged pelvic nodes.Demographic, intraoperative and postoperative data are presented in Table-1.
A retrograde cystogram was performed with 200 cc of contrast on postoperative day 3 and postoperative day 7 in the first and second cases respectively, showing no signs of contrast media extravasation (Figure -4).In both cases, bladder catheter was removed on postoperative day 21.In both cases, cystoscopic viewing in the second postoperative month did not reveal any stones at the staple lines, which were almost entirely covered by the intestinal mucosa, except by a single spot where 3 staples could be visualized in the first case (Figure -5).We used a smaller 5-cm Pfannenstiel incision (Figure -6) to perform the bowel work, the Y-shaped orthotopic ileal neobladder and the ureteral re-implantation, thus further improving cosmesis and perhaps further decreasing surgical morbidity.Pathology revealed a T2G3 transitional cell carcinoma (TCC) of the bladder with negative surgical margins in the first case and a T3aG3 TCC of the bladder in the second case.Lymph nodes were negative in both cases.

COMMENTS
Over the past decade, a few studies have reported that the use of non-absorbable titanium staples inside the urinary tract may be safe and secure (4)(5)(6)(7)(8)(9).The corrosive resistant nature, low toxicity and excellent tissue and fluid biocompatibility of titanium may explain why such non-absorbable staples are well tolerated here.In fact, in 1993, Kerbl and colleagues from Washington University have reported the initial encouraging laboratory and clinical data with laparoscopic stapled (titanium staples) bladder closure (4).However, this article was criticized by reviewers at that time, who used comments such as: "…just because it is new, rapid and easy to use does not mean that it should be used in a cavalier fashion;" and "… sutures are less expensive than staples and less likely to result in stone formation."However, in 2000 this same group discussed its follow up research conducted over a more than 10-year period, and attesting to the safety of using non-absorbable titanium staples to secure the bladder cuff during laparoscopic nephroureterectomy (5), and demonstrating that no stones have ever been observed at the titanium staple line even when the staples were not entirely covered by the vesical mucosa.
In 2004, an Italian group from Piedmont reported an acceptable 6% rate of stones formation when fifty Y-shaped orthotopic ileal neobladders were created in open surgical procedures with non-absorbable titanium staples in a mean follow up of 20 months (total follow up range: from 8 to 47 months) (7).Encouraged by the Fontana and colleagues study, we recently performed and documented the first orthotopic ileal neobladder constructed totally intracorporeally using non-absorbable titanium staples exclusively (8).Although the procedure was possible, it took a long time (approximately 10 hours) and it required a considerable amount of disposables (8 stapler loads) to complete it.In an attempt to overcome these difficulties, we sought to incorporate Fontana's idea of creating an ileal neobladder with non-absorbable titanium staples with the technique discussed by Basillote and colleagues of laparoscopic assisted radical cystectomy (2).Basillote et al. have demonstrated that when radical cystectomy is performed laparoscopically and the neobladder is performed open surgically with conventional techniques through a Pfannenstiel incision, the patient has the benefits of a minimally invasive approach, including decreased post-operative pain and quicker recovery, without a significant increase in operative time (2).Therefore,   we performed 2 cases of laparoscopic assisted radical cystoprostatectomy wherein the Y-shaped orthotopic ileal neobladder was created extracorporeally using non-absorbable titanium staples.

* 200 cc of contrast
Although longer follow-up is required to fully evaluate the safety of this approach, we believe that our initial results are encouraging.It is also worth noting the mean overall surgical time of 5.7 hours, mean blood loss of 375 cc and mean total hospital stay of 5 days.Moreover, over a very short period ranging from 3-7 days post-operatively, we were able to demonstrate that there were no signs of contrast extravasation during retrograde pouchgram performed with 200 cc of contrast.Furthermore, cystoscopy performed in the second post-operative month did not reveal any stones at the staple line, and only a few A B staples were visualized within the neobladder while the remainder of the staple line was recovered by the intestinal mucosa.
We differed from the technique described by Basillote et al., who used a 15-cm Pfannenstiel incision to perform bowel work, Studer orthotopic ileal neobladder, ureteral re-implantation and the urethralileal anastomosis (2).As reported, we used a smaller 5-cm Pfannenstiel incision to perform the bowel work, Y-shaped orthotopic ileal neobladder and ureteral reimplantation, thus further improving cosmesis and perhaps further decreasing surgical morbidity.In our approach, the urethral-ileal anastomosis is performed using free-hand laparoscopic suturing after the recently fashioned neobladder is pushed back into the abdominal cavity, the extraction incision is closed and pneumoperitoneum is re-established.
Moreover, our approach to the bilateral ureteral re-implantation was different from that originally described by Fontana et al.In their report, the ureters were spatulated anteriorly and were anastomosed to the dorsal aspect of the two limbs of the Y with 5-0 sutures using the direct (end-to-side) Nesbit technique.Subsequently, the previously placed ureteral stents were brought out through the distal portions of each chimney and then through the anterior abdominal wall.In our procedure, the ureters were freshened and spatulated for approximately 1.5-cm, and then directly anastomosed (end-to-end) to the already open ends of the 2 limbs with 4-0 sutures over previously placed double J ureteral stents, resulting in a wide patent anastomosis.We thus avoided the presence of external ureteral stents and did not have to close the open ends of the limbs or create 2 new openings in the chimneys in order to implant the ureters, thus saving some time and perhaps decreasing the chances of developing a urinary fistula in the reservoir.

CONCLUSION
Laparoscopic assisted radical cystoprostatectomy with Y-shaped orthotopic ileal neobladder constructed using non-absorbable titanium staples through a 5-cm Pfannenstiel incision is feasible and our preliminary results are encouraging.Continued surveillance will be necessary to determine the lithiasis-inducing potential of these titanium staples within the urinary tract.approach.Similarly, morbidly obese patients may prove challenging, specifically when managing the open neobladder creation through the smaller Pfannenstiel incision.Although convalescence data and long-term follow-up are lacking, this procedure should prove effective and beneficial.The authors diligently state the need for long-term follow-up of the neobladder for stone disease, although most experts would agree this would not be problematic.
In 2005, cystoprostatectomy and neobladder creation remains an open operation in most centers, despite the fact that many bladder cancer patients would benefit from the improved convalescence and cosmesis of the minimally invasive approach.Moreover, a more rapid recovery would be beneficial for bladder cancer patients requiring adjuvant chemotherapy.This report adds nicely to the growing body of literature supporting minimally invasive cystoprostatectomy and urinary diversion.

Dr. Stephen Y. Nakada
Professor and Chairman of Urology University of Wisconsin Madison, Wisconsin, USA

EDITORIAL COMMENT
The authors should be commended for presenting a hybrid procedure combining a novel open technique, the Y-shaped orthotopic ileal neobladder, and a minimally invasive laparoscopic approach.As with any hybrid procedure, the urologist will need broad surgical skills.Urologists using this approach must possess advanced laparoscopic skills, as they must perform a laparoscopic cystoprostatectomy and complete the urethrovesical anastomosis laparoscopically.Similarly, the creation of the Yshaped neobladder requires experience with urinary diversion, and specifically care must be taken to avoid twisting or rotating the ureter or blood supply to the neobladder during the procedure through the 5 cm incision.
It is evident that careful patient selection will be critical when using this technique.Patients having prior abdominal procedures, or with aggressive disease may be better suited to an alternative

Figure 2 -
Figure 2 -A) Photograph showing the ureters (arrowheads) being directly anastomosed to the open ends of the limbs of the neobladder; B) Schematic drawing.

Figure 3 -
Figure 3 -A) Photograph showing the Y-shaped neobladder being created with non-absorbable titanium staples; B) Schematic drawing.

Figure 4 -
Figure 4 -Retrograde pouchgram with 200 cc performed on post-operative day 7 showing no signs of contrast extravasation, but free reflux of contrast from the limbs (L) of the pouch (P) to the ureters (U).

Figure 5 -
Figure 5 -A) Photograph showing the staple line (multiple arrows) covered by the intestinal mucosa; and B) Single spot where 3 staples were viewed within the reservoir (there is mucus adherent to the staples).