LESS radical cystectomy

Abstract

Laparoscopic surgery made radical cystectomy and urinary diversion a less invasive procedure but still remains one of the most complex urological techniques, prone to high rate of complications. This chapter provides a comprehensive review of the accumulated experience to convert conventional five-port laparoscopic radical cystectomy plus 10–12-cm midline minilaparotomy for specimen retrieval into laparoendoscopic single-site (LESS) radical cystectomy, pelvic lymphadenectomy, and permanent urinary diversion. Different approaches are presented. We describe in detail our experience with two-port approach using a reusable umbilical multichannel platform with curved instruments provided with double rotation system and an accessory 10-mm port placed in the right iliac fossa to overcome the current limitations of a pure single-port technique at a reasonable time and cost. Specimen extraction through the vagina in females makes unnecessary to extent the umbilical incision, and in candidates for ileal conduit, the accessory port is converted into the ileostomy orifice. If an orthotopic reservoir is preferred, the neobladder can be performed extracorporeally outside the umbilicus and, once completed, reintroduced to be anastomosed to the urethra. Perioperative outcomes, postoperative visual analogue pain scale (VAPS), and short-term morbidity confirm umbilical cystectomy which constitutes the least invasive alternative to efficiently treat muscle-invasive bladder cancer, with excellent esthetic result and patient recovery, low postoperative pain, and satisfactory hospital stay. The umbilical scar decreases the analgesic requirements and becomes practically invisible. We definitely believe LESS radical cystectomy with reusable platforms is an important step in the development of minimally invasive surgery for bladder cancer because the abdominal wall is damaged less than with any other technique.