© 2 0 0 5 B J U I N T E R N A T I O N A L | 9 7 , 3 7 – 4 1 | doi:10.1111/j.1464-410X.2005.05897.x 37 Original Article LAPAROSCOPIC RADICAL CYSTOPROSTATECTOMY WITH BNU BERGLUND et al. Laparoscopic radical cystoprostatectomy with bilateral nephroureterectomy: initial report RYAN K. BERGLUND, SURENA F. MATIN, MIHIR DESAI, JIHAD KAOUK and INDERBIR S. GILL Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA Accepted for publication 17 August 2005 avoided and en bloc urothelial integrity between the bladder and the two renal specimens was maintained throughout the procedure. The intact, entrapped specimens were removed en bloc via a Pfannenstiel incision at the end of the procedure. RESULTS The total operative duration was 573 and 660 min, respectively, including repositioning and re-draping between each major step. Blood loss was 350 and 1000 mL, respectively. Both patients tolerated the procedure well and there were no intraoperative complications. The first patient resumed oral intake 3 days after surgery and was discharged home after 5 days. The second patient’s course after surgery was complicated by a prolonged adynamic ileus and infection of the catheter placed for continuous ambulatory peritoneal dialysis. He was discharged 28 days after surgery and died from unknown causes at 30 days. CONCLUSIONS To our knowledge, this is the first report of radical urotheliectomy, consisting of bilateral pelvic lymph node dissection, radical cystoprostatectomy, and bilateral nephroureterectomy, using entirely intracorporeal laparoscopic techniques. KEYWORDS laparoscopy, TCC, nephroureterectomy, cystectomy, end-stage renal disease OBJECTIVES To present our experience with laparoscopic radical cystoprostatectomy and bilateral nephroureterectomy for organ-confined, muscle-invasive transitional cell carcinoma (TCC) of the bladder in two patients with dialysis-dependent end-stage renal disease (ESRD). PATIENTS AND METHODS Two men aged 77 and 65 years with organ- confined, muscle-invasive TCC of the urinary bladder and pre-existing dialysis-dependent ESRD underwent laparoscopic bilateral pelvic lymphadenectomy, radical cystoprostatectomy and bilateral nephroureterectomy. Urine spillage was INTRODUCTION TCC of the bladder is the sixth most common malignancy in the USA, accounting for 10% of cancers in men and 4% in women; ≈ 54 500 new cases a year are diagnosed in the USA, with > 12 500 deaths [1]. Upper tract tumours are found in 2–4% of patients with TCC of the bladder [2]. While open radical cystectomy and urinary diversion remain the preferred treatment options for muscle-invasive TCC of the bladder, recent advances in minimally invasive techniques have allowed the entire procedure, including urinary diversion, to be performed by completely intracorporeal laparoscopic techniques [3–5]. These procedures have been limited to selected institutions with experience in advanced laparoscopic techniques, as the intracorporeal construction of a conduit or reservoir is a time-consuming and technically challenging undertaking. However, in patients with dialysis-dependent end-stage renal disease (ESRD) bilateral nephrectomy should be concomitant to obviate the need to create a urinary diversion. Herein we present our experience with laparoscopic radical cystoprostatectomy and bilateral nephroureterectomy (BNU) for organ-confined, muscle-invasive TCC of the bladder in two patients with pre-existing ESRD. The aim of this study was not just to describe each procedure in detail, as such descriptions have been published by us and others [3–6], but to address the salient details and considerations unique to such a laparoscopic endeavour, which attempts to duplicate time-tested open surgical and oncological principles. PATIENTS AND METHODS Two men, aged 77 and 65 years, respectively, and American Society of Anesthesiologists class 3, presented with gross haematuria. Both had TUR of bladder tumours, which were determined to be pT2 grade 3 TCC. The baseline clinical variables are listed in Table 1. The diagnostic evaluation before surgery, i.e. CT, a complete metabolic panel, chest X-ray and bone scan, was negative for metastatic disease in both patients. The radical cystectomy and bilateral pelvic lymphadenectomy (BPLND) was transperitoneal, and performed with the patient in the low lithotomy position. The primary port (12 mm), inserted into the abdomen through a semicircular infra- umbilical incision, serves as the camera port for all subsequent procedures. The remaining ports for laparoscopic radical cystectomy and BPLND are placed as for laparoscopic prostatectomy (Fig. 1). Laparoscopic radical cystectomy is performed as previously described [3–5] but the ureters are not divided, instead being left intact and dissected cephalad to above the iliac vessels, thus freeing the bladder specimen adequately to allow placement in a specimen-retrieval bag. Surgical clips placed on both ureters early in the procedure will ensure that the bladder is completely empty before removing the Foley catheter and urethral transection. As an added precaution, the prostatic apex urethra is suture ligated to prevent any potential