Eur Urol Suppl 2007;6(2):298 V24 RObOtIC ASSIStEd LApAROSCOpIC RAdICAL CyStECtOMy IN tHE MALE: A tECHNIqUE ILLUStRAtEd StEp by StEp Gaboardi F., Galli S., Gregori A., Goumas Kartalas I., Sceri F., Knez R., Stener S. Ospedale Luigi Sacco, Department of Urology, Milano, Italy Introduction & Objectives: In this video we propose the step by step technique for the robotic assisted laparoscopic radical cystectomy in male. Material & Methods: A 5 port W shape transperitoneal approach is used. The irst 12 mm Trokar for the laparoscope is placed with an open technique through a minilaparotomy 1 cm above the ombelicus. In the two medial ports, 8 mm metallic Trokars are used. These Trokars are controlled by the Da Vinci Robot. In the other two ports, that are placed laterally and cranially, 5 mm and 10 mm Trokars are used. The left umbelical artery is identiied close to the abdominal inguinal ring and the peritoneun is incised just lateral until the vas deferens is reached. The vas deferens is dissected and the umbelical artery is isolated further down in a retrograde fashion towards the internal iliac artery. At this point the vesical arteries and distal ureter are identiied and dissected. The peritoneum at the Douglas pouch is incised and the inferior part of the left seminal vesicle is isolated. The same manouver is performed on the right side. The vas deferens are pulled upwards. By this way the bladder and prostate are suspended and the Denonvilliers fascia is exposed and then incised so the prerectal space is prepared. The ureteres and umbelical arteries are clipped with Hemolocks and transected. The vesical vascular pedicles are coagulated and divided with ultrasonic scalpel. The umbelical arteries and the uracus are divided in the midline. The prevesical space is entirely opened and the bladder is dissected of the anterior abdominal wall. The endopelvic fascia is incised on its line of relection and the lateral surface of the prostate is separated from the levator ani. A number 1 CT plus absorbable stitch is passed and the dorsal vein complex is ligated. The dorsal vein complex and the anterior urethra wall are incised. The distal end of the bladder catheter is ligated, transected and pulled into the abdominal cavity, maintaining the baloon inlated in the bladder in order to avoid intra-abdominal urine contamination. The posterior wall of the urethra and the rectourethralis muscle are divided. The prostatic vascular pedicles are coagulated and divided, totally releasing the specimen. The specimen is immediately entrapped in an endoscopy bag. Extended bilateral iliac lymphadenectomy is performed. Finally through a midline incision the specimen is extracted and a urinary diversion is performed by means of a combined extracorporeal-intracorporeal technique. Results: With the robotic assisted laparascopic radical cystectomy blood loss and operative time are reduced compared to the standard laparoscopic procedure. Conclusions: Dissection and suturing are extremely facilitated by the 3D visualization, the 7 degrees of freedom and 90 degrees of articulation of the robotic wristed instruments. Robotic assisted laparoscopic radical cystectomy is a safe, feasible and reproducible technique. V21 LApAROSCOpIC ILIAC LyMpHAdENECtOMyCOULd dUpLICAtE tHE pRINCIpLES Of OpEN tECHNIqUE dURING RAdICAL CyStECtOMy Shoma A. Urology and Nephrology Center, Urology, Mansoura, Egypt Introduction & Objectives: This video demonstrates the technique of iliac lymphadenectomy as an integral part of laparoscopic radical cystectomy for muscle invasive bladder tumors. Material & Methods: The patient is placed in supine position. The procedure is done through ive ports. Left iliac lymphadenectomy is performed using endo-scissor and endo-forceps with the aid of bipolar forceps. The lymphatics around the iliac artery and vein are dissected followed by removal of the obturator lymph nodes. Right iliac lymphadenectomy is performed in the same manner. Results: Bilateral iliac lymphadenectomy could be done in 35 patients. The average number of the removed lymph nodes was 14. The mean operative time was one hour. Conclusions: Laparoscopic iliac lymphadenectomy could duplicate open technique with satisfactory outcome. V22 LApAROSCOpIC NERVE SpARING CyStECtOMy ANd ORtHOtOpIC NEObLAddER IN fEMALE pAtIENtS Nagele U., Anastasiadis A.G., Sievert K.D., Kuczyk M., Seibold J., Stenzl A. University of Tübingen, Urology, Tübingen, Germany Introduction & Objectives: Urethrasparing and nerve-preserving cystectomy and orthotopic urinary diversion to the urethra has established itself both for male and female patients with bladder malignancies. Recent reports have demonstrated that laparoscopic radical cystectomy is feasible. The important steps of the previously published nerve-preserving cystectomy in females have been adapted to a laparoscopic technique. The urethra-sparing laparoscopic cystectomy is combined with a previously described technique with direct subserosal ureteral implantation. In this video, the main aspects regarding the surgical technique of laparoscopic cystectomy with special emphasis on nerve preservation and subsequent orthotopic urinary diversion in a female patient is shown. Material & Methods: After pelvic lymphadenectomy, a laparoscopic nerve sparing cystectomy with hysterectomy using intelligent thermo fusion for bloodless dissection is performed. The important surgical steps as well as anatomical landmarks are outlined. The anterior vaginal wall is removed together with the bladder and uterus. After laparoscopical transposition of the left ureter under the mesosigmoideum, both ureters and the terminal ileum are brought out of the abdomen through a 5 cm incision. The urinary reservoir is created by isolating 40 cm terminal ileum, reconiguration according to the Goodwin technique and subserosally implanting the conjoined ureters. The neovesicourethral anastomosis is performed laparoscopically. Waterthightness is conirmed and the reservoir is attached to the symphisis pubis as in the open technique. Conclusions: Nerve-preserving and urethra-sparing laparoscopic cystectomy in women using the same principles as in open surgery is feasible. The magniied and direct craniocaudal vision facilitates clear identiication and precise dissection of important anatomical structures such as the sacrouterine ligaments, pelvic autonomic nerves and the urethral sphincter. Laparoscopic surgery reduces blood loss and shift of luids, whereas the extracorporal creation of the neobladder reduces operating time. V23 LApAROSCOpIC CyStECtOMy ANd NEO-bLAddER fORMAtION IN WOMAN Baumert H. 1 , Rebai N. 1 , Shah N. 2 , Massoud W. 1 , Peyrat L. 1 , Aho T. 2 , Neal D. 2 1 Saint-Joseph Hospital, Urology, Paris, France, 2 Addenbrookes Hospital, Urology, Cambridge, United Kingdom Introduction & Objectives: Laparoscopic cystectomy with neo-bladder can be performed in woman. This ilm shows the diferent steps of the procedure. Material & Methods: The patient was placed in the Trendelenburg position. Five trocars were used: one 10 mm and four 5 mm. The diferent steps of the procedure were: Step 1: dissection and section of the ureters, Step 2: Dissection of the anterior aspect of the vagina, Step 3: Lateral dissection of the bladder, Step 4: Section of the urachus and dissection of the anterior part of the bladder, Step 5: Section of the urethra, Step 6: Extensive lymph node dissection, Step 7: Preparation of a segment of bowel intra-corporaly. Step 8: Removal of the specimen through a 5 cm incision around the umbilicus and display of the bowel through this incision. Step 9: Bowel de- tubularisation and construction of a neo-bladder performed extra-corporally which was then reinserted into the abdominal cavity. Step 10: The two uretero-ileal and the urethro-ileal anastomosis performed intra-corporally. Results: The operative time was 300 minutes, and blood loss was 250 ml. Intestinal transit recurred on day 2. Conclusions: Laparoscopic cystectomy with neo-bladder can be performed in woman. This technique is now well standardized.