Laparoscopic orthotopic ileal neobladder

Background and Purpose: Orthotopic ileal neobladder is currently the prefer red continent urinary diversion in suitable patients undergoing radical cys tectomy for muscle-invasive bladder cancer. To our knowledge, presented her ein is the initial report of laparoscopic orthotopic ileal neobladder follo wing cystectomy that was performed completely intracorporeally in a porcine model. Materials and Methods: The laparoscopic technique was developed in seven pi gs. Subsequently, a long-term survival study was performed in 12 consecutiv e animals, Laparoscopic cystectomy was performed, preserving the urethral s phincter. An ileal segment of 35 cm (first three animals), 45 cm (next four ), or 55 cm (final five animals) with adequate mesentery was isolated; and ileal continuity was restored intracorporeally by a stapled anastomosis. Il eal detubularization for construction of an ileal neobladder, urethroileal anastomosis, and bilateral stented ileoureteral anastomoses to a tubular St uder limb extension were all created completely intracorporeally using only laparoscopic free-hand suturing and knot-tying. Biochemical data (preopera tive and serial postoperative hemoglobin, renal panel, blood gases), radiol ogic studies (intravenous urogram, retrograde pouchgram), functional measur es (neobladder urodynamics, Whitaker pressure-flow study of both ureters), and microscopic evaluation of the neobladder and ureteroileal and urethroil eal anastomotic sites were obtained to evaluate the long-term functional an d anatomic outcome. Results: Completely intracorporeal laparoscopic construction of an ileal or thotopic neobladder was successful in all 12 animals without intraoperative or early postoperative complications or open conversion. The mean operatin g time was 5.4 hours (range 4.5-6.5 hours), and the blood loss was minimal. All study pigs survived their predetermined follow-up period, ranging from 1 to 3 months. Late complications occurred in three animals: one port-site abscess and two cases of E. coli pyelonephritis and azotemia, leading to o ne death at 2 months. The mean serum creatinine concentrations were 1.33 mg /dL, 1.61 mg/dL, and 1.55 mg/dL at 1, 2, and 3 months, respectively. The me an neobladder capacity was 420 mL (range 250-700 mL) with pressures less th an or equal to 20 cm H2O (range 17-20 cm H2O). Pre-euthanasia Whitaker test ing confirmed excellent drainage in all 24 ureters. No ileoureteral or ileo urethral anastomotic strictures or leaks were noted on intravenous urograph y, retrograde pouchgram, or postmortem physical calibration of the anastomo tic sites. Histologic examination confirmed excellent healing without obvio us fibrosis. Conclusion: Laparoscopic construction of an orthotopic neobladder is feasib le. The anatomic and functional outcome is excellent and comparable to that of open surgery. Clinical application is imminent.