Department of Urology, ABC Medical School and Brazilian Institute of Cancer Control, BrazilFulltext PDF
Introduction: The use of laparoscopic procedures is widespread and well documented in Urology. Advances such as decreased use of analgesics and shorter length of stay can be disrupted by an abdominal incision. Natural Orifice Specimen Extraction (NOSE) can be a powerful allied to minimize complications. Minimally invasive radical cystectomy increased importance and decreased side effects, despite still being usual, specially related its wound. NOSE in Urology does not focus on transanal extraction, focus of this report. Objective: Present initial experience of laparoscopic radical cystectomy with transanal specimen extraction. Methods: Between January 2016 and February 2017, five patients, all male, with hi-grade muscle invasive tumor previously evidenced on TURB with important comorbidities and low performance status were enrolled. Previous CT showed no signs of metastasis. Cutaneous ureterostomy was chosen as the diversion method, including simplified pelvic bilateral lymphadenectomy. Surgical technique: After bowel preparation including manitol and cefoxitine, five trocars, three 12 mm trocars and two 5 mm were inserted to the abdomen, observing the same position usually used to laparoscopic radical prostatectomy. Deep venous control was followed by ureters isolation and bilateral preservation up to the bladder insertion. Bladder vascular control used both polymeric clips and harmonic scalpel, also used to achieve final specimen release. A Right after, a single 5 cm vertical incision was done towards sigmoid taeniae and an 15 mm endoscopic bag was inserted, packed the specimen and was gently extracted. Taeniae repair was performed using a 60 mm stapler with reinforcement stitches. Ureters were placed outside through the 5 mm ports. Results: Total surgical procedure time had an average of 180 min, including median of 25 min of specimen extraction and sigmoid reconstruction. Length of Stay (LOS) had a median of 3 days, with early food intake initiated right after signs of bowel peristalsis. Discussion: Laparoscopic radical cystectomy is a powerful tool to decrease postoperative complications. Its use in association with NOSE can be an even better strategy, leading to shorter LOS, avoiding external organ exposition and decreased use of analgesics. Proctology literature has a better experience using NOSE on Oncology, evidencing promising data. Conclusion: The use of NOSE concept is a promising area that needs further studies to prove and replicate the findings on this issue and be used not only for cutaneous ureterostomy, but also to other forms of urinary diversion.
Ureters; Cutaneous ureterostomy; Specimen extraction; Laparoscopic radical cystectomy
obias M. Natural Orifice Specimen Extraction in Laparoscopic Radical Cystectomy: Initial Report. Ann Clin Surg. 2019; 1(1): 1002..