Division of Urology, H. Lee Moffitt Cancer Center, Tampa, Florida, USA.
Int Braz J Urol. 2009 Sep-Oct;35(5):609. doi: 10.1590/s1677-55382009000500014.
Standard treatment for urachal adenocarcinomas is open partial cystectomy and urachal resection; however, minimally invasive surgical approaches including laparoscopic and recently described robotic assisted laparoscopic partial cystectomy and urachal resection is feasible with potential less morbidity. A case of robotic assisted partial cystectomy and urachal resection for urachal adenocarcinoma is presented. Few articles in the literature have being published describing this technique and to the best of our knowledge, this is the largest and potentially most complex case approached in such a manner.
A 55 years old African American male presented with hematuria and mucosuria, cystoscopy demonstrated a tumor involving the dome of the bladder. Transurethral biopsy confirmed a urachal adenocarcinoma. Further studies revealed a negative metastatic evaluation. Preoperative abdominal/pelvic CT imaging revealed an enhancing mass extending from the inferior level of the umbilicus to the dome of the bladder. A total of 6 laparoscopic ports were used. The robotic assisted laparoscopic dissection was started at the level of the umbilicus, dissecting lateral to the right and left medial umbilical ligaments up until the dome of the bladder. A simultaneous cystoscopy with transillumination to define the bladder boundaries of this mass, with robotic assisted laparoscopic opening of the bladder, with the entire mass (including bladder component) excised and sent for frozen pathology for margin evaluation. After specimen extraction, the bladder was closed in two layers. Total surgery time was 300 minutes and intra-operative blood loss was 150cc.
Final pathology reported a pT2N0Mx adenocarcinoma with negative margins and negative pelvic lymph nodes. Patient was started on clear liquids on postoperative day 2 and on regular diet on postoperative day 3. He was discharged on postoperative day 4. A cystogram perfomed on postoperative day 7 revealed a good bladder capacity (350 cc) and no leakage was identified.
Robotic assisted partial cystectomy and urachal resection for urachal adenocarcinoma of the bladder is feasible even in challenging cases. This surgical approach is less morbid in terms of postoperative pain and cosmesis when compared to the open standard approach. The postoperative recovery is faster; however, application of oncological principles and comfort with laparoscopic and robotic surgery is needed prior to attempting such challenging cases. [Video - Available at: www.brazjurol.com.br/videos/september_october_2009/Spiess_609].
标准治疗脐尿管腺癌是开放部分膀胱切除术和脐尿管切除术;然而，微创外科方法，包括腹腔镜和最近描述的机器人辅助腹腔镜部分膀胱切除术和脐尿管切除术是可行的，潜在的发病率较低。本文介绍了一例机器人辅助部分膀胱切除术和脐尿管腺癌切除术。文献中很少有文章描述这种技术，据我们所知，这是此类方法中最大和潜在最复杂的病例。
一名 55 岁的非裔美国男性因血尿和黏液尿就诊，膀胱镜检查显示肿瘤累及膀胱顶部。经尿道活检证实为脐尿管腺癌。进一步研究显示无转移性评估。术前腹部/盆腔 CT 成像显示从脐下水平延伸至膀胱顶部的增强肿块。总共使用了 6 个腹腔镜端口。机器人辅助腹腔镜解剖从脐水平开始，在右侧和左侧中线脐韧带外侧解剖，直到膀胱顶部。同时进行膀胱镜检查和透照，以确定该肿块的膀胱边界，并用机器人辅助腹腔镜打开膀胱，切除整个肿块（包括膀胱成分）并进行冷冻病理检查以评估边缘。标本取出后，膀胱分两层关闭。总手术时间为 300 分钟，术中失血量为 150cc。
最终病理报告为 pT2N0Mx 腺癌，边缘阴性，盆腔淋巴结阴性。患者术后第 2 天开始进流食，第 3 天开始正常饮食。第 4 天出院。术后第 7 天行膀胱造影显示膀胱容量良好（350cc），无渗漏。
即使在具有挑战性的情况下，机器人辅助部分膀胱切除术和脐尿管切除术治疗膀胱脐尿管腺癌也是可行的。与开放式标准方法相比，这种手术方法在术后疼痛和美容方面的发病率较低。术后恢复较快;然而，在尝试此类具有挑战性的病例之前，需要应用肿瘤学原则并熟练掌握腹腔镜和机器人手术。[视频-可在 www.brazjurol.com.br/videos/ 获得：2009 年 9 月-10 月/Spiess_609]。
