title: Simplified laparoscopic radical cystectomy with orthotopic ileal neobladder creation in a porcine model.
abstract: OBJECTIVE
  Laparoscopic radical cystectomy with orthotopic ileal neobladder creation is a technically challenging and lengthy surgical procedure. We present our experience with a simplified technique for laparoscopic cystectomy and neobladder creation in the porcine model.
  
  
  METHODS
  Ten female minipigs underwent a purely laparoscopic radical cystectomy with orthotopic ileal neobladder creation. Nine ureterointestinal anastomoses were performed using a simplified "dunk" technique, where the ureter was prolapsed 5 mm into the afferent limb and the periureteral tissue was secured to the bowel serosa with three superficial sutures. Six ureters were not stented, and three had indwelling stents inserted. In 11 ureters, the anastomosis was performed using a running mucosa-to-mucosa technique (three with stents, eight without stents). The Lapra-Ty suture clip (Ethicon Endosurgery, Cincinnati, OH) was used to secure the running sutures on the urethra, ureters, and neobladder. Animals were harvested at 3 to 8 weeks (mean 6.5 weeks) after surgery. Serology, static cystogram, intravenous urography, and gross and histopathologic evaluations were performed.
  
  
  RESULTS
  Of six unstented dunked ureterointestinal anastomoses, two (33%) were widely patent, two were strictured but patent, and two were completely obstructed. In the three stented ureters implanted using the dunk technique, one (33%) was widely patent, one was strictured, and one was completely obstructed. All ureterointestinal anastomoses performed with a mucosa-to-mucosa running anastomosis, whether stented (three ureters) or not stented (eight ureters), were widely patent. Lapra-Ty clip migration into the neobladder pouch caused urethral obstruction resulting in delayed bladder perforation in two animals.
  
  
  CONCLUSIONS
  Laparoscopic cystectomy and ileal neobladder creation is technically feasible. Attempts to simplify the ureterointestinal anastomosis require further evaluation and modification. Stent placement appears to be unnecessary in the laparoscopic ureterointestinal anastomosis. Laparoscopic creation of the ileal neobladder remains a technically challenging procedure.
authors.affiliation: Department of Urologic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
authors.forename: D Duane
authors.initials: DD
authors.lastname: Baldwin
authors.forename: S Duke
authors.initials: SD
authors.lastname: Herrell
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Dunbar
authors.forename: C
authors.initials: C
authors.lastname: Jung
authors.forename: Amy H
authors.initials: AH
authors.lastname: Nunnally
authors.forename: Richard L
authors.initials: RL
authors.lastname: Roberts
authors.forename: Jeffrey R
authors.initials: JR
authors.lastname: Leach
authors.forename: Dipen J
authors.initials: DJ
authors.lastname: Parekh
authors.forename: Elspeth M
authors.initials: EM
authors.lastname: McDougall
mesh_terms: D000714:Anastomosis, Surgical; D000818:Animals; D015653:Cystectomy / Q000379:methods*; D004195:Disease Models, Animal; D005260:Female; D007082:Ileum / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D020127:Recovery of Function; D013556:Swine, Miniature; D016896:Treatment Outcome; D016476:Urinary Reservoirs, Continent; D014563:Urodynamics