8
Radical Cystectomy (Female)

Indications

• Invasive urothelial cell carcinoma, primary intravesical squamous cell, bladder adenocarcinoma or sarcoma, refractory bladder carcinoma in situ
• Intravesical extension of tumors from adjacent organs precluding bladder preservation
• Persistent refractory intravesical bleeding (rare)

Essential Steps

1. Explore the pelvis to assess bladder mobility, and the abdominal contents for visible or palpable metastatic disease.
2. Properly pack the bowel to optimize exposure.
3. Perform a thorough bilateral pelvic lymph node dissection.
4. Identify the ureters at their crossing over the common iliac arteries and carefully dissect them distally, preserving the periureteral tissue.
5. Ligate the lateral and posterior vascular pedicles to the bladder and mobilize the bladder caudally.
6. Incise the posterior vaginal wall and develop a plane between the vagina and anterior rectum. During dissection of the anterior vaginal wall, it is important to achieve meticulous hemostasis to avoid bleeding from its rich vascular plexus.
7. Dissect the entire urethra (transvaginally). In patients undergoing an orthotopic diversion, the anterior vaginal wall and urethra should be preserved and dissection in those areas limited to avoid injury to the rhabdosphincteric mechanism.
8. Remove the bladder, uterus, cervix, anterior vaginal wall, and urethra en bloc and obtain meticulous hemostasis.
9. Perform a urinary diversion.

Note These Variations

• Preoperative bowel preparation and oral antibiotics varies by surgeon preference and institutional guidelines.
• The timing of the lymph node dissection within the procedure, and extent of the dissection, may vary by surgeon preference and patient disease.
• If the reason for the cystectomy is refractory vesical bleeding, a pelvic lymphadenectomy is not routinely performed.
• The lymph nodes may be removed and sent separately based on their anatomic origin, rather than as one packet from each side. This will allow for a more thorough histologic lymph node evaluation.
• In the case of an invasive posterior bladder wall tumor involving the vagina, the anterior vaginal wall should be removed en bloc with the bladder. This may restrict appropriate vaginal reconstruction and subsequent sexual function.

Complications

• Bleeding
• Infection
• Ileus/bowel obstruction/leak
• Ureteral injury/obstruction
• Urine leak/urinoma
• Intraabdominal organ injury
• Nerve injury
• Lymphocele

Template Operative Dictation

Preoperative diagnosis: Bladder cancer

Postoperative diagnosis: Same

Procedure: Anterior pelvic exenteration

Indications: The patient is a ____ ‐year‐old female with clinical stage T___ urothelial cell/squamous cell/adeno carcinoma of the bladder presenting for an anterior pelvic exenteration.

Description of Procedure: The indications, alternatives, benefits, and risks were discussed with the patient and informed consent was obtained.

The patient was brought onto the operating room table, positioned supine, and secured with a safety strap. Pneumatic compression devices were placed on the lower extremities.

After the administration of intravenous antibiotics and initiation of general endotracheal anesthesia, the patient was positioned with the break just above the anterosuperior iliac spine, and the operating table flexed 15°. The lower extremities were placed in low (Allen) universal stirrups. The lower chest, abdomen, genitalia, and upper thighs were prepped and draped in the standard sterile manner.

The radiographic images were in the room.

A time‐out was completed, verifying the correct patient, surgical procedure, and positioning, prior to beginning the procedure.

A 20 Fr urethral catheter was inserted into the bladder and connected to a drainage bag.

A midline abdominal incision was made 3 cm above the umbilicus and carried down to the pubic symphysis. The subcutaneous tissue was incised with electrocautery, exposing the underlying rectus abdominis aponeurosis. This was incised at the linea alba and the rectus abdominis muscles separated at the midline and retracted laterally, taking care not to injure the underlying inferior epigastric vessels.

The space of Retzius was developed by sweeping the infrapubic space posterolaterally and mobilizing the peritoneum cranially on both sides along the pelvic sidewall. Blunt dissection was used to expose the endopelvic fascia inferiorly and the obturator nerve and vessels, posteriorly. The bladder was carefully palpated and noted to be mobile without any fixation to the pelvic sidewall or adjacent organs. The round ligaments were ligated and divided to facilitate mobilization of the peritoneal sac, and the peritoneum was entered above the umbilicus. A systematic intraabdominal exploration was performed. There was no evidence of hepatic metastases or retroperitoneal lymphadenopathy.

The urachus was ligated with a 2‐0 silk tie and divided, and the peritoneum incised obliquely on both sides of the bladder in a V‐configuration, lateral to the medial umbilical ligaments. The ascending and descending colon were mobilized along the white line of Toldt, and the root of the small bowel mesentery dissected off the retroperitoneum providing sufficient cephalad bowel mobility. The bowel was thoroughly covered with three moistened open laparotomy pads, and a moist rolled towel placed horizontally at the base of the covered bowel. A self‐retaining retractor (e.g. Bookwalter, Omni‐Tract, Balfour) was appropriately positioned to optimize exposure, using padding on each retractor blade.

The iliac vessels were exposed from just above the common iliac bifurcation to the femoral canal, and the perivascular fibroareolar sheath carefully opened over the external iliacs. The lymph nodes appeared unremarkable/enlarged/matted on palpation. The nodal tissue was circumferentially swept off the left/right external iliac vessels, using electrocautery and surgical clips to secure the lymphatic channels. The left‐/right‐sided lymphadenectomy was completed with the limits of dissection being the genitofemoral nerve laterally, the ureter medially, the common iliac artery bifurcation cranially, the endopelvic fascia caudally (node of Cloquet) and the obturator nerve inferiorly. The entire nodal package was removed en bloc and sent to pathology for evaluation. Meticulous hemo‐ and lymphostasis were achieved with surgical clips and electrocautery.

An identical lymph node dissection was performed on the contralateral side, completing the lymphadenectomy.

The ureters were identified bilaterally at the common iliac bifurcation, circumferentially dissected and encircled with vessel loops. Ureteral dissection was continued distally to the ureterovesical junction, ligating the obliterated umbilical artery and superior vesical pedicle. Each ureter was mobilized cephalad, leaving the lateral periureteral tissue intact to avoid vascular compromise. Hemostasis was achieved with electrocautery.

The ureters were individually clipped and divided at the level of the ureterovesical junction, and the distal stumps ligated with a 2‐0 silk suture. The distal ureteral margins were sent for frozen section section. Each ureter was tagged with a long 3‐0 chromic suture, covered with a moist sponge and placed craniolaterally in the retroperitoneal space.

Using gentle anterior traction on the cut urachus for exposure, the right/left lateral vascular pedicles to the bladder were sequentially ligated and divided using an endovascular stapler. The identical procedure was performed on the contralteral side.

The infundibulopelvic ligaments were identified, clamped, suture ligated with 1‐0 polyglactin (Vicryl) and divided, freeing the fallopian tubes and ovaries. An Allis clamp was placed on the uterine fundus, which was retracted anterocaudally, exposing the peritoneum posterior to the bladder. This was incised transversely and a plane developed within the pouch of Douglas, using sharp and blunt dissection to separate the bladder from the rectum. The bladder was further mobilized caudally exposing the posterior vascular bladder pedicles and cardinal ligaments on each side, which were individually ligated and divided with the endovascular stapler.

An intravaginally placed povidone−iodine (Betadine)‐soaked sponge stick was used to identify the apex of the vagina, which was opened posteriorly distal to the cervix. The anterior vaginal wall was sharply dissected off the bladder to the level of the bladder neck and circumferentially excised from its cervical attachments. Vaginal reconstruction was accomplished with a horizontal closure using a running 1‐0 Vicryl suture, and the vaginal wall was suspended from Cooper's ligament to prevent subsequent prolapse.

The bladder was displaced posteriorly and the pubourethral suspensory ligaments identified, carefully dissected and divided, exposing the dorsal vein complex. This was ligated with a running 2‐0 Vicryl suture and the underlying urethra freed.

Attention was directed at the external genitalia. A weighted vaginal speculum and labial traction sutures were placed to facilitate exposure. A circumferential full‐thickness perimeatal incision...