This radical cystectomy (RC) section is restricted only to those parts that are essential for good function of the neobladder.

Modifications of pelvic lymphadenectomy and the approach to the pelvic ureter are made to allow for optimum ileal neobladder construction (1,2,3,4). Pelvic lymphadenectomy and RC are performed according to standard technique with modifications. Ideally, the ileal neobladder anatomically replaces the native bladder (i.e., it is located extraperitoneally in the pelvic cavity) and ileourethral anastomoses are located also extraperitoneally. Depending on tumor stage and location, this goal can be easily achieved by the creation of two large peritoneal flaps obtained from the visceral pelvic peritoneum (Fig. 79.1).

The standard vertical incision lateral to the sigmoid mesocolon should not be used. The peritoneal sac should be mobilized medially on both sides. The surgeon should continue to locate the ureter extraperitoneally, realizing that it is displaced during exposure because it adheres to the peritoneum (see Fig. 79.1).

The ureters are mobilized with sufficient periureteral adventitia in a cephalad direction on both sides. A plane is established between the ureter and the lateral pedicles of the bladder. As the ureter and bladder are retracted medially, the lateral pedicle is exposed. Finally, the ureter is clamped distally. Fine-traction sutures are inserted in the proximal surface of the ureter, and it is divided against the clamps with scissors. Then, the ureter is dissected proximally so that not more than 3 to 6 cm are free.

Depending on tumor stage and location, the bladder is completely extraperitonealized, and the peritoneum is bisected over the bladder (see Fig. 79.1). If this cannot be done safely, an incision in the peritoneum is made high on the base of the bladder, leaving a peritoneal patch on the posterior bladder wall.

Special details other than those described in Chapter 19 (RC in men) and Chapter 20 (RC in women) that are critical for a perfect outcome including preservation of the erectile function are presented here.

We describe a new technique for nerve-sparing RC and orthotopic diversion with preservation of the vasa deferentia, seminal vesicles, and neurovascular bundles (NVBs). No prostatic tissue is left behind, thus eliminating the risk of local recurrence from bladder cancer as well as de novo prostate cancer (5).

RC is begun with an intrafascial prostatectomy, which is done in a retrograde fashion. For optimal protection of the NVB and to avoid damage to the autonomic nerves running into the membranous urethra, a “high-release” approach with incision of the endopelvic and periprostatic fascia and bunching of Santorini plexus at the level of the prostate and not distal to it is of utmost importance (Figs. 79.2 and 79.3). The dorsolateral NVB can be separated from the prostatic capsule, or the prostatic capsule can be left in place. The prostatic apex is approached laterally directly along the prostatic capsule, and the membranous urethra is delivered sharply out of the donut-shaped prostatic apex to avoid nerve damage on the dorsolateral side of the urethra and to maintain maximum urethral length.

Despite the intrafascial approach, Denonvilliers fascia very often remains on the posterior surface of the prostate specimen where it is fused with the prostatic capsule in the midline. At the base of the prostate, a 2- to 3-cm transverse incision of Denonvilliers fascia is carried out, and both the vases and the seminal vesicles are transected (Fig. 79.4). A cleavage plane is easily developed anterior to the ampullae/seminal vesicles and dorsal to the trigone. The balloon of the transurethral catheter serves a control because it is easily palpated. In this fashion, most of the NVB are spared. The ascending cleavage plane easily reaches the cul-de-sac, with the inferior bladder pedicles still intact.

The remainder of the RC can be done in an ascending or descending fashion. The latter seems to offer better control of the bundles. The vases are identified and left on the pelvic peritoneum. The peritoneum is incised transversely 5 cm anterior to the cul-de-sac. Care is taken to enter the plane between posterior bladder wall ventrally and the vases and seminal vesicles dorsally (Fig. 79.5).

This is absolutely critical if an orthotopic neobladder is considered. Helpful tricks are as follows: Preparation of the urethra requires special attention to surgical detail to avoid damage to the proximal urethra, anterior vaginal wall, urethral support, and NVB, which could jeopardize the continence mechanism and micturition. This is particularly true when a nerve-sparing approach is planned (2).

This step is greatly facilitated when a povidone-iodine pack is placed into the vagina and the urethra rides on top of the
anterior vaginal wall (Fig. 79.6). It is not sufficient just to put sponge stick into the vagina. Packing the vagina snugly has four distinct advantages:

The endopelvic fascia is incised immediately lateral to the posterior urethra at the urethrovesical junction (Fig. 79.7). As much of the urethra at the urethropelvic ligament and paraurethral vascular and nerve plexus as possible must be saved.

The proximal urethra is carefully (little sponge stick) prepared. Most surgeons do not transect the urethra, but the bladder neck, assuming that the external sphincter mechanism is located in the proximal urethra. However, this is not the case. An extraordinary helpful trick to find the correct site for urethral transection is to inflate the balloon of the transurethral catheter to 50 mL, pull it into the bladder outlet, and to ligate proximal urethra and catheter before transection (Fig. 79.8).

As the proximal urethra is transected, six interrupted 2-0 polyglycolic acid sutures are placed circumferentially in the urethra (Fig. 79.9). Frozen sections for pathologic examination are taken from the urethra/bladder neck to identify carcinoma in situ or overt carcinoma, which would result in subsequent urethrectomy.