Ileal Neobladder

Ileal Neobladder



Cystectomy (Radical Cystectomy)

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).

Ureteral Mobilization

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).

FIGURE 79.1 Modified pelvic lymph node dissection has been completed. Ureters are exposed extraperitoneally. The peritoneum over the bladder is bisected to create two large peritoneal flaps for later total extraperitonealization of the ileal neobladder.

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.

Approach to the Membranous Urethra in the Male Patient

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.

FIGURE 79.2 Standard dissection laterally to the prostatic fascia to free the NVBs from the prostate and the lateral surface of the seminal vesicles carries a high risk to ruin the erectile function by injuring these nerves.

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).

Approach to the Female Urethra

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).

FIGURE 79.3 The radical cystectomy is begun as a standard nervesparing radical prostatectomy, with high release of the NVBs. Gentle traction is exerted on the balloon catheter to extrude the vesical neck. Denonvilliers fascia is opened with a short transverse incision over the ampullae of the vases and the base of the vesicles. After transection of vesicles and ampullae, an easy cleavage plane is developed between the trigone and catheter balloon anteriorly and the vesicles posteriorly until the cul-de-sac has been reached.

FIGURE 79.4 Posterior view. The plane anterior to seminal vesicles/ampullae of the vases and dorsal to the prostate has been developed. The posterior pedicle of the bladder is transected 3 cm ventral to the NVBs.

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:

FIGURE 79.5 Final situation. NVBs covered and protected by seminal vesicles.

FIGURE 79.6 Packed vagina gives ideal exposure to urethra and pelvic support structures.

  • The firm urethra is palpable at all times.

  • The urethra is lifted out of the depth of the pelvic cavity into the center of the operative field.

  • The NVBs slip downward and are no longer at risk.

  • The urethra (catheter) rides on top of the vagina and is visible and palpable at all times.

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.

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Apr 24, 2020 | Posted by in UROLOGY | Comments Off on Ileal Neobladder

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