Male

Bladder cancer is more common in males, and as a result 75% to 80% of all radical cystectomies are performed in male patients. A similar technique of LRC with minor modifications has been reported in various initial series . LRC is performed transperitoneally, with four to five ports placed in a peri-umbilical fan arrangement across the lower abdomen, with a possible sixth port in the suprapubic area ( Fig. 1 ). The camera port is placed two fingerbreadths above the umbilicus, but may be moved to just below the umbilicus in large patients; this supra-umbilical camera position facilitates performance of the high-extended lymphadenectomy up to the inferior mesenteric artery. Although surgery can be performed in the supine position, a low lithotomy is preferred to allow access to the rectum and allow perineal pressure as needed during the urethral anastomosis in an orthotopic reconstruction. A steep Trendelenburg position is essential to keep the bowel out of the pelvis during surgery.

Port placement. ( Courtesy of the Cleveland Clinic Foundation, Cleveland, Ohio; with permission.)

Surgery usually starts by visualizing the pelvis and releasing adhesions of the sigmoid colon to the pelvic side wall, which are present in almost all cases. This mobilization of the sigmoid allows retraction out of the pelvis and identification of the left ureter, and assists in the subsequent lymphadenectomy. If the sigmoid continues to fall into the pelvis, it can be held in place by a suture placed through an appendix epiploica and held to the abdominal wall. At this time, the major landmarks in the pelvis should be visualized; these are the ureters, medial umbilical ligaments, vasa deferentia, and the urachus. The tip of the urethral catheter frequently is seen in the bladder dome also.

Important planes of dissection for radical cystectomy are the posterior plane between the seminal vesicles and prostate anteriorly, and the rectal wall posteriorly, as well as the lateral plane, between the bladder within the perivesical fat and the pelvic side wall including the iliac vessels, obturator fossa, and pelvic floor muscles. These planes are generally avascular; understanding and meticulously developing and following them are essential for a technically and oncologically sound operation.

The posterior plane usually is developed first, keeping the bladder attached to the anterior abdominal wall to allow exposure ( Fig. 2 ). The ureters can be dissected and mobilized distally towards the bladder before or after opening the posterior plane. This plane is entered by dividing the peritoneum of the recto–vesical pouch a little higher than its lowest point. Following the vas deferens medially can facilitate identifying this plane in difficult cases. The tips of the seminal vesicles are visualized easily, and keeping the seminal vesicles anterior, the plane is developed distally towards the prostate ( Fig. 3 ). Denonvillier’s fascia is encountered at the level of the prostate–vesicular junction posteriorly. This fascia needs to be divided sharply, allowing the posterior plane to be developed further distally between the prostate and the anterior rectal surface ( Fig. 4 ). Extreme care should be exercised at this time to avoid injuring the rectum, which lies in an oblique, rather than transverse plane in this area.

Pelvic peritoneotomy incision. The initial peritoneotomy incision is made posteriorly, deep in the cul-de-sac, staying posterior to the seminal vesicles and vas. Dotted line indicates the ultimate peritoneotomy required as the operation proceeds. ( Courtesy of the Cleveland Clinic Foundation, Cleveland, Ohio; with permission.)

Posterior dissection. Developing the posterior plane and the right postero–lateral vesicle pedicle. ( Courtesy of the Cleveland Clinic Foundation, Cleveland, Ohio; with permission.)

Incising Denonvillier’s fascia. ( Courtesy of the Cleveland Clinic Foundation, Cleveland, Ohio; with permission.)

If the ureters have not been mobilized previously, they should be at this time. Proximal dissection to a level above the iliac vessels greatly facilitates the subsequent lymphadenectomy and the urinary diversion. The ureters are divided distally close to the bladder between clips, and the distal ureter margin is sent for frozen section pathological examination.

The lateral planes then are developed. This is done easiest by dividing the peritoneum over the obliterated medial umbilical ligaments until the anterior abdominal wall. The vas deferens is encountered commonly at this time and can be divided also. The lateral plane is identified readily lateral to the ligament, which is retracted medially. This plane is developed distally into the pelvis until the pelvic floor muscle and the endopelvic fascia is reached. The reflection of the endopelvic fascia over the prostate can be divided at this time or left for a later stage in the operation.

The posterolateral bladder pedicles thus are exposed between the posterior and lateral planes. These pedicles are sometimes separable into a lateral and posterior portion (with the ureter between the two), or in some thin patients may be one posterolateral attachment. The superior and inferior vesical vessels course with the lateral portion of the pedicle, and accordingly, the pedicles usually are divided with a laparoscopic linear stapler ( Fig. 5 ). Other energy-based coagulating instruments or clips can be used also. These pedicles are followed to the level of the pelvic floor, or if the endopelvic fascia has been opened, along the side of the prostate as distally as the apex of the prostate.

Transecting the right posterior pedicle using the endo-GIA stapler. ( Courtesy of the Cleveland Clinic Foundation, Cleveland, Ohio; with permission.)

After the posterior and lateral bladder attachments are freed, the bladder is mobilized from the anterior abdominal wall, including a triangle of peritoneum with the urachus to the umbilicus ( Fig. 6 ). The pubic bones are exposed, the space of Retzius developed, and the puboprostatic ligaments exposed. The superficial branch of the dorsal vein is coagulated and divided. The endopelvic fascia is opened on both sides of the prostate at this time if not previously opened; the pelvic floor muscles are swept off the sides of the prostate, exposing the apex, urethra, and sides of the dorsal vein complex. The dorsal vein can be controlled by various techniques ( Fig. 7 ). The authors commonly utilize a laparoscopic GIA stapler to control the well-mobilized complex, although a controlling stitch can be placed across the dorsal vein. Coagulating instruments like bipolar electrocautery also can be used, although they are less reliable. After the puboprostatic ligaments and the dorsal vein complex are divided, the urethra comes into view. The attachments of the prostatic apex to the pelvic floor are released, and the urethral catheter can be removed at this time. A locking clip or a suture should be placed at the proximal urethra to prevent tumor spillage from the bladder, and the urethra is divided. Proximal traction on the prostatic apex allows the final attachments of the prostate to the anterior rectal surface (rectourethralis muscle) to come into view; these are divided carefully, and the specimen is placed in an impermeable laparoscopic retrieval sac, which is placed out of the pelvis to allow subsequent inspection, hemostasis, and lymphadenectomy.

Anterior dissection. The triangular inverted V peritoneotomy is created and space of Retzius entered. ( Courtesy of the Cleveland Clinic Foundation, Cleveland, Ohio; with permission.)

Completing the prostate apical dissection. Transection of the dorsal vein complex and urethra. The specimen side of the transected prostate apex is secured with a stitch or clip to eliminate local spillage of urine from the bladder. ( Courtesy of the Cleveland Clinic Foundation, Cleveland, Ohio; with permission.)

Female

LRC in the female usually involves an anterior exenteration with en bloc resection of the bladder, uterus, fallopian tubes, and ovaries. The authors’ technique in females starts similar to a laparoscopic cystectomy in the male, with identification of the ureters and dissection into the pelvis. The ovarian vessels are divided in the infundibulopelvic ligaments, allowing the ovaries to be mobilized into the pelvis. The bladder is mobilized laterally in the same manner as in males, using the obliterated medial umbilical ligament as a guide, and dividing the round ligament of the uterus in the process. The endopelvic fascia is visualized, although it does not need to be divided in the female. Anterior retraction of the uterus is very helpful, and facilitates identification of the posterior and posterolateral structures. This can be accomplished with a laparoscopic instrument held by an assistant, or by various instruments that can be placed vaginally and used to manipulate the uterine cervix. A good example is the RUMI uterine manipulator with the Koch colpotomizer system (Cooper Surgical, Trumbull, Connecticut). The posterolateral bladder pedicles are identified; these include the uterine vessels and are controlled with a linear stapler.

The posterior fornix is identified with a sponge stick placed in the vagina, and the vagina is opened close to the cervix. The vaginal incision is continued around the cervix, and distally along the anterior vaginal wall. The vaginal wall is well-vascularized, and various cutting/coagulating instruments (eg, Harmonic scalpel, Ligasure) are especially useful for this part of the procedure. As the bladder neck area is reached, this dissection can proceed closer to the urethra, which is removed in its entirety. If an orthotopic neobladder is planned, the dissection ends at the bladder neck; the urethra is transected at the bladder neck, and the bladder neck is sutured closed immediately to prevent spillage. The distal dissection of the bladder neck and urethra can be performed vaginally, and the specimen can be removed from the vaginal incision (useful in cases where intracorporeal diversion is planned). The vagina then is closed with a continuous Vicryl suture. The distal part of this closure also can be performed vaginally according to surgical preference.