Orthotopic Urinary Diversion in Women

Fig. 3.1

Demonstration of the location of the cather ballon in relation to the pelvic floor and vagina (Courtesy of Siamak Daneshmand, M.D.)

1st: Longitudinal midline abdominal incision between the pubic symphysis and the umbilicus with incision of the fascia and dissection of rectus abdominis muscle.

2nd: Opening of the transversal fascia and blunt dissection of Retzius space to enter the paravesical space bilaterally.

3rd: V-shaped incision of the bladder peritoneum followed by dissection and ligation of the round ligament.
Landmark: Round Ligament
(Info: Preservation of maximal length of the round ligaments for suspension of the vagina later on.)

4th: Continuation of the peritoneal incision along the external and common iliac vessels up to the promontorium.

5th: Performance of pelvic lymphadenectomy up to the crossing of the ureters with common iliac vessels.
Landmark: Ureter
(Info: In case of normal findings on cross-sectional imaging lymph node dissection in the presacral region is discouraged to avoid injury of autonomous nerve fibers which traverse along the interval iliac artery and its branches to the cervix and vaginal walls [ 23 ]).

6th: Lateral division with identification of the ureters at their crossing with the common iliac vessels.
(Info: In order to preserve blood supply to the ureters, their fascial sheet should stay intact. This can be achieved by mobilization of all the tissue adjacent to the peritoneum toward the ureter.)

7th: Preparation of the ureters toward the bladder and ligation ca. 2–3 cm proximally to the ureteral orifice. A circumferential biopsy of both ureteral stumps should be sent to frozen section analysis [21].
(Info: Clipping of distal end of ureters results in temporary hydrodistention which facilitates ureteroileal anastomosis later on.)

8th: Ligation of the anterior pedicles as distally as possible (if oncologically possible) to minimize dissection of neurovascular structures with traverse along the branches of the internal iliac artery.
Landmark: Sacrouterine Ligament

9th: Identification of the lateral vaginal walls and posterior vaginal fornix.
(Info: Compression of the posterior vaginal fornix by an intravaginally placed curved sponge facilitates its anatomical identification.)

Landmark: Cul-de-Sac
10th: Identification and incision of the vaginal fornix at the level of cul-de-sac.

Info: Compression of the posterior vaginal fornix by an intravaginally placed curved sponge facilitates its anatomical identification (Fig. 3.2).

Fig. 3.2

View at the vaginal fornix after incision at the level of cul-de sac (Courtesy of Siamak Daneshmand, M.D.)

11th: Opening of the posterior vaginal fornix and identification of the cervix (Fig. 3.3).
Landmark: Cul-de-Sac and Cervix

Fig. 3.3

This illustration shows the cervix and opened vaginal apex during dissection of the lateral vaginal wall (Courtesy of Siamak Daneshmand, M.D.)

12th: Continued dissection of the anterior from the lateral vaginal walls.
(Info: Identification and separation of the lateral vaginal walls from the bladder wall can be facilitated by continuous digital replacement of the catheter balloon during dissection. Ligation and dissection of the lateral from the anterior vaginal wall using hook clamps are preferred; electrocautery should be avoided whenever possible as it may result in damage of autonomic nerve fibers.)

13th: When dissection of the anterior vaginal wall has reached the bladder neck on both sides, a hook clamp is introduced posteriorly to the bladder neck and gently crossed to the opposite side.
(Info: Retraction of balloon catheter toward distal aids in the identification of the bladder neck.)

14th: Transverse transection of the distal end of the anterior vaginal wall.
(Info: A distance of at least 1.5–2 cm proximal to the level of urethral dissection should be met in order to prevent overlapping of the suture lines and decrease the risk of a neobladder-vaginal fistula formation. In vaginal-sparing cystectomy, the bladder is carefully separated from the anterior vaginal wall after opening the posterior vaginal fornix ( Fig. 3.4 ).)

Fig. 3.4

Intrapelvic view demonstrating the level of urethral and anterior vaginal dissection. Please note anatomical distance between the two levels (Courtesy of Siamak Daneshmand, M.D.)

15th: Visualization of the endopelvic fascia.
(Info: Dissection should be avoided below the level of the endopelvic fascia.)

16th: Ligation of the pubovesical complex by passing a clamp underneath the plexus and anteriorly to the urethra.

17th: Sharp dissection of the pubovesical complex from the bladder neck. Now the anterior aspect of the bladder neck and urethra can be visualized.

18th: Removal of the catheter slowly in order to accurately identify the transition area between the bladder neck and urethra.

19th: A smooth clamp is placed at the level of urethral dissection and the procedure completed by sharp dissection of the anterior and posterior urethra (Fig. 3.5).
(Info: A full-thickness biopsy of the urethra should be sent to frozen section analysis.)

Fig. 3.5

Longitudinal view on the en bloc specimen comprising bladder, uterus, anterior vagina, ovaries and fallopian tubes (Courtesy of Siamak Daneshmand, M.D.)

20th: Closure of the anterior vaginal wall is performed initially by anchoring the long remnants of the round ligaments to the most lateral aspect of the vaginal opening.
(Info: This approach suspends the vaginal neofornix cranially and serves as anchoring point for the omental flap which will be placed later on onto the anterior vaginal wall to prevent backfall of the reservoir.)

21st: The vagina is closed symmetrically in a traverse manner using locked polyglactin sutures.
(Info: This technique will avoid narrowing the vaginal lumen and decrease the risk of postoperative dyspareunia.)

22nd: Isolation of an adequate ileal length with ileoileal anastomosis and formation of an I-Pouch neobladder reservoir (or creation of other ileal neobladder reservoirs according to other techniques [24–28]).

23rd: Mobilization of an omental flap (if available) along the left paracolic trough into the pelvis with fixation to the round ligament and anterior vaginal wall.
(Info: Preservation of vascular supply of the omental flap is mandatory.)