Preoperative Preparation and Planning
Partial cystectomy may be a viable treatment option for select urothelial carcinomas, urachal adenocarcinomas, and certain benign tumors. Paramount to the use of this technique is appropriate patient selection and, in the case of malignancy, care taken to use partial cystectomy only in cases when oncologic efficacy is not compromised in comparison with radical surgery. Essential to proper patient selection is a consideration of tumor characteristics, histology, the health of the remaining bladder urothelium, and the feasibility of resection with adequate negative margins. To provide appropriate counseling, certain functional characteristics require elucidation preoperatively, including an assessment of functional bladder capacity, an estimation of postoperative capacity, and a determination of coexisting urinary urgency or urinary incontinence.
As with any tumor, appropriate staging must be performed. In the case of urothelial carcinomas, this should include thorough assessment of the local and distant stage. Most commonly, this is accomplished via cross-sectional imaging through computed tomography of the abdomen and pelvis with the aid of contrast to evaluate for nodal spread and inclusion of delayed films to adequately assess the upper urinary tract. Chest imaging, either with cross-sectional imaging or conventional plain films, is needed to rule out distant metastatic disease. Local clinical T-staging remains the jurisdiction of a well-trained urologist because cross-sectional imaging is notoriously inaccurate in the elucidation of tumor depth. For an adequate assessment of the clinical T-stage, a complete endoscopic evaluation with a note of size, location, and health of the remaining urothelium is necessary. To accomplish this, certain useful guides can be used. First, the standard loop used for most cases measures 8 to 10 mm from left to right and can serve as a guide when measuring the tumor. Additionally, so-called cold-cup biopsies of the distant urothelium serve to rule out carcinoma in situ (CIS) in cases of high-grade urothelial cancer. The presence of CIS is a contraindication to partial cystectomy. Additionally, when noting the location of the tumor, proximity to the bladder neck and ureteral orifices is vital to ensure a 1- to 2-cm margin or normal-appearing tissue can be obtained at the time of partial cystectomy. For tumors in close proximity to a ureteral orifice, a ureteral reimplantation may be necessary in conjunction with partial cystectomy. Although there is some controversy regarding the risk of local recurrence in these patients, it is the opinion of these authors, based on available data, that partial cystectomy should be avoided in cases in which a ureteral reimplantation would be necessary to ensure oncologic efficacy. Last, with the bladder emptied, an examination under anesthesia should be performed after the tumor has been resected to visual completion to ensure a lack of palpable mass (clinical stage T3b), another contraindication to partial cystectomy.
Functional considerations should also be elucidated in the clinical setting. Clinicians should question prospective patients regarding voiding habits, frequency, urgency, and for the presence of urinary incontinence. Additionally, preoperative capacity should be assessed to establish a baseline from which the patient can expect a reduction and in cases of severely diminished capacity a partial cystectomy should be avoided. Voiding diaries can be particularly helpful in addition to invasive and noninvasive clinic testing (e.g., urodynamic testing and pressure flow studies).
Proper patient counseling should highlight the possibility of impact on urinary function, bother, and the possibility of persistent urgency and diminished capacity. Bladder augmentation at the time of partial cystectomy with a concurrent enterocystoplasty can also be discussed (it is the opinion of these authors that enterocystoplasty in the setting of urothelial malignancy is ill advised), and all patients should be made aware of the possibility of radical cystectomy and make a choice of urinary diversion for this possibility. Routine considerations to preoperative clearance and preparation should be used and specific considerations made according to urinary diversion preference if a radical cystectomy becomes necessary. Routine bowel preparation is not necessary, and enhanced recovery pathways should be used whenever possible.
Patient Positioning and Surgical Incision
As discussed earlier, despite a plan for partial cystectomy, both the patient and surgeon should be prepared for a possible radical cystectomy. As such, patient positioning is optimized for possible radical resection rather than the ideal scenario of a noncomplicated partial cystectomy. We recommend the following for an open partial cystectomy:
Male patients: The patient is positioned supine with the pubic symphysis aligned just below the flexion point of the bed. To aid in visual access to the pelvis, flex the bed approximately 5 to 10 degrees and adjust with either Trendelenburg or reverse Trendelenburg positioning to achieve a level lower abdominal wall. A raised kidney rest can also be used to provide lumbar support if needed. Alternatively, some surgeons prefer to have access to the perineum to apply pressure during apical prostatic dissection or urethral anastomoses (in the case of orthotopic diversion). In this setting, stirrups or spreader bars can be used according to surgeon preference. If this is the case, the patient should be positioned such that he is at the end of the bed without overhanging the edge. For most operative beds, flexion is not possible in conjunction with stirrups or spreader bars.
Female patients: As with male patients, female patients should be approached as if a radical cystectomy may be necessary. As such, access to the vaginal introitus is needed. This can be achieved with either stirrups or spreader bars and the patient positioned as discussed earlier.
Consideration to the location of the mass aids in determining which surgical approach, preperitoneal or transperitoneal, will be best suited to the patient. Specifically, a transperitoneal approach should be used when a tumor lies near or adjacent to the peritoneally lined posterior wall of the bladder. Regardless of peritoneal approach, after a Foley catheter has been placed sterilely and accessibly on the operative field, a longitudinal midline incision extending from cephalad margin of the pubic symphysis to the level of the umbilicus should be made ( Fig. 47.1 ). Alternatively, the cephalad extent of the incision may be shortened initially and extended according to need.
For the purposes of this chapter, only open partial cystectomy will be discussed, although minimally invasive techniques can be used for these patients. Please see the appropriate chapters for techniques and approaches to minimally invasive bladder surgery. In the case of open partial cystectomy, after skin and subcutaneous tissue is dissected and the anterior abdominal wall fascia identified, the umbilicus can be grasped and lifted toward the ceiling to aid in the identification of the linea alba. The fascia is then incised in the midline, and the preperitoneal space of Retzius entered. When dissecting through the linea alba, care should be taken to ensure this is done in the midline; if not, inadvertent injury to the rectus abdominis and release at the tendinous insertion can occur. When in the space of Retzius, blunt dissection is carried out to separate the bladder from the pelvic sidewall and anterior abdominal wall. Self-retraining or fixed retractors can be used according to surgeon preference. The abdominal wall should be adequately protected and care taken to ensure vital structures (e.g., external iliac artery/vein) are not entrapped.
In cases in which transperitoneal exposure is needed, the peritoneum is incised lateral to the lateral umbilical fold (≈1–2 cm lateral to the medial umbilical ligament) on both sides. After this is done, the urachus can be controlled and ligated close to the umbilicus and according to surgeon preference (e.g., vessel-sealing bipolar electrocautery or suture ties). In cases where an en bloc umbilectomy is oncologically indicated the urachus and umbilicus should be maintained in continuity. In a fashion analogous to a radical cystectomy, the peritoneum lateral to the lateral umbilical fold can be incised farther posteriorly to achieve adequate mobility ( Fig. 47.2 ). Additionally, the vas deferentia or round ligaments can be ligated at the level of the internal inguinal ring to further aid mobility. A discussion of this possibility and the resultant effects on fertility should occur preoperatively.