Preoperative Preparation and Planning
There are few differences in preoperative preparation for women facing radical cystectomy compared with men. Prior gynecologic surgery should be noted, and when oncologically sound, discussion regarding vaginal sparing in women who wish to remain sexually active should be undertaken. Detailed preoperative medical evaluation and optimization, counseling regarding urinary diversion together with an enterostomal therapist, comprehensive metastatic evaluation, and mitigation of thromboembolic complications remain important aspects in women. Availability of a sponge stick for intravaginal manipulation during dissection and Babcock forceps for retraction of the uterus are notable additions to the instruments required for radical cystectomy in men. Refer to the Chapter 48 for further details on preoperative planning for radical cystectomy.
Patient Positioning and Surgical Incision
Position the patient with the umbilicus over the break in the table in a hyperextended position using the kidney rest and flexing the table ( Fig. 49.1 ). To permit access to the vagina, the lower extremities are placed in a frog-legged position with the knees well-supported. Alternatively, the patient may be placed into a low dorsal lithotomy position. The skin is prepped from the nipples to the midthigh, including a thorough vaginal prep. After draping the abdomen, including maintaining access to the vagina, insert an 18-Fr urethral catheter. Clip the catheter to the drapes for accessibility throughout the case. A primary right-hand-dominant surgeon should stand on the left side with the assistant on the right. Make a lower midline abdominal incision from the symphysis pubis to just below or lateral to the umbilicus.
Incise the anterior rectus fascia and the transversalis fascia. Bluntly with a Kittner sponge stick but under direct visualization, open the space of Retzius and establish the potential space between the bladder and the pelvic sidewall and the external iliac vessels. Examine the lymph nodes; if concern for disease exists and neoadjuvant chemotherapy has not been given, proceed with lymph node dissection and frozen section. Otherwise, lymph node dissection can be completed after bladder removal.
Incise the peritoneum in line with the abdominal incision. Locate, ligate, and then divide the urachus and incise the peritoneum in a V shape, dissecting the “wings” of the bladder peritoneal attachment. A Kocher clamp on the urachus is useful for traction ( Fig. 49.2 ). Assess mobility of the tumor and bladder (this should have been assessed preoperatively as well via examination under anesthesia and rectal examination). Explore the abdomen, palpating especially the liver and preaortic and pelvic nodes. Release intraabdominal adhesions at this time.
The peritoneum lateral to the bladder is incised, and the round ligament is ligated and divided. The ovarian vessels in the infundibulopelvic ligament are identified, ligated, and divided. Alternatively, these vessels can be controlled with a vessel-sealing device such as the Caiman, LigaSure, or Harmonic ( Fig. 49.3 ).
Mobilization of Bowel and Exposure
Mobilize the sigmoid colon to allow exposure for dissection of the left ureter. The small bowel should then be packed into the upper abdomen using several radiopaque laparotomy towels with a symmetric exposure of the left and right side and sigmoid colon in the middle. The Bookwalter retractor provides excellent exposure. Extensive mobilization of the right colon is not necessary.
Identification of Ureters
A malleable blade can be used to retract the sigmoid colon to either side when identifying and dissecting the ureters ( Fig. 49.4 ). On the right side, the peritoneum is incised parallel to the common iliac vessels, and the ureter is identified as it crosses this structure. The ureter is isolated with a vessel loop and dissected with preservation of as much periureteral tissue as possible to avoid devascularization. Grasping the ureteral tissue with instruments should be avoided. The obliterated umbilical artery or superior vesical artery is encountered as the ureter runs posteriorly. This is ligated to help provide adequate ureteral length, and the dissection is carried to the level of entry into the bladder. The ureter is ligated and divided, avoiding spillage from the bladder.
If desired, frozen section biopsy can be performed. In the setting of small ureters, the distal end can be clipped and tied to allow for some dilatation during the remaining dissection before urinary diversion. A tacking suture should be placed to help with manipulation and to avoid ureteral trauma.
Dissect similarly the left ureter but continue more proximally than on the right. When the dissection has arrived at the bladder, transect the ureter as done previously. Under direct vision, incise the retroperitoneum on each side of the sigmoid colon and establish a generous opening from one retroperitoneal opening to the other coursing under the sigmoid colon and its mesentery. This should be done just anterior to the sacrum and, if cephalad to the bifurcation of the aorta, anterior to the aorta. Place a McDougal clamp or other large curved clamp and bring the ureter to the right side. Be sure that the ureter is not twisted or kinked by the peritoneum or vessels and that it courses in a smooth curve through this passage.
Using anteriorly directed traction on the uterus and concomitant posterior and superior retraction on the rectosigmoid, excellent exposure is provided for incision of the rectouterine pouch and mobilization of vaginal wall off the rectosigmoid colon. The classic anterior pelvic exenteration includes removal of the bladder, uterus, bilateral fallopian tubes and ovaries, anterior vaginal wall, and urethra. A povidone-iodine–soaked sponge-stick is placed in the vagina and pushed into and upward and anteriorly to facilitate identification of the cervix at the vaginal apex. The cervix can usually be easily palpated and using electrocautery; an incision is made into the vagina posterior or below the cervix ( Fig. 49.5 ).