Preoperative Preparation and Planning
Timely diagnosis and prompt surgical treatment are paramount in the management of muscle invasive bladder cancer (MIBC), and a delay in either diagnosis or radical cystectomy (RC) is known to adversely impact outcomes. Many patients today receive neoadjuvant chemotherapy (NAC), which should be considered during preoperative planning given the potential for treatment related side effects. A thorough metastatic workup and medical evaluation, bearing in mind nutrition, age, and performance status, is necessary before proceeding with RC. Adherence to practice guidelines and surgical pathways has improved outcomes.
Metastatic evaluation includes careful pelvic clinical examination, routine blood work, and radiographic studies of the chest abdomen and pelvis, with upper tract evaluation. Results of serum studies, including complete metabolic panel, complete blood count, and coagulation parameters, may influence surgical planning. Both computed tomography (CT) and magnetic resonance imaging (MRI) are acceptable, and ongoing studies are evaluating the role of positron emission tomography (PET) imaging to evaluate for metastatic disease. If hydronephrosis is present, stent placement or nephrostomy tube drainage may be required, especially in the setting of renal insufficiency. In patients without skeletal symptoms and normal alkaline phosphatase, a bone scan is not necessary because the likelihood of bony metastatic disease is low. In the setting of preexisting gastrointestinal disease, including any suspected adenocarcinoma, a colonoscopy should be performed, especially if large bowel will be used for the diversion.
The morbidity associated with radical cystectomy necessitates preoperative medical preparation, including optimizing nutritional status, which has been shown to impact the risk of morbidity and mortality after cystectomy. Nutritional parameters that influence outcomes include preoperative albumin, body mass index, and preoperative weight loss. Prospective studies evaluating accurate nutritional assessment and optimization to improve RC outcomes are ongoing.
Bladder cancer primarily affects older patients, and as the population ages, urologists are increasingly treating older, comorbid patients. Concern regarding the impact of advanced age on postcystectomy morbidity and mortality has prompted numerous studies evaluating outcomes in the older adults. Results demonstrate that the older adult population does not necessarily experience a significantly higher rate of major or minor complications, perhaps because of better patient selection or enhanced patient care. Until a clear age cut point is established, RC should remain the standard of care for MIBC, and age alone should not preclude appropriate surgical therapy.
In addition to age, parameters such as frailty and performance status have been used to evaluate fitness for surgery. Patients with increased frailty based on validated scoring systems and diminished performance status have been shown to experience a statistically significant increase in perioperative complications and mortality. It is imperative to consider an individual patient’s ability to tolerate such a potentially morbid procedure.
Existing guidelines and practice statements dedicated to preventing perioperative complications such as infection and venous thromboembolism (VTE) help guide management. Based on patient and procedural factors, as well as the potential morbidity of infection, the American Urological Association (AUA) advocates use of a second- or third-generation cephalosporin or a combination of an aminoglycoside with metronidazole or clindamycin for a maximum of 24 hours for surgery involving the intestine. The 2008 AUA best practice statement for the prevention of deep venous thrombosis (DVT) in urologic patients notes that for those undergoing open cystectomy, a prophylactic dose of preoperative subcutaneous or low-molecular-weight heparin (LMWH) and sequential compression stockings (SCDs) are recommended before the start of the procedure ( ). SCDs are to remain in place until the patient is fully ambulatory. In select patients, especially those with a current or history of DVT or pulmonary embolus, an inferior vena cava filter should be considered to mitigate the risk of VTE.
Although historically preoperative bowel preparation has been used, more recent data do not support the routine use of mechanical bowel preparation with agents such as polyethylene glycol or oral sodium phosphate. A nasogastric or orogastric tube is placed to decompress the stomach but is generally removed at the completion of the procedure.
Patient education cannot be understated in light of the substantial magnitude of this procedure and should include discussion of possible complications, risks, and anticipated lifestyle and psychosocial changes. Counseling with an enterostomal therapist, even when orthotopic reconstruction is planned, can improve familiarity with urinary diversion and appliance materials and can be helpful for selecting an optimal stoma location. Stoma site marking is performed with the patient in sitting and standing positions to minimize postoperative complications, including leakage, skin irritation, pain, and clothing concerns ( Fig. 48.1 ).
Instruments and Sutures
Use a basic set, genitourinary (GU) long set, and GU fine set and the following instruments and materials: Bookwalter retractor with an oval ring, suction tip, smooth and toothed Cushing forceps, 9-inch vascular forceps, 11-inch Mayo scissors, long straight Allis clamp, long Kelly clamp, long right-angle clamp, McDougal clamp, vessel loops, smooth Adson forceps, 4-0 Vicryl or Monocryl ureteral holding stitch, #1 polydioxanone (PDS) suture (fascial closure), articulating gastrointestinal anastomosis (GIA) stapler or vessel sealing device (e.g., LigaSure or Caimen M ), hemoclips with long clip appliers, right-angle clip applier, and a Jackson-Pratt drain with medium Hemovac needle.
Patient Positioning and Surgical Incision
Position the patient supine with the top of the anterior superior iliac spine over the break in the table in a hyperextended position using the kidney rest and some flexion in the table to open the space between the pubis and umbilicus ( Fig. 48.2 ). Arms are padded and placed out to the side with care taken not to overextend at the shoulder and thus risk injury to the brachial plexus. Although others have described spreader bars or stirrup support for the lower extremities, we prefer slight abduction of the legs with knee flexion and pillow support. For simultaneous en bloc urethrectomy, place the patient in stirrups in a low lithotomy position. Carefully pad all pressure points.
The skin is prepped from the nipples to the midthigh, including the genitals and perineum. After draping the abdomen, maintaining access to the penis, insert an 18-Fr preconnected 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 side.
Make a lower midline abdominal incision from the symphysis pubis to just below or lateral to the umbilicus (usually to the left side of the umbilicus if an ileal conduit is planned).
Incise the anterior rectus fascia and the transversalis fascia. Bluntly with a 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. Systematically examine the lymph nodes; if concern for disease exists and neoadjuvant chemotherapy has not been given, proceed to lymph node dissection with frozen section. Otherwise, lymph node dissection can be completed after bladder removal.
Incise the peritoneum in line with the abdominal incision. Locate, circumscribe, ligate, and divide the urachal remnant (median umbilical ligament) and incise the peritoneum in a V shape dissecting the peritoneal “wings” of the bladder. A Kocher clamp on the urachus is useful for traction ( Fig. 48.3 ). 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 vas deferens is ligated and divided.
Mobilization of Bowel and Exposure
Mobilize the right and left colon by incising the white line of Toldt to allow for exposure of the ureters and to set up the operative field. 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. Adequate mobilization and careful packing of the small bowel superiorly with the Bookwalter retractor will allow for critical exposure for the remainder of the procedure. Extensive mobilization of the right colon is not necessary unless orthotopic diversion in planned ( Fig. 48.4 ).
Identification and Dissection of the Ureters
A malleable blade can be used to retract the sigmoid colon to either side when identifying and dissecting the ureters. On the right side, the peritoneum is incised parallel to the common iliac vessels, and the ureter is identified as it crosses these vessels ( Fig. 48.5 ). The ureter may be isolated with a vessel loop and dissected superiorly and inferiorly with preservation of as much periureteral tissue as possible to avoid devascularization. Directly grasping the ureteral tissue with any instrument should be avoided. Inferiorly, the ureter will run posterior to the obliterated umbilical artery or superior vesical artery, which is ligated to help provide adequate ureteral length ( Fig. 48.6 ). The ureter is dissected to the level of the bladder, where it is ligated and divided, avoiding spillage from the bladder.