A 30° down lens can be used at the outset of the procedure. This allows for better visualization of the pelvis and retroperitoneum during the lymphadenectomy. This will be changed to a 0° lens for the posterior dissection. The procedure is begun by incising the peritoneum lateral to the left colon. The left colon and sigmoid colon should be released from the left sidewall to allow access to the left iliac vessels and left ureter.

With the left medial umbilical ligament identified, the peritoneum lateral to the ligament and medial to the left iliac vessels should be incised. Blunt dissection is employed to expose the endopelvic fascia. In male patients, dividing the vas deferens allows the bladder to be retracted medially and facilitates exposure of the pelvic vasculature.

The left ureter is identified crossing over the iliac vessels. The ureter should be dissected free of its underlying structures while preserving as much periureteral tissue as possible. The distal end can be dissected down to its insertion into the bladder. The left umbilical artery and/or left superior vesical artery should be seen just lateral to the insertion of the ureter into the bladder and clipped/ligated to allow for more length on the ureter. The ureter can be clipped distally with a locking clip. The proximal clip on the ureter should have a suture pre-tied to the clip (10–12 in.) so no additional “tagging” or marking of the ureter is required later in the procedure. The ureter should be dissected free of its attachments cephalad. Attempt should be made to preserve any vital blood supply to the ureter from the left common iliac artery. This should be done before dividing the ureter as proximal dissection can be difficult once the ureter is divided. The ureter can then be divided sharply. A margin can be sent for frozen section at this point if desired. It should be noted that too much or too aggressive dissection proximal on the ureter can result in devitalization of the ureter and may contribute to anastomotic stricture in the postoperative setting. In many cases, individual vessels from the common iliac or distal aorta can be seen and preserved to maintain ureteral blood flow.

At this point the left pelvic lymphadenectomy can be performed. It is the preference of the authors of this chapter to perform the lymphadenectomy at this time. Please refer to Chap.​ 9 for details. In some cases, the lymphadenectomy can be deferred until after the cystectomy is performed. Early in a surgeon’s experience, one may elect to complete the cystectomy first.

The right paravesical space is developed similar to the left. Dissection is similar as done on the left, but it should be noted that the incision in the retroperitoneum on this side should be extended onto the right side of the sigmoid mesentery to develop the preaortic space and allow for passage of the left ureter. It is important to develop a relatively large space in this region. Often there is fear to do aggressive blunt dissection due to concern for the mesenteric vessels; however, if the surgeon stays close to the great vessels, the space is very safe to develop.

The umbilical and superior vesical arteries are clearly seen at the completion of the lymphadenectomy and are clipped—locking clips are preferred. Clipping is recommended and may allow for more distal dissection of the ureters. If the ureters have not already been tagged with a pre-tied clip, then one should switch instruments to needle drivers and tag the distal ends of both ureters.

The left ureter can be transposed behind the sigmoid mesentery with the help of the right side assistant. The right side assistant should gently advance a blunt-tipped instrument below the mesentery along the anterior surface of the aorta. If the robotic “third arm” has been placed on the right side then it can be passed through very easily as well. The tag on the left ureter can be grasped and the ureter should easily pass through the mesenteric window.

The ileum should be tagged with a 2-0 Vicryl suture. This too should be left at least 10–12 in. in length. We recommend mobilizing the lateral attachments of the cecum so as to facilitate delivery of the ileum into the abdominal incision and make identification of the distal portion of the ileum easier.

The camera lens can be changed to a 0° (degree) lens for optimal visualization. The peritoneum extending from the posterior bladder to the anterior sigmoid should be incised. Using blunt and careful cautery dissection, the prerectal space is developed. One must employ the assistant(s) to retract the bladder and its posterior structures anteriorly. In male patients, Denonvillier’s fascia needs to be incised to carry the dissection as far caudad as possible. The dissection should be carried down to the rectourethralis muscle. If a nerve sparing is desired then one should dissect anterior to Denonvillier’s fascia and leave it on the anterior rectal surface staying close to the prostate.

Once the limits of dissection are reached along the posterior aspect of the bladder, the lateral attachments of the bladder can be divided. For a non-nerve sparing procedure, this can be done with locking clips or a combination of the bipolar instrument and the monopolar instrument of choice. An endovascular stapler can be used on both sides as well, but we recommend using locking clips as it yielded a more controlled dissection and preserved planes of dissection. It should be remembered that the dissection should be carried caudad through the endopelvic fascia thereby completely mobilizing the bladder from its lateral attachments and the rectum. Often a combination of lateral and posterior dissection is used in an alternating fashion to complete the dissection.

In nerve-sparing procedures, the neurovascular bundles are encountered as they project off the posterior–lateral aspects of the prostate down to the anterior surface of the colon. The bundles can be mobilized by releasing lateral fascia anterior to the bundles along the surface of the prostate or vagina. This should be done before ligating the inferior vesical pedicles in order to have them visualized. This is particularly important in cases which energy devices and staplers are employed for vascular ligation. This dissection is connected to the incision anterior to Denonvillier’s fascia that has already been performed during creation of the prerectal space. The inferior vesical pedicles and prostate pedicles should be clipped and divided with cold scissors to avoid neurovascular injury. The nerve sparing should be carried down to the genitourinary diaphragm to prevent injury during the apical and urethral dissection.

The remaining bladder attachments should only be the urachus, anterior attachments, prostate, and urethra. The medial and median umbilical ligaments should be divided as far proximally as possible with electrocautery. The dissection and peritoneal incision is carried lateral to the medial umbilical ligaments caudad to the anterior surface of the bladder. If not already done, the endopelvic fascia should be incised bilaterally. The apical dissection of the prostate or vagina is then completed. At this point the dorsal venous complex can be ligated with a 1 Vicryl suture in a figure of eight fashion. Although an endovascular stapler can be employed for this step, we feel the suture ligation allows for better visualization and identification of the urethra. Furthermore, when a stapler is used, there is likely to be venous ooze into the pelvis once the abdomen is opened for the diversion.

It is very important to dissect out a generous urethral stump. This is important even in cases without a planned neobladder. A generous urethral stump allows for easier application of a locking clip or suture ligation to prevent tumor spillage during division. If the previous posterior dissection was adequate, there should be minimal posterior tissue other than some minor remnants of rectourethralis. The urethral catheter is removed by the bedside assistant and a locking clip is placed on the urethra by the bedside assistant or the robotic clip applier. The urethra is divided distal to the clip. A frozen section can be taken from the proximal portion of the divided urethra if needed.

Following division of the urethra the specimen is placed in a 15-mm specimen retrieval bag and retracted into the superior aspect of the abdomen. It is very important to ensure that there is excellent hemostasis in the pelvis. Often there is venous ooze from structures such as the dorsal venous complex, urethra, rectourethralis, and neurovascular bundles. Dropping the pneumoperitoneum to 5 mmHg can help identify potential bleeding areas. Strategic placement of “figure-of-eight” sutures and additional maneuvers will prevent postoperative pelvic bleeding. This is a key point as many times this bleeding would otherwise go unnoticed until the diversion is being created and the pneumoperitoneum has been released.

The entire specimen can be entrapped in a 15-mm specimen retrieval bag. It will be extracted though a 5–6-cm infraumbilical or periumbilical incision. Prior to extraction, the tags on the ureters and the ileum should be grasped in a locking grasper by the bedside assistant to allow delivery into and through the extraction incision.