These steps are as would be performed during anterior pelvic exenteration or female cystectomy and are described in detail in other sections of this book.

During the posterior dissection step as described in other sections of this book, antegrade dissection through the cul-de-sac allows for the separation of the posterior bladder from the uterus. This dissection plane is carried as far posteriorly as possible, preferably to the junction of the corpus uteri and cervix. The superior portion of the sacro-uterine ligaments along with the round ligaments is transected. However, the cardinal ligaments that attach to the lateral walls of the vagina along with the ovaries are left intact to maintain support to the vagina and to preserve hormonal function, respectively. Next, the bladder is dropped in a standard fashion similar to that of robotic prostatectomy and is described in other section of this book. During this step, the endopelvic fascia is identified and opened to expose the dorsal venous complex (DVC), urethrovesical junction, and lateral walls of urethra. The DVC is controlled using 0-vicryl suture and transected. Using both blunt and sharp dissection, a space between the urethra and the anterior wall of the vagina is created. Control of the bladder pedicles are achieved with Hem-o-lock clips (Teleflex Medical, Research Triangle Park, NC) or a stapler. It’s important to know that while the vagina receives its arterial blood supply from multiple sources, vaginal branches from the uterine and inferior vesical arteries are among the important contributors. Additionally, since these branches travel in close proximity to the nerve supply of the vagina and clitoris, it’s important to spare them during this step to avoid potential devascularization and denervation.

Using the lateral sulci of the vagina and lateral walls of the urethra as landmarks, dissection of the vesicovaginal space is performed sharply with minimal monopolar coagulation to prevent inadvertent thermal injury to the neurovascular bundles. The authors typically utilize a sponge stick dipped in betadine and inserted into the vaginal vault to help identifying the vaginal apex and anterior vaginal wall during the course of dissection. Hemostasis is obtained with pinpoint monopolar coagulation and suturing. Once the vesicovaginal space is fully developed, the urethra is encountered and transected.

In 2002, Ali-El-Dein et al. [35] introduced the Mansoura modification in hope of preventing postoperative chronic urinary retention or hypercontinence that frequently plagued those who had received a neobladder. The authors demonstrated that by attaching the preserved ends of the round ligaments to the vaginal stump, this effectively fixed and provided support to the vaginal vault as well as prevented posterior and caudal displacement of the neobladder as demonstrated by cystogram. This has resulted in a reported 55 % reduction in the incidence of urinary retention among their patients. Armed with this knowledge, we also perform vaginal stump fixation among all patients who will receive a neobladder. During the standard hysterectomy as described in other section of this book, transection of the round ligaments is made close to its origins in the uterine horns to ensure adequate length for the vaginal fixation. Closure of the vaginal stump is performed horizontally with 2–0 vicryl to prevent narrowing of the vagina. The free ends of the round ligaments are then sutured to both ends of the vaginal apex, in effect suspending and supporting the vagina.

These steps are similar to those that have been described in detail in other sections of this book.

After ureteral and posterior bladder mobilizations, the bladder pedicles are carefully controlled as they come off the internal iliac artery using an athermal technique with Hem-o-lock clips (Teleflex Medical, Research Triangle Park, NC) or a stapler to prevent inadvertent thermal injury to the prostatic neurovascular bundles. The dissection is carried towards the prostate base, and only the internal iliac pedicles and superior vesical arteries are clipped and divided while the inferior vesical arteries along with its prostatic branches are spared to promote sexual potency recovery. The bladder is then dropped in a fashion similar to robotic prostate surgery and as described in other chapters of this book. To expose the prostatic–vesical junction in preparation for the bladder neck dissection, one must first develop the lateral pelvic spaces as previously described in sections on developing the endopelvic space on either side of the prostate. Minimal to no dissection is done at the apex of the prostate. Once completed, this allows for the identification of levator ani muscles on the lateral pelvic side wall and the lateral and posterior bladder walls medially. “Defatting” of the prostatic–vesical junction can be made with a combination of blunt dissection and point cautery. Occasionally, an accessory pudendal artery is encountered and should be spared. Additionally, once the prostatic–vesical junction is cleanly exposed, the bladder neck is dissected circumferentially (Fig. 8.5) and ligated to prevent tumor spillage as it is being dissected (Fig. 8.6). The bladder is transected at the bladder neck and placed in an Endo-catch bag (Covidien, Mansfield, MA) which will later be removed with an extended midline port incision.