Radical cystectomy

RADICAL
CYSTECTOMY
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai 1

Moderators:
Professors:
◦ Prof. Dr. G. Sivasankar, M.S., M.Ch.,
◦ Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
◦ Dr. J. Sivabalan, M.S., M.Ch.,
◦ Dr. R. Bhargavi, M.S., M.Ch.,
◦ Dr. S. Raju, M.S., M.Ch.,
◦ Dr. K. Muthurathinam, M.S., M.Ch.,
◦ Dr. D. Tamilselvan, M.S., M.Ch.,
◦ Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

Definition:
◦ Men:
◦ En bloc removal of bladder
◦ Urachus
◦ Prostate,seminal vesicles
◦ Perivesical fat
◦ Women: anterior pelvic exentration
◦ Ovaries
◦ Fallopian tubes
◦ Uterus,cervix,portion of vaginal wall
3
Dept of Urology, GRH and KMC, Chennai.

Indications for radical cystectomy
◦ Infiltrating muscle-invasive bladder cancer
- without evidence of metastasis
- low-volume, resectable locoregional metastases (stage T2-T3b)
◦ Superficial bladder tumors characterized by any of the following:
◦ Refractory to cystoscopic resection and intravesical chemotherapy or immunotherapy
◦ Extensive disease not amenable to cystoscopic resection
◦ Invasive prostatic urethral involvement
◦ Stage-pT1, grade-3 tumors unresponsive to intravesical BCG therapy
◦ CIS refractory to intravesical immunotherapy or chemotherapy
◦ Palliation for pain, bleeding, or urinary frequency
◦ Primary adenocarcinoma, SCC, or sarcoma
4

Pre-op preparation
◦ Pre-op evaluation & counselling by enterostomal nurse:
◦ Site marked for a cutaneous stoma – supine, sitting and standing
◦ Antibiotic bowel preparation challenged
◦ Clear liquid diet 1-2 days prior to surgery
◦ Simple mechanical bowel preparation with peglec
◦ Pre op fluid management
◦ Iv broad spectrum antibiotics
◦ Lower extremity intermittent compression devices
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CYSTECTOMY IN THE
MALE
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Patient positioning
◦ Hyper extended supine position
◦ Superior iliac crest at fulcrum
◦ Legs are slightly abducted
◦ Apply a 20-degree Trendelenburg tilt
until the legs are parallel to the floor.
◦ For urethrectomy, subsequently
elevate the legs and braces together.
10

◦ lower midline abdominal incision from
the symphysis pubis to the periumbilical
area.
11

◦ Incise the anterior rectus fascia and the
transversalis fascia.
◦ open the space of Retzius by blunt
dissection
◦ the potential space between the
bladder/prostate and the pelvic
sidewall and the external iliac vessels
created.
12

◦ Incise the peritoneum in the line of the abdominal incision.
◦ Urachus ligated and divided
◦ the peritoneum incised in a V shape dissecting the “wings”
of the bladder peritoneal attachment.
◦ Check the mobility of the tumor and bladder .
◦ Explore the abdomen.
◦ Examine the lymph nodes.
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Bowel mobilization
◦ Caecum and ascending colon mobilized medially by incising white line of toldt upto the
root of mesentry
◦ Small bowel mobilized and retroperitoneal duodenum exposed-lymph node dissection
◦ Inverted triangle-
base-3 rd and 4 th part of duodenum
right edge by ascending colon
left edge by sigmoid and descending colon
◦ Descending colon and sigmoid mesentry elevated of sacral promontry
◦ Window created in sigmoid mesentry below inf.mesenteric vessels for left ureter to pass to
right side of abdomen
◦ All bowel except descending colon and sigmoid packed into epigastrium
◦
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Identification of ureters
◦ the ureter can be easily identified as it crosses the iliac vessels.
◦ The ureter isolated with vessiLoop
◦ dissected with preservation of as much periureteral tissue as possible to avoid
devascularization.
◦ dissected to the level of entry into the bladder.
◦ The obliterated umbilical artery/superior vesical artery is encountered & ligated to help
provide adequate ureteral length
◦ The ureter is then ligated and divided with avoidance of any spillage from the bladder
side.
◦ A tacking suture should be placed to help with manipulation and to avoid ureteral
trauma
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Pelvic Lymphadenectomy
◦ The limits for node dissection are:
◦ Laterally-genitofemoral nerve
◦ medially- the bladder
◦ cephalad- the bifurcation of the
common iliac artery
◦ caudad-cooper ligament
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Extended lymphadenectomy
◦ proximal common iliac artery cranially,
◦ the genitofemoral nerves laterally,
◦ Cooper ligament inferiorly
◦ Obturator canal and hypogastric
vessels, laterally and medially, caudally
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◦ Sharp dissection anterior to the external iliac
vessels, extending from above the bifurcation
of the common iliac artery to the level of
inguinal ligament
◦ psoas and iliopsoas muscles
◦ posterolateral aspect of the common and
external iliac veins.
◦ planes around the iliac artery and vein -strip
the perivascular tissues cleanly from the vessels.
◦ preserve - circumflex iliac,inferior epigastric
vessels, genitofemoral nerve.
◦ Dissect the contents of the femoral canal
immediately medial to the external iliac vein
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◦ Blunt dissection around the obturator foramen
to define the obturator nerve and vascular
bundle.
◦ Obturator vessels divided and obturator nerve
preserved
◦ posterior pelvic wall is cleared of nodal tissue
and fat and exposes the internal iliac artery
◦ fat pad lateral to rectum bluntly dissected
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DIVISION OF LATERAL PEDICLE
◦ Clear the internal iliac artery and identify its first branch,
the superior gluteal.
◦ Dissect distal to the gluteal branch.
◦ Vesical pedicle dissected and ligated
◦ the index finger used to develop the plane and protect
the rectum.
◦ Do not ligate the internal iliac artery
◦ Avoid the autonomic nerves from the superior internal
iliac, pelvic, and vesical plexuses when dividing the
superior and inferior vesical pedicles.
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DIVISION OF LATERAL PEDICLE
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DIVISION OF POSTERIOR PEDICLE
◦ Draw the bladder (uterus) up to be
able to view the cul-de-sac.
◦ Incise the peritoneum on either side of
the rectum, and join the incisions in the
cul-de-sac exactly at its junction with
the anterior rectal wall.
◦ Develop a plane behind the bladder
by sharp dissection,
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◦ Enter the plane under Denonvilliers'
fascia
◦ bluntly sweep the rectum back from
the bladder, seminal vesicles, and
prostate (or posterior vaginal wall) to
develop the posterior pedicles on
either side.
◦ Prior radiation-perineal dissection
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◦ Dissect the pedicles lateral to the seminal vesicles
◦ neurovascular bundles are seen on the ventrolateral surface
of the rectum.
◦ Clip and divide the pedicles along the anterolateral border
of the seminal vesicle until the endopelvic fascia is reached.
◦ extravesical extension - widely excise the neurovascular
bundle on that side, including the pelvic plexus, and divide
the pedicle close to the pelvic wall
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DISTAL /ANTERIOR DISSECTION
◦ The surgeon opens the endopelvic
fascia bilaterally
◦ divides the puboprostatic ligaments if
wide,
◦ Ligates and divides the dorsal venous
complex.
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Nerve-sparing technique
◦ neurovascular bundle of the prostate
released sharply on both sides of the
prostate with incision of its thin fascia
while remaining outside the capsule of
theprostate
◦ from the apex of the prostate to the
tip of the seminal vesicles
◦ limited traction and cautery
◦ neurovascular bundles laterally and
the striated sphincter at the apex.
36

◦ Urethra dissected and stretched with umblical tape
◦ avoid the neurovascular bundles that lie posterolaterally
◦ Place a silk ligature around the urethra to prevent
contamination at the time of division.
◦ the urethra can be mobilized from the urogenital
diaphragm preparatory to perineal urethrectomy ‘
◦ Clamp the urethra near the prostate
◦ Pass the left index finger behind the urethra, and divide
the space along the indwelling catheter.
◦ Elevate the rectourethralis muscle with a clamp, and
sharply divide it under vision, again avoiding the
neurovascular bundles that lie immediately adjacent in
the posterolateral quadrants
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◦ The free end of the cut Foley catheter is
retracted up
◦ Using both hands, the surgeon can now feel
a thin web of tissues separating the proximal
and distal dissections
◦ This thin web is punctured with the surgeon’s
fingers.
◦ Remove the specimen
38

◦ place a figure-eight 1-0 synthetic absorbable suture through both levators anteriorly just behind the
pubis.
◦ Check for bleeding elsewhere
◦ Replace the bowel carefully, and pull the omentum down to cover the anastomoses.
◦ Suction drainage is usually needed for protection of the diversion.
◦ If a bladder substitute is not constructed, a balloon catheter placed through the urethra helps drain
the pelvic cavity for the first few days postoperatively.
◦ Close the wound appropriately.
39

CYSTECTOMY IN THE
FEMALE
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Urethra involved-St. Mark's
position,
a not-quite-full lithotomy position
Place the thighs abducted at 45
degrees to
the body with the legs parallel to the
floor, supported in
cradles.
◦ Urethra not invovlved-Frog legged
position
◦ Lithotomy position
◦ All pressure points to be well padded
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Intraabdominal Exposure
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◦ The peritoneum lateral to the bladder is
incised
◦ round ligament is ligated and divided.
◦ The ovarian vesselsin the
infundibulopelvic ligament are
identified, ligated,and divided
◦ These maneuvers allow the peritoneal
contents to be packed away from the
pelvis
43

◦ Divide the ureters at their exit from the paracervical
tunnel.
◦ Prior pelvic radiation- transect the ureters above
the pelvic brim
◦ Ligate the distal ureteral stumps.
◦ Open the space of Retzius by incising the
peritoneal reflection over the bladder.
44

ANTERIOR DISSECTION
◦ Dissection of the anterior bladder wall
to the level of endopelvic fascia
bilaterally
◦ incised on each side to allow for better
exposure of the urethra all the way to
the perineum.
45

LATERAL DISSECTION
◦ The round ligaments on each side are
cut at the pelvic wall, and the posterior
and anterior leaves of the broad
ligament are completely opened.
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PARARECTAL DISSECTION
◦ Doubly clamp the right cardinal
ligament and ligate it.
◦ Keep well anterior to avoid the pelvic
plexus. Do the same for the left
cardinal ligament.
47

Posterior dissection
◦ Incise the peritoneum in the cul-de-sac, and
dissect the rectum from the posterior wall of the
vagina
◦ Clamp, divide, and suture-ligate the uterosacral
ligament on both sides.
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◦ ligate the lateral vesical pedicles at
the level of endopelvic fascia with 2-0
nonabsorbable suture
◦ Place a stick sponge in the posterior
fornix of the vagina, open the vagina
over it with the cutting current, and
incise the lateral wall for a short
distance.
49

Anterior Dissection and Urethral
Dissection with Urethrectomy
◦ Suture the cuff with a hemostatic running
locking 1-0 CCG suture.
◦ Identify and suture-ligate the dorsal vein
of the clitoris.
◦ Dissect the urethra to the perineum and
excise it.
◦ Divide the anterior vaginal wall several
centimeters above the perineum, and
remove the entire specimen en bloc.
◦ Close the posterior wall of the vagina by
bringing it to the short anterior leaf.
◦ Irrigate the pelvic basin. Insert a suction
drain.
◦ Reperitonealize the floor of the pelvis.
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ILEAL CONDUIT
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Ureter mobilization
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◦ select a suitable segment of ileum near the ileocecal
junction by visualizing the mesenteric vessels.
◦ Place a temporary stay suture of 4-0 silk on a detachable
needle in the bowel 10 to 15 cm from the ileocecal valve
and beyond the ileocecal arcade
◦ Select a loop of ileum that contains one or two distinct
vascular arcades
◦ the segment should be long enough to reach the skin
level plus another 2 cm
◦ place Kocher clamps at45-degree angles on the ends of
the bowel
◦ Divide the bowel with the cutting current
◦ the ileal contents are essentially sterile.
PREPARING THE LOOP
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Divide the mesentry
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Harvest the bowel
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ILEOILEAL ANASTAMOSIS
Stapled technique-side to side Sutured technique-end to end
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Close the Mesenteric Trap
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URETERAL ANASTOMOSIS
Direct Anastomosis, Right
(Cordonnier)
◦ Cut the right ureter obliquely to freshen
the end and spatulate
◦ The site of implantation of the ureter will
be more distal on the conduit than the
left and will also be on the lateral
aspect.
Implant the left ureter first
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◦ Place a 4-0 SAS through the adventitia
and muscularis of the ureter 2 cm from
the end, and stitch it on the
antimesenteric border of the ileum
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Open Bowel Mucosa
◦ Pinch the bowel between the thumb
and forefinger of the left hand, and
incise through the muscularis with a
#15 blade, exposing the submucosa
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◦ About 10 to 12 interrupted 4-0 braided synthetic
absorbable stitches
used.
◦ interrupted sutures
◦
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◦ When the anastomosis is more than
half complete, a 7-French single-J stent
is placed up the ureter (blue on the
left,red on the right
◦ The distal aspect of the stent can be
drawn through the window and out
through the distal opening in the
conduit
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CREATION OF THE STOMA
Excise the Skin and Subcutaneous
Tissue Cruciate Incision in the Fascia
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Tack and Mature the Stoma Completed Conduit
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TRIMMING AND CLOSURE OF THE
PROXIMAL END OF THE LOOP
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Conjoined (End-to-End)
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STOMA ALTERNATIVES
Z-Incision Stoma Loop Stoma
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COMPLICATIONS
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RC
◦ Mortality
◦ Hemorrhage
◦ Rectal injury
◦ Venous
thromboembolism
◦ Postoperative ileus
◦ Bowel leak &
enterocutaneous fistula
◦ Lymphocoele
◦ Wound dehiscence(3-
6)%
CONDUIT
◦ Acute necrosis
◦ Calculi
◦ Malignancy
◦ Parastomal hernias/prolapse
◦ Stomal stenosis
◦ Ureteroileal anastomotic leak
◦ Anastomotic strictures
◦ Pyelonephritis & renal
damage
PLND
• Nerve injury-obturator,femoral
,genitofemoral nerve injury
• Lymphocoele:!-4%
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◦ Mortality-
◦ 1-5%
◦ Hemorrhage:
◦ Lateral pedicle,posterior pedicle and
dorsal venous complex
◦ Rectal injury:
◦ 0.3-9.2%
◦ Prior surgery,IBD,radiation
◦ Two layered closure
◦ Loop simoidostomy
◦ DVT:1-4%
◦ Obesity,smoking,age,immobility
◦ Compression stockings/pneumatic
compression devices
◦ Warfarin/enoxaparin prophylaxis
◦ Ileus:7-23%
◦ Bowel leak /fistula:
◦ Laparotomy/conservative
management
75

◦ NECROSIS :
◦ Dusky ,oozing stoma
◦ Metabolic acidosis,hperphosphatemia,shock
◦ Early exploration ,resection and replacement of diseased segment
◦ CALCULI:
◦ 5-20%
◦ Stasis, contact with bowel and infection
◦ Prevention with urinary alkanization and catherization
◦ Upper tract calculi- eswl/pcnl
◦ Conduit-laser lithotripsy
◦ MALIGNANCY:
◦ rare
◦ Adenocarcinoma,carcinoids,TCC
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◦ BOWEL RELATED:
◦ Malabsorption syndromes
◦ Vitamin B12 deficiency
◦ PARASTOMAL HERNIA/PROLAPSE:
◦ 4-6.5%
◦ Incorrect placement of stomal opening lateral to rectus fascia
◦ STOMAL STENOSIS:
◦ 2.8-19%
◦ Poorly fitting appliances
◦ Uretero-ileal leak:
◦ 1.9-5.5%
◦ Poor surgical technique,prior radiation,recurrence,stomal edema,extraluminal
hematoma/seroma/pelvic abscess.
◦ Upto 10 days- conservative approach
◦ >14 days-complete resection of devitalized ureter and ileal transposition or
transureteroureterostomy
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◦ Anastomotic stricture:
◦ 1.5-8.4%
◦ Tension anastomosis,ischemia,prior radiation,leak
◦ <1 c mstricture- endoscopic stricture incision
◦ >1 cm –open reimplantation
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THANK YOU
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Radical cystectomy

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