Radical cystectomy, the removal of the bladder and surrounding tissues, involves several key steps. These include initial patient positioning and port placement for robotic or laparoscopic approaches, followed by dissection and mobilization of surrounding organs like the rectum and pelvic side walls. The surgeon then identifies and dissects the ureters, bladder, and prostate (in males) or uterus and vagina (in females), carefully controlling the pelvic vasculature. Finally, urinary diversion, such as an ileal conduit or neobladder reconstruction, is performed to collect and manage urine. Detailed Steps: Pre-operative Preparation: This includes anesthesia, catheter insertion, and

1. RADICAL
CYSTECTOMY
D R . S U S H M I T H A K
M C H U R O L O G Y 1 S T
Y R P G

2. SCHEME OF PRESENTATION
• Definition
• Stages
• Indications
• Preop optimization
• Open cystectomy
• Robotic and lap cystectomy
• Complications

3. Definition:
• MALE:
• Bilateral pelvic lymphadenectomy
• Bladder, peritoneal covering, perivesical fat, distal ureters
• Prostate, seminal vesicles, vas deferentia
• Membranous or entire urethra. (sometimes)
• FEMALE: Anterior pelvic exenteration
• Bilateral pelvic lymphadenectomy
• Cystectomy, urethrectomy
• Hysterectomy, salpingo-oophorectomy, and partial anterior vaginectomy.

4. Stages:

5. Indications:
MIBC- no metastasis or with low-volume, resectable locoregional metastases
(stage T2-T4a)
NMIBC-
• Refractory to cystoscopic resection and intravesical chemotherapy or immunotherapy
• Presence of lymphovascular invasion
• Variant histology (e.g., micropapillary, sarcomatoid, or plasmacytoid histology)
• Extensive invasion into the lamina propria
• Large high grade T1 tumours (>5 cm),
• Invasion of prostatic urethra
CIS- refractory to intravesical immunotherapy or chemotherapy

6. Indications:
Palliation for pain, bleeding, or urinary frequency
Primary adenocarcinoma, SCC, or sarcoma
Indications for urethrectomy :
• Tumour in the anterior urethra
• Prostatic stromal invasion that is non-contiguous with the primary
• Positive urethral margin during radical cystectomy
• Diffuse CIS of bladder, prostatic ducts, or prostatic urethra (a relative indication)
Salvage treatment for recurrent prostate cancer or intractable hematuria following
primary therapy with radiation.

7. Preoperative optimization
• Cardiac optimization
• Pulmonary optimization
• Smoking and alcohol consumption cessation
• Antibiotic prophylaxis
• Thromboembolic prophylaxis
• Adequate hydration
• No role of bowel preparation
• Stoma site marking

8. Open Radical cystectomy

9. • STEP 1 – Mobilize the urachus from the
umbilicus

10. • STEP 2 – Mobilize the bladder from the
bowel

11. • STEP 3 – Isolate and transect the ureters

12. • STEP 4 – Complete lymph node dissection

13. STEP 5- Division of lateral vascular pedicle

14. • STEP 6 – Separate bladder from sigmoid colon

15. • STEP 7 – Complete posterior dissection and cut off bladder blood
supply

16. STEP 8- Exposure of the posterior vascular pedicle of the
bladder for ligation. Ligation and division of the posterior
pedicle.

17. • STEP 9 – Complete anterior dissection and isolate urethra

18. MALE RADICAL
CYSTOPROSTATECTOMY
• Foley catheterization
• Midline incision
• Develop space of retzius
• Mobilize bladder from pelvic side wall
• Divide the urachal remnant
• Divide vas
• Divide posterior peritoneum expose
ureters
• Mobilize ureter proximally to preserve
periureteral blood supply
• Pelvic lymphadnectomy
• Divide endopelvic fascia
• Divide lateral vascular bladder pedicles
• Establish plane between rectum and
posterior bladder wall
• Ligate dorsal vein
• Dissect neurovascular bundles off prostate
bilaterally
• Incise urethra
• Divide posterior bladder pedicle

19. FEMALE RADICAL CYSTECTOMY
• Foley catheterization
• Midline incision
• Mobilization of bladder from pelvic
side wall
• Divide urachus
• Ligate infundibulopelvic ligaments
(ovarian artery) round ligaments
• Incise broad ligament to expose
ureters and mobilize
• Pelvic lymphadenectomy
• Circumferential incise cervix
• Divide urethra
• Close vaginal defect

20. Identification of the vaginal cuff posterior to the cervix.
Incision of the posterior vaginal cuff.

21. Posterior vaginal wall and defect at the level of the introitus after en bloc removal of the
bladder in an anterior pelvic exenteration in the female patient. (B) Intraoperative
photograph of the introital defect. (C) Coverage of the introital defect with a flap made
from the posterior vaginal wall.

22. Circumferential division of the vaginal cuff from the attachments to the cervix.
(B) Closure
of the vaginal cuff and placement of the urethral anastomotic sutures. (C)
Intraoperative photograph of the completed repair.

23. Complications
• Re operation (10%)
• Bleeding (10%)
• Sepsis and wound infection (10%)
• Intestinal obstruction or prolong ileus (10%)
• Cardio pulmonary morbidity
• Rectal injury (4%)
• Cx of urinary diversion
• Peri operative mortality – 3%
• Early complications (within 3 months of surgery) in 28%

24. LYMPHNODE DISSECTION

26. Robotic and lap radical
cystoprostatectomy
• Evolving
• Morbidity – limited
• Operative time – comparable
• Long term oncologic outcomes – awaited

27. • Technically demanding in laparoscopic procedures.
• Urinary diversion is usually performed extracorporeally.
• No difference in term of lymph node yield and complication rate.
• Increased operation time but blood loss reduced.
• No consensus on oncology outcome.

28. Surgical Positioning and Port Placement
•Two bedside assistants are used .
•Patient is placed in the dorsal
lithotomy position
• Patient is placed in 30-degree steep
trendelenburg position

30. Indications and contraindications
• Indications: similar to open radical cystectomy
• Contraindications:
• Include extensive prior abdominal surgeries
• morbid obesity (positioning and ventilation issues)
• Bulky or locally advanced tumors.

31. Complications
• Intraoperative:
• Hemorrhage
• Rectal perforation
• Early:
Wound hernia or Dehiscence
Bowel obstruction
Ureteral stricture
UTI / Pyelonephritis
stones
Renal deterioration

32. • Late:
wound Infection
Intra abdominal abscess
Pyelonephritis
Hemorrhage
Urine leak / Fistula
Bowel leak / Fistula
Ileus
Bowel Obstruction

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