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    Radical cystectomy for bladder cancer: Tools vs. technique

    Basic principles of cystectomy remain the same regardless of surgical approach used

     

    Ureteral dissection

    Ureters are best identified where they cross over the common iliac arteries. Incisions in the peritoneum should be performed a few millimeters away from the ureter and dissection should be carried out widely, leaving tissue surrounding the ureters intact, ensuring the preservation of blood flow and minimizing the risk of subsequent ischemic urine leaks or strictures. The ureters are transected at the level of the detrusor muscle unless there is suspected malignant involvement, in which case ureters may be taken proximally.

    Ureteral dissection

    Frozen sections of the distal ureters may also help determine the need for additional tissue removal. The finding of CIS at the distal margin requires the excision of additional ureter until a negative margin is achieved, or the length of ureter remaining would preclude anastomosis to the urinary diversion. Clipping the ureters keeps the operative field dry and allows dilation of ureters and facilitation of the later ureteral anastomoses (figure 1).

    Preparation of the vascular pedicles

    The space of Retzius should be developed laterally, the vas deferens clipped and transected near the internal inguinal ring, and the bladder mobilized completely off the pelvic side walls, exposing the endopelvic fascia bilaterally. The peritoneum in the pouch of Douglas is then incised and the rectum is dissected off the base of the bladder. This can be done under direct vision using the robotic approach, allowing for the cauterization of small vessels. Seminal vesicles are dissected to their tips and damage to surrounding tissues in this area should be minimized to avoid injury to the neurovascular bundles critical for the maintenance of erectile function.

    Ligation of right vascular pedicle of bladder

    At this point, the bladder is left attached to the prostate and vascular pedicles. With the exception of the superior vesicle artery coming off the internal iliac artery, the pedicle consists of numerous arteries and veins that are difficult to isolate and clip. A vessel sealer is thus an ideal tool for this portion of the operation. Furthermore, the size and depth of the “bites” allow for continuous reassessment of tissue planes, ensuring a wider dissection when indicated by the disease (figure 2).

    Next, the endopelvic fascia is opened, the puboprostatic ligaments are transected, and Denonvillier’s fascia is opened posterior to the prostate, allowing the rectum to be dissected away from the prostate from base to apex. Prostatic vascular pedicles can then be taken similarly with a vessel sealer or in an athermal manner (eg, with clips) if a nerve-sparing dissection is performed.

    Next: The dorsal venous complex

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