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    Radical cystectomy for bladder cancer: Tools vs. technique

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

     

    The dorsal venous complex

    Improper handling of the dorsal venous complex (DVC) can lead to significant blood loss; therefore, this portion of the surgery should be performed with care. First, the DVC is bunched and suture ligated with a strong suture (eg, >2-0 vicryl or V-Loc suture) that can be cinched and tied tightly (figure 3). The DVC can then be transected, leaving a clear margin on the anterior/apical prostate. Occlusion of the proximal urethra by suture, clip, or catheter prevents tumor spillage.

    Ligation of dorsal venous complex (DVC) of prostate

    The urethra can then be transected sharply with preservation of urethral length when an orthotopic neobladder is planned, and a urethral margin may be sent when indicated (eg, when there is suspected involvement of the urethra based on tumor location, presence of extensive CIS, etc.). The specimen can then be removed in the open approach or bagged and later extracted when the robotic approach is used.

    Pelvic lymph node dissection

    When performed for malignancy, a radical cystectomy should always be accompanied by an extended pelvic lymph node dissection (LND). There is evidence that a complete LND improves staging and may also improve the prognosis of the disease (although the results of a randomized trial are not yet available). The extended pelvic LND should include external and internal iliac, obturator, presacral, and common iliac lymph nodes to the aortic bifurcation (figure 4). Although some perform the LND in conjunction with the cystectomy, most do it after the bladder has been removed, allowing for more working space and greater exposure of the pelvic vessels.

    Extended pelvic lymph node dissection of left side

    Significant lymphatic channels should be clipped or sealed in order to avoid lymph leaks or lymphoceles. Adequate exposure allows this to be performed safely; therefore, the retractor will need to be adjusted in the open approach.

    The root of the sigmoid colon mesentery should be completely mobilized in order to properly access the presacral lymph dissection as well as the left common iliac artery to the aortic bifurcation. This also allows for the passage of the left ureter to the right side through a wide opening, thus preventing acute angulation of the ureter.

    Next: Surgical tips and tricks

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