Editing Cystectomy (section)

=== Summary of Steps ===
* '''See [https://pubmed.ncbi.nlm.nih.gov/15217471/ BJUI Surgical Atlas] for details and figures'''
* '''Enter space of Retzius.''' After the midline is identified, the fascia is divided and the space of Retzius is entered.
** Upward retraction of the umbilicus (toward the ceiling) aids in the identification of the linea alba.
* '''Mobilize the bladder from the pelvic sidewall''' attachments anteriorly and bilaterally with blunt dissection. This is carried superiorly to the level of the vas deferens in men and the round ligament in women.
* '''Make a peritonotomy lateral to either medial umbilical ligament'''
*'''Ligate and divide the urachus'''
* '''Extend peritoneal incision lateral to the medial umbilical ligaments bilaterally to the level of the internal inguinal rings at which point the vas deferentia in men and the round ligaments in women will be identified'''
*'''Ligate and divide the vas/round ligaments'''
* '''Setup a self-retaining retractor, such as a Bookwalter.''' Exposure is maximized and the bowel retracted cephalad. Communication with the anesthesiologist at this point is vital to ensure that inadvertent compression of the vena cava has not resulted. A moistened laparotomy pad or pads should be placed behind retractor blades to protect the abdominal contents.
* '''Identify the ureter and dissect free from attachments beginning a few cm above where they cross the iliac arteries to the level of the detrusor hiatus'''. 
**Care should be used to ensure that adequate ureteral adventitia is maintained.
**'''Superior vesical artery should be ligated and divided before completing the ureteral dissection''' as this aids in maximizing ureteral length. '''The ureter is then controlled with either suture ties or suture ligature and is divided.'''
** '''Send distal ureteral margin for frozen section analysis'''. Studies have shown a correlation between findings of carcinoma in the ureteral margin and subsequent upper tract recurrence, however, an impact on survival has not been well established
* '''Ligate lateral vascular pedicles'''. 
**If sealing instruments are used, the heat they generate can transmit and may injure the rectum if in close proximity. With a gloved finger surgeons should shield the rectum from the tips of such instruments while in use
* '''Posterior dissection'''
**'''Identify rectal cul-de-sac and make transverse incision in the peritoneum where it overlies the seminal vesicles'''
** '''The rectum is dissected free with either blunt dissection or sharp dissection in the midline and is carried to the level of the prostate, at which point Denonvillier's fascia is encountered and incised.'''
* '''Anterior dissection'''
**'''Similar to a radical prostatectomy'''
**'''Incise endopelvic fascia overlying the levator muscles sharply, allowing for identification of the confluence between the urethra and the dorsal venous complex.''' 
**'''Ligate and divide the dorsal venous complex, which allows for visualization of the anterior urethra'''
**'''Incise anterior urethra'''
** '''If continent ileal neobladder urinary diversion, adequate urethral length must be maintained and a frozen section analysis of the urethral margin performed. Orthotopic neobladder is contraindicated patients with a positive urethral margin due to risk of urethral recurrence'''
** Nerve-sparing
***The role of preservation of the neurovascular bundles, unlike in radical prostatectomy, remains controversial in radical cystectomy. A technique analogous to radical prostatectomy can be used, however, the '''functional outcomes remain significantly worse than radical prostatectomy.'''

==== Female cystectomy ====
* '''The initial steps for anterior bladder mobilization and ureteral dissection are the same in males and in females with the exception of the gonadal vessels. In female patients the ovarian vessels should be identified and ligated''' with a 2-0 silk suture distally, and both a 2-0 silk suture ligature and a tie proximally, and then divided.
* '''Anterior pelvic exenteration begins with identification of the posterior cervical fornix, and the vaginal cuff is incised at this position.'''
* '''After gaining entry to the vaginal canal, control the lateral and posterior vascular pedicles to the bladder.''' According to surgeon preference, vascular staplers, sealing devices, or clips are applied and the specimen can be dissected free inclusive of the uterus, cervix, anterior vaginal cuff, and bladder.
* '''The urethral meatus is then incised''', either antegrade from the pelvis or externally from the vaginal introitus, '''and the specimen is removed''' (Fig. 95-15A and B). Care should be taken to ensure that sufficient vaginal mucosa is maintained above the urethral meatus to allow for closure of the vaginal defect in subsequent steps.
** Radical cystectomy in the female patient historically included total anterior pelvic exenteration inclusive of the bladder, urethra, anterior vagina, uterus, and cervix. However, in the absence of bladder neck involvement and the presence of low-stage disease (≤cT2), '''orthotopic neobladder can be considered. This necessitates urethral sparing with adequate length proximal to the striated sphincter and anterior vaginal wall sparing to provide support to the neobladder.'''
*** Maintaining the integrity of the striated sphincter, the specimen is removed at this level and a frozen section of the urethral margin is sent and managed in the same fashion as in male neobladder candidates. Again, if the urethral margin analysis demonstrated malignancy, orthotopic diversion is contraindicated.
* Because of the vascular nature of the female pelvis and the sinusoidal nature of the vascular pedicles as they pass over the lateral vaginal wall, care is needed to '''ensure hemostasis'''
** Lateral vascular pedicles are intimate with the lateral wall of the vagina and to control these vessels properly they must be separated from the vagina before ligation. This can be achieved either after removal of the cervix and uterus at the level of the cervical fornix (Fig. 95-16A) or while they are still in place. A vaginal packing during this step can aid in defining the plane of separation between the bladder and the anterior vaginal wall in the midline. After development this space is extended laterally, separating the lateral vascular pedicles from the lateral vaginal wall. To ensure that an adequate bladder margin is maintained, the vessels should not be divided until the midpoint of the lateral vaginal wall, in the anterior posterior plane, has been reached. This dissection is carried to the level of the bladder neck, which can easily be identified by use of the Foley catheter balloon as a guide.
* To complete the vaginal closure with a 2-0 polyglactin suture, the '''posterior vaginal wall must be released from the rectum. The posterior vaginal flap is then closed to the corresponding mucosae of the introitus in a clamshell fashion to maintain vaginal girth at the cost of some vaginal length. Bothersome drainage of peritoneal fluid will result if the vaginal closure is not watertight, and an interrupted closure is preferred.'''
* '''A vaginal packing is then placed with the dual purpose of distending the vagina and tamponading any residual vaginal wall hemorrhage''' (particularly useful if vaginal sparing is performed; discussed later) and aids in the identification of unrecognized defect in the closure. This packing should be removed within two postoperative days.