Editing Cystectomy (section)

==== 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.