Editing Orthotopic Urinary Diversion (section)

== Surgical techniques for continence preservation during radical cystectomy ==

* '''The innervation of the striated urethral rhabdosphincter arises from the branches of the pudendal nerve and is most important to maintain continence in patients with an orthotopic neobladder'''
* The striated rhabdosphincter muscle fibers are concentrated in the anterior and lateral to the proximal urethra
* The surgical dissection at the prostatic apex in men and bladder neck in women must be carefully and precisely performed to achieve optimum continence while taking care not to compromise the oncologic effectiveness of the surgery.
* Anterior Apical Dissection in the Male Patient
** Minimal manipulation of the muscle fibers of the rhabdosphincter, fascial attachments, and corresponding innervation is essential to providing optimal urinary continence
** Obtain careful control of the DVC and avoidance of deep suture bites into the pelvic floor muscles
** Further technical details in Campbell’s
* '''Preservation of the Urethra in the Female Patient'''
** The endopelvic fascia and levator muscles should not be disturbed
** '''In women undergoing neobladder reconstruction, preserving the uterus and its supportive ligaments:'''
**# '''Eliminates the risk of vaginal fistula'''
**# '''Improves sexual function'''
**# '''May decrease urinary retention'''
**# '''Improved daytime continence'''
** Whenever possible the bladder is dissected completely off the anterior vaginal wall rather than excising it, whether the uterus is removed or not. However, a deeply invasive tumor on the posterior bladder or trigone may necessitate excision of a portion of the anterior vaginal wall. This does increase the risk of subsequent pouch-vagina fistula but is not an absolute contraindication to orthotopic reconstruction.
** '''The issue of nerve-sparing cystectomy in women is controversial. It appears that preservation of the perivaginal nerves may not be absolutely required to maintain continence in women.'''