Initial reports of cystectomy are attributed to Bardenheuer et al of Cologne in 1887, with the first female cystectomy being performed by Pawlik in Czechoslovakia around the same time. The modern steps of the radical cystectomy with pelvic lymph node dissection were described by Whitmore and Marshall in 1962.1 Further refinements have taken place over the years, with Schlegel and Walsh describing the nerve-sparing approach in 1987.2 With the advent of minimally invasive surgery, the first laparoscopic radical cystectomy (LRC) was described by Parra et al in 1992,3 and, in 2003, Menon et al4 demonstrated the feasibility of robotic-assisted radical cystectomy. Both of these new techniques have proven to have oncologic equivalency when compared with the open technique. In addition, the minimally invasive approach offers improved perioperative outcomes (lower blood loss, shorter hospital stay, and morbidity), although long-term outcomes have shown only small benefits with limited follow-up.5
INDICATIONS AND CLINICAL APPLICATIONS
The most common indication for cystectomy worldwide is invasive bladder cancer in the form of urothelial carcinoma, or squamous cell carcinoma, as is more common in areas with endemic schistosomiasis infection.6 In addition, bladder cancer involvement of reproductive organs has been shown to occur in 7.5% of females, with the vagina (3.8%) and cervix (0.7%) being the most commonly involved.7
However, in the setting of gynecologic malignancy involvement of adjacent pelvic organs, such as the bladder, is less common. The most common scenario is cervical cancer, with involvement of adjacent organs occurring in fewer than 5% of North American patients.8 Cystectomy for gynecologic malignancy is a treatment often done for recurrent disease with about one-half of the patients having undergone previous treatment, either chemotherapy or radiotherapy. Less common indications for cystectomy include intractable hematuria, end-stage bladder secondary to radiation injury, neurologic disease, or refractory fistula disease.
The bladder is an ovoid, muscular organ with a capacity of 400 to 500 mL. The bladder occupies the anterior pelvis and is juxtaposed to the posterior border of the symphysis pubis, separated only by the potential retropubic space of Retzius. The paired paravesical spaces laterally bound the bladder. The bladder and adjacent structures define the inner surface of the lower abdominal wall, which includes the median umbilical fold (urachus), the paired medial umbilical folds (obliterated umbilical arteries), and the paired lateral umbilical folds (inferior epigastric vessels). The internal anatomy of the bladder includes the base or trigone (defined by the internal urethral orifice and both ureteral orifices), a ventral wall, and a dorsal wall. The ventral and dorsal walls meet at the bladder apex, where the urachus begins its course toward the umbilicus. In women, the bladder base rests on the anterior cervix and proximal anterior vagina. As such, radical cystectomy in the female patient includes removal of the bladder and surrounding fat, the uterus and adnexa (unless previously removed), and a portion of the proximal anterior vaginal wall (Figure 6-1). Radical cystectomy may or may not include urethrectomy. While it is similar in theory to an anterior pelvic exenteration, the scope of pelvic sidewall and vaginal resection with radical cystectomy is comparatively less radical than with a classic exenterative surgery (Chapter 8). The bladder has a dual blood supply by way of the superior vesicle pedicle, which carries the superior vesicle artery, and the inferior vesicle pedicle, which carries the inferior vesicle artery. Both pedicles arise from the anterior division of the internal iliac (hypogastric) artery. The inferior vesicle artery supplies the bladder base and proximal urethra. The innervation of the bladder is via the vesicle plexus (anterior part of the inferior hypogastric plexus), which runs with the arteries of the bladder base.
Box 6-1 KEY SURGICAL INSTRUMENTATION
A major open tray with a long and fine instrument tray
Bookwalter or Omni abdominal retractor
7-French ureteral diversion stents × 2
Jackson-Pratt or other abdominal drain
Tenotomy and Potts scissors
Smooth Gerald forceps
Short and long Allis clamps
Regular, long handle, and right angle clip appliers
Optional: hemostatic device (eg, LigaSure [Covidien, Mansfield, Massachusetts])
Ureteral anastomosis: 4-0 monocryl on RB-1 needle
Stoma: 3-0 delayed absorbable suture on SH needle
Ureteral stents: 3-0 chromic on SH needle
Fascial closure: 1 Ethibond (Ethicon, Somerville, New Jersey) or 1 PDS
Preoperative preparation for radical cystectomy should include relevant imaging studies to accurately define the extent of tumor, depending on the primary disease process, determine the scope of resection and whether resection of additional anatomic structures will be necessary, and exclude the presence of regional or distant metastatic disease. As for any other major surgical procedure, patients should undergo a complete physical examination and laboratory studies and have adequate nutritional and performance status to withstand a major operation. Radical cystectomy necessarily will involve reconstruction of the urinary tract, diversion of the urinary stream, or both. As such, patients should undergo preoperative evaluation and counseling regarding the most appropriate choice for urinary diversion: incontinent diversion, continent diversion, or orthotopic neobladder creation. Preoperative consultation with an enterostomal therapist with marking for optimal stoma placement is recommended. With regard to preoperative bowel management, recent data from the colorectal literature showed no difference in complication rates between those who were prepped and those who were not. Of note, surgeons may still elect to prep when using the colon for diversion, because it may have the advantage of technical ease in bowel handling. Prophylactic antibiotics should be administered and thromboembolic prophylaxis methods should be in place prior to surgery.
Box 6-2 MASTER SURGEON’S PRINCIPLES
The retropubic space of Retzius, paravesical spaces, and pararectal spaces should be fully developed to optimize exposure
Resection of the anterior vaginal wall should be limited to the surface area juxtaposed to the bladder base
Preservation of the urethra and division of the ureters as distally as possible will maximize options for urinary diversion/reconstruction
The female patient is positioned supine and slightly frog-legged or in low lithotomy in stirrups to facilitate access to the vagina. The abdomen is prepared from the xiphoid to the pubis; the vagina is also prepped. A Foley catheter is inserted on the field.
Initial incision is lower midline from the symphysis pubis to umbilicus; we prefer an infraumbilical incision, which can be superiorly extended, as needed, depending on exposure requirements. Dissection is carried down through the subcutaneous tissues to expose the anterior rectus fascia. The anterior rectus fascia is incised and the rectus muscle bellies are retracted laterally. The transversalis fascia is incised, exposing the preperitoneal space. The bladder is then bluntly dissected anteriorly off the pubis and pelvic sidewalls to expose the retropubic space of Retzius. The retractor is usually placed at this point, and the peritoneum can be opened with sharp incision.
The urachus is identified, ligated, and a clamp is placed for applying traction to the bladder. Most cystectomies for gynecologic malignancy will be performed in the recurrent setting in which patients likely would have undergone previous hysterectomy and bilateral salpingo-oophorectomy. If not, then removal of the uterus and adnexa is included in the scope of resection. Incising the peritoneum lateral to the bladder will expose the round ligaments, which are identified and divided followed by incision of the broad ligaments to expose the ureters. The pelvic sidewall peritoneum is opened and the paravesical and pararectal spaces are developed bilaterally. The ovarian vessels in the infundibulopelvic ligaments are identified and divided. The fallopian tube/utero-ovarian ligament pedicles are clamped and divided, and the adnexa are removed from the field to facilitate exposure. The ureters are isolated with vessel loops and dissected both proximally and distally toward the bladder and divided to provide enough length for later diversion construction (Figure 6-2). We usually ligate the distal ureters before dividing them to allow for distention of the ureters to make subsequent spatulation for diversion easier.