Radical Cystectomy

Published on 16/04/2015 by admin

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Chapter 55

Radical Cystectomy

Jessica M. Yih, Jonathan E. Kiechle and Edward E. Cherullo

Introduction

In the United States, bladder cancer is the fourth most common type in men and the ninth most common type of cancer in women. Non–muscle-invasive bladder cancer can often be treated with transurethral resections of bladder tumors and possible intravesical immunotherapy or chemotherapy with cystoscopic surveillance. Unfortunately, for muscle-invasive bladder cancer or for tumors with high-grade features and invasion into the lamina propria (T1) without metastatic disease, radical cystectomy with urinary diversion remains the cornerstone of treatment. Other indications for cystectomy include bacille Calmette-Guérin (BCG)–refractory carcinoma in situ (CIS), and as a palliative procedure for patients with severely symptomatic, metastatic bladder cancer necessitating acute hospital care and readmissions.

The first reported total cystectomy was in 1887 by Bernhard Bardenheuer. Radical cystectomy in men classically involves the removal of the bladder, distal ureters, prostate, and seminal vesicles. In women who choose not to maintain their fertility and who have extensive disease, anterior pelvic exenteration is traditionally performed, including cystectomy, salpingo-oophorectomy, hysterectomy, urethrectomy, and resection of the anterior one third of the vaginal wall. For radical cystoprostatectomy, advances in surgical technique have included nerve-sparing procedures to preserve potency in men and prostate-sparing procedures to accompany orthotopic bladder substitution. Recent data also challenge anterior pelvic exenteration in female patients and support more limited resection in those without extensive disease, preserving the anterior vaginal wall, uterus, ovaries, and pelvic supporting ligaments. Pelvic lymphadenectomy is performed regardless of gender.

Surgical Approach

Cystectomy has traditionally been performed through a low abdominal midline incision. Advances in laparoscopic technique now offer patients the option of laparoscopic or robotic-assisted cystectomy. However, despite reports of successfully completed intracorporeal laparoscopic construction of urinary diversions, the postcystectomy method of urinary reservoir formation is generally still completed with open techniques.

Bladder Mobilization

The midline incision length is determined on the basis of surgeon preference and experience, individual patient anatomy, extent of disease, and planned urinary diversion. Inferiorly, the incision should extend to the symphysis pubis to obtain adequate exposure. After incision of the skin and anterior and posterior layers of anterior abdominal wall fascia, the extraperitoneal space is entered first, and the space of Retzius is developed to mobilize the bladder away from the symphysis pubis anteriorly and to expose the external iliac artery and vein laterally.

The peritoneum located at the proximal midline incision is opened and extended laterally from the medial umbilical ligament to the internal inguinal rings. The urachus is divided high near the level of the umbilicus and subsequently used for retraction. Anatomically, an avascular plane of fibroareolar connective tissue can be followed, between the posterior rectus sheath and the peritoneum and along the medial umbilical ligaments. Care should be taken to avoid injury to the inferior epigastric arteries, which course in this plane and serve as the primary blood supply to the rectus abdominis muscle.

With the medial umbilical ligaments traced inferiorly and the space of Retzius open, a self-retaining retractor can be placed to facilitate exposure. Extra care is taken when applying traction on the most inferior aspect of the wound; injury to the femoral and genitofemoral nerves can result from prolonged stretch or compression. The symphysis should be visible with the retractor in place (Fig. 55-1, A).

FIGURE 55–1 Male: fascial planes and pelvic contents.

The sigmoid colon is often adherent laterally to the side wall and occasionally to the bladder. The sigmoid colon is mobilized medially at this point by opening the peritoneum at the white line of Toldt. The small bowel can be placed in a damp, countable towel and pushed cephalad, and the sigmoid laid in the midline, with gentle retraction holding this exposure. These maneuvers provide excellent exposure and facilitate dissection.

The peritoneal wings previously left in place by developing the space of Retzius and opening the peritoneum from the umbilicus to the inguinal ring are easily seen and divided with electrocautery to the level of the vas deferens in the male patient. The vas deferens is divided with the understanding that vascular structures are associated with both vasa. The authors prefer to use ties to allow later identification of the seminal vesicles (Fig. 55-1, B).

Dissection of Ureters

After bilateral ligation of the vas deferens, the immediate posterior peritoneum along the bladder and above the sigmoid is opened. This approach allows identification of the ureters as they cross the iliac vessels and anterior mobilization of the bladder off the proximal rectum to the level of the prostate and seminal vesicles. This maneuver can be done with a gentle blunt movement; extra care should be taken because this loose plane of connective tissue becomes dense at the level of the prostate and cannot always be easily bluntly dissected. Forceful blunt dissection here risks rectal injury.

The left ureter is identified posterior to the sigmoid colon, in a position often more medial than expected. The retroperitoneal space behind the sigmoid colon at the level of the sacral promontory is opened to allow the ureter to be passed to the other side after its division. The right ureter is found by dividing the visible peritoneal fold overlying it (Fig. 55-2).

FIGURE 55–2 Peritoneum of posterior abdominal wall.

The ureters are mobilized cephalad approximately 5 cm and caudad to the ureterovesical junction. Care must be taken to preserve soft tissue around the ureter. The periureteral blood supply is enveloped in this layer, and excellent vascularity will aid in a successful, patent anastomosis for the urinary diversion. The distal 5 mm of each ureter can then be divided and sent as a frozen section to ensure adequacy of the margin. In some cases of CIS, numerous frozen sections may need to be sent before an adequate margin is achieved. However, this practice has come under debate in recent years, with contradictory conclusions regarding the value of a negative margin in reducing risk of upper tract cancer recurrence.

This dissection allows for clear visualization of the common, external, and internal iliac arteries and prepares the surgeon to commence with pelvic lymphadenectomy.

Pelvic Lymphadenectomy

Limits of the lymphadenectomy are often variable depending on extent of disease. It has been demonstrated that 25 to 30 nodes should be resected to determine nodal status, and that this can be curative in some cases of micrometastatic nodal disease. The most limited dissection should at least include all fibroadipose and lymphatic tissue between the external iliac artery laterally, the internal iliac artery medially, the crossing of the ureter at the common iliac artery cranially, the circumflex iliac vein or inguinal ligament of Cooper caudally, and the obturator nerve inferiorly. More extensive dissection can extend to the genitofemoral nerve laterally and the bifurcation of the aorta cranially or even to the inferior mesenteric artery (Fig. 55-3).

FIGURE 55–3 Lymph vessels and nodes of kidneys and bladder.

Two important anatomic notes during the lymphadenectomy are the frequent presence of an accessory obturator vein draining into the external iliac vein and the proximity of the obturator nerve during dissection. Injury to the obturator nerve will result in difficulty adducting the ipsilateral lower extremity. The obturator artery and vein can be sacrificed with no adverse sequelae.

Pedicle Dissection

Knowledge of vascular anatomy is the key to successful dissection of the lateral and posterior pedicles of the bladder. With the internal iliac artery already exposed and the vas deferens divided, the superior vesical artery, the first anterior branch of the internal iliac artery, can be safely ligated near its branching from the internal iliac artery (Fig. 55-4, A).

FIGURE 55–4 Male: vascular supply of pelvic organs and loss of erection.

The remainder of the vascular supply to the bladder and prostate, although termed vessels, is carried in arteries of small enough caliber that collective division between stapling devices, clips, thermal dissectors, or ligation can be accomplished without individual identification. It is extremely important to remember that the use of stapling devices or thermal dissectors will divide tissues irrespective of tissue planes, and precise knowledge of the patient’s anatomy is critical to avoid injury to adjacent structures.

After ligating the superior vesicle artery, the surgeon can divide the remaining lateral and posterior pedicles of the bladder as previously described, to the level of the endopelvic fascia. Anterior retraction of the bladder exposes the pedicles, facilitating their division.

Using a combination of sharp and blunt dissection, the surgeon brings bladder with the seminal vesicles forward off the rectum. The posterior pedicles can now be visualized, posteromedial to the divided ureteral stump. This pedicle is divided to the level of the seminal vesicles with a thermal dissector or surgical stapler. Continuing distally, a plane may be developed between the rectum posteriorly and the posterior lamina of Denonvilliers’ fascia anteriorly, taking care to stay anterior to the prerectal fat.

The space posterior to the prostate is developed caudally as close to the prostatic apex as possible. Here the surgeon may choose to continue with either nerve-sparing or non–nerve-sparing technique. Care should be taken to avoid damaging any of the autonomic nerves from the pelvic plexuses, because these nerves innervate the urinary sphincters and will play an important role in postoperative continence if an orthotopic urinary diversion is constructed (Fig. 55-4, B).

To preserve the autonomic plexus, an incision should be made between the lateral pelvic fascia and Denonvilliers’ fascia to find the neurovascular bundles that lie posterolaterally along the prostate (Fig. 55-4, C and D).

Urethral Ligation

After dissection of the pedicles, urethral ligation is completed in a manner similar to a prostatectomy.

Continuing caudally from the previously developed space of Retzius, the space anterior to the prostate is first opened, and the prostate is separated from its anterior attachments to the pubis. The endopelvic fascia and puboprostatic ligaments are exposed anteriorly, and the endopelvic fascia is opened, revealing the muscular attachments of the levator muscles to the prostate. With the endopelvic fascia open bilaterally, the anterior prostatic fascia, the extension of the endopelvic fascia over the prostate, can be suture-ligated. The dorsal venous complex (Santorini’s plexus) is located within this fascia (Fig. 55-5).

FIGURE 55–5 Pelvic viscera and perineum: male

The lateral edges of the prostate are dissected from the remaining muscular attachments of the levator ani muscle. The urethra is then freed with blunt dissection, isolated, and divided. This approach exposes the triangular extension of Denonvilliers’ fascia; when incised, this exposes the rectum. Any remaining pedicle attachments of the bladder or prostate are then divided. The specimen, comprising the bladder, terminal ureters, seminal vesicles, and prostate, can then be removed en bloc. Anastomotic sutures can be placed in the remaining proximal urethra if orthotopic urinary diversion is planned.

Anterior Pelvic Exenteration

In female patients who have extensive disease, anterior pelvic exenteration is traditionally performed, including cystectomy, salpingo-oophorectomy, hysterectomy, urethrectomy, and resection of the anterior one third of the vaginal wall. After a lower abdominal midline incision, the peritoneum is incised laterally toward the round ligaments, which are then ligated. An anterior retraction stitch on the fundus of the uterus facilitates exposure of the uterine vessels.

First, the ovarian vessels and infundibulopelvic ligaments are ligated, which allows for better exposure because the intestines can be packed upward into the abdomen away from the pelvis. The ureters are traced to the vascular supply of the uterus. The uterine vessels are suture-ligated at their origin from the internal iliac vessels to mobilize and expose the ureters to the ureterovesical junction, where they are ligated (Fig. 55-6, A).

FIGURE 55–6 Female: vascular supply of pelvic organs and anterior exenteration resections.

The uterus is now mobilized laterally from its attachments at the cervix and inferior ligaments. The uterus can be left attached anteriorly to the posterior aspect of the bladder to be removed en bloc with the specimen.

Bladder Mobilization

Technique for division of the lateral pedicles varies depending on whether a vagina-sparing procedure is being performed. The lateral blood supply is isolated as it branches from the internal iliac artery, and the inferior uterine arteries must be ligated. The bladder is mobilized medially away from the lateral walls of the pelvis to expose the endopelvic fascia, the perirectal fat pad, and the lateral pedicles.

A povidone-iodine (Betadine) swab stick in the vagina is elevated cranially and ventrally to aid exposure of the apex of the vagina, which is opened immediately distal to the cervix into the posterior vagina by cautery. The incision at the apex of the vagina can be continued down bilaterally on the anterolateral sides of the vagina to the bladder neck.

The authors’ preference is to spare the anterior vaginal wall when the disease appears confined to the bladder or when cystectomy is being performed for benign disease. If vaginal sparing is not possible, on entering the vagina anteriorly, the surgeon can divide the lateral bladder pedicles en bloc with the anterior wall of the vagina, using thermal dissectors or suture ligation (Fig. 55-6, B). Staples and clips should be avoided in this situation because these objects may migrate into the vagina postoperatively.

The lateral pedicles with the remaining small, unnamed vessels can be ligated to the level of the endopelvic fascia.

Vagina-Sparing Technique

Alternatively, if the vagina is to be spared fully, or in cases of limited disease and previous hysterectomy, the space between the anterior vagina and the posterior bladder wall is developed, taking care to dissect closely to the anterior vaginal wall. If hysterectomy is required, a circumferential incision of the vagina close to the vaginal apex allows for removal of the cervix and uterus. Closure of the vagina depends on the method of urethrectomy described below (Fig. 55-6, B).

Urethrectomy

Classically, a urethrectomy is performed in radical cystectomy. In the event that an orthotopic neobladder is planned, a frozen section of the urethra can be sent to confirm a negative margin, in which case the urethra can be left intact to aid in maintenance of continence with the neobladder. Otherwise, to perform a complete urethrectomy, the patient must be positioned to allow for access to the introitus.

The labia are retracted laterally to expose the urethra. If vagina-sparing techniques are not used, a U-shaped incision can be made from the top of the introitus surrounding the anterior vaginal wall and carried around the urethra (Fig. 55-7, A). Within the pelvis, the pubourethral suspensory ligaments, corresponding to the puboprostatic ligaments in men, are ligated to release the bladder and urethra. The dorsal vein complex superior to the urethra is isolated and ligated. Any other periurethral attachments are released circumferentially and passed in continuity through the vaginal incision in to the pelvis.