How is partial cystectomy performed?

Updated: Apr 03, 2019
  • Author: E Jason Abel, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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The patient may be placed in the supine or low-lithotomy position with a slight amount of Trendelenburg positioning. Bimanual examination under anesthesia is performed to determine suitability for resection. A catheter is inserted through the urethra, and the bladder is instilled with Mitomycin C (1 mg/mL) to decrease local tumor spillage. The Foley catheter is clamped so that the intravesical chemotherapy remains inside the bladder, and the bladder is allowed to partially expand, which facilitates dissection.

The surgical approach is either transperitoneal or extraperitoneal through a lower midline incision. The transperitoneal approach may be more suitable for tumors located posteriorly. Pelvic lymph node dissection can be performed before or after partial cystectomy. In urothelial carcinoma, it is known that improved survival can be achieved with extended pelvic lymph node dissection. [26]

After completing the pelvic lymph node dissection, the Mitomycin C is drained from the bladder into a contained Foley bag system and discarded according to biohazard principles. Next a combined endoscopic and open approach is utilized to ensure resection of the mass with adequate tumor margins. A flexible cystoscope is introduced via the urethra into the bladder. While the assistant surgeon displays the location of the mass on the video monitor with the cystoscope, the primary surgeon can now see exactly where to place four sutures (inferior, superior, medial, lateral) strategically into the detrusor muscle of the bladder, to outline the exact area to be resected.

Next, the bladder is mobilized while dividing the vas deferens and the obliterated hypogastric artery. A portion of the ipsilateral vascular pedicle including the superior vesical artery is divided and ligated. The superior vesical artery division is especially helpful in the lateral mobilization of the bladder to expose a posteriorly located lesion. The tumor is excised with a 1-cm to 2-cm margin. The perivesical fat and the overlying peritoneum are removed, if necessary, with care to protect both ureters and the rectum. Frozen sections of the specimen are sent for analysis to ensure negative surgical margins.

An alternative method of excision involves placement of a Satinsky clamp around the portion that contains the tumor, excision of the segment, and cauterization of the wound edges.

The bladder is closed in 2-layers, and drains are placed in the perivesical space. A suprapubic tube is avoided because of possible tumor spread. Bladder drainage is managed with a temporary Foley catheter. Tumor spillage is detrimental and can be prevented via instillation of intravesical chemotherapy into the bladder prior to making the lower midline incision, careful draping, and meticulous isolation and manipulation of the tumor. The wound edges should be protected and the wound copiously irrigated with sterile water prior to closure. Concurrent procedures, such as prostatic adenoma enucleation or transurethral incisions of the bladder neck for bladder outlet obstruction, should be avoided because of the risk of tumor implantation in the prostatic bed.

Partial cystectomy can also be performed laparoscopically or robotically with similar technique to open procedures. [27, 28] The patient is placed in the extreme Trendelenburg position with his or her legs abducted in Allen stirrups. A 5-mm port may be used for a transperitoneal approach. The camera port is positioned at least 2-3 cm above the umbilicus to facilitate adequate mobilization of the urachal remnant. The peritoneum is incised lateral to each medial umbilical ligament, and the urachus and peritoneum along with the surrounding pre-peritoneal fat are widely mobilized en bloc. Alternatively, some advocate that leaving the bladder attached to the anterior abdominal wall whenever possible while the remainder of the bladder is mobilized aids in laparoscopic exposure. [29]  

Once the space of Retzius is fully developed and the bladder is completely mobilized, the tumor is typically identified. A circumferential cystotomy is made under simultaneous cystoscopic guidance (with or without cystoscopic tattooing) at a distance of 2 cm from the tumor to provide an adequate margin. The surgical specimen is then immediately placed into an EndoCatch bag (USCC, Norwalk, CT).

Bladder margins are sent for frozen section analysis and the bladder is then closed in 2 layers. The retrieval bag is removed through an extension of the camera trocar site, and a Jackson Pratt drain is positioned in the prevesical space through one of the previous trocar sites. In selected patients, with skilled surgeons, laparoscopic or robotic approaches can afford the patient a shorter recovery time and hospital stay. [30, 31, 29]

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