What is the anatomy of the bladder relevant to radical cystectomy?

Answer

The bladder is an extraperitoneal muscular urine reservoir that lies behind the pubis symphysis in the pelvis. At the dome of the bladder lies the median umbilical ligament, a fibrous cord that is anchored to the umbilicus and that represents the obliterated urachus. This ligament contains vessels that must be ligated when divided. The ureters, which transport urine from kidney to bladder, approach the bladder obliquely and posterosuperiorly, entering at the trigone. The intravesical ureteral orifices are roughly 2-3 cm apart and form the superolateral borders of the trigone. The trigone consists of the area between the interureteric ridge and the bladder neck. The bladder neck serves as an internal sphincter, which is sacrificed during a radical cystectomy.

In males, the seminal vesicles, vas deferens, ureters, and rectum border the inferoposterior aspect of the bladder. Anterior to the bladder is the space of Retzius, which is composed of fibroadipose tissue and the prevesical fascia. The dome and posterior surface of the bladder are covered by parietal peritoneum, which reflects superiorly to the seminal vesicles and is continuous with the anterior rectal peritoneum. In females, the posterior peritoneal reflection is continuous with the uterus and vagina.

The vascular supply to the bladder arrives primarily via the internal iliac (hypogastric) arteries, branching into the superior, middle, and inferior vesical arteries, which are often recognizable as lateral and posterior pedicles. The arterial supply also arrives via the obturator and inferior gluteal artery and, in females, via the uterine and vaginal arteries. Bladder venous drainage is a rich network that often parallels the named arterial vessels, most of which ultimately drain into the internal iliac vein.

Recent extensive anatomic pathology studies have determined that initial lymphatic drainage from the bladder is primarily into the external iliac, obturator, internal iliac (hypogastric), and common iliac nodes. Following the drainage to these sentinel pelvic regions, spread may continue to the presacral, paracaval, interaortocaval, and paraaortic lymph node chains. For a more detailed explanation of lymphatic drainage, see Treatment.

For more information about the relevant anatomy, see Bladder Anatomy.

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Mobilizing the lateral peritoneum after transection of the vas deferens with preservation of the spermatic cord.
Pelvic lymph node dissection with removal of lymphatic tissue from the genitofemoral nerve to the obturator nerve and from the pelvic sidewall to above the bifurcation of the iliac vessels.
Mobilization of the distal ureters into the bladder, taking care to preserve vascular supply. The bladder is lifted to the left; the pouch of Douglas is seen between the bladder and rectum.
Exposure and ligation of the lateral pedicle, which extends from the internal iliac vessels over the distal ureter on its way to the bladder.
Opening the pouch of Douglas between the rectum and posterior bladder wall.
Pelvic ileal neobladder ready for anastomosis to the urethra.
The bowel segment of the Indiana pouch includes the entire ascending colon, a small portion of the transverse colon, and about 7-8 cm of the terminal ileum.
The colon has been opened on its antimesenteric border, and the terminal ileum has been plicated by application of the gastrointestinal anastomosis (GIA) stapler to reduce the lumen to approximately 16F. A 14F catheter is shown traversing the efferent limb. The ileocecal valve also has been bolstered with 2-0 absorbable sutures.
Dissection of the lateral pedicle extending from the internal iliac vessels over the distal ureters. These vessels can be ligated, allowing full mobilization of the ureter down to the bladder.
The posterior peritoneum has been entered, and the rectum is retracted to the right. The posterior plane between the bladder and prostate anteriorly and the rectum posteriorly can then be entered using a combination of sharp and blunt dissection; this defines the posterior pedicles.
The rectum is retracted down and to the left, and the articulating stapler is applied to the posterior pedicle. Three such applications of the stapler typically advance the dissection all the way to the lateral endopelvic fascia. The apex can then be addressed in a manner similar to a radical prostatectomy.
The ureters are anastomosed to the posterior wall of the pouch and are shown from behind the pouch. They are brought through the wall and sutured to the pouch with interrupted absorbable 4-0 sutures. An antirefluxing anastomosis has traditionally been recommended, using the LeDuc technique. Both anastomoses are stented.

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