What are the alternative surgical approaches to radical cystectomy?

Updated: Nov 27, 2016
  • Author: Michael Christopher Large, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

See the list below:

  • Perineal access may be used for mobilization of the posterior plane between the rectum and the prostate following radiation therapy to the pelvis (salvage cystectomy).

  • Laparoscopic (or robot-assisted laparoscopic) cystectomy is an emerging treatment option with early perioperative outcomes that suggest less blood loss, potentially earlier return of bowel function, and apparently similar pathologic outcomes. While intracorporeal neobladder or conduit construction has been successfully performed, most specialized centers create the urinary diversion extracorporeally through a miniature laparotomy. Current minimally invasive series are small and immature; further evaluation is necessary. [20, 21]

  • Radical cystectomy in women is often technically easier because women have a larger pelvic cavity. Warn patients of a smaller vaginal cavity and the possibility of dyspareunia. Unique technical considerations in females include the following:

    • When the superior vesical artery is ligated, the uterine arteries should also be addressed.

    • The broad ligament is incised on the posterior side down to the posterior fornix of the vagina.

    • The round ligament is ligated and divided.

    • Sacrifice the gonadal vessels above the ovaries.

    • The fallopian tubes and ovaries are removed, along with the uterus and bladder.

    • The vagina is mobilized and incised at the posterior fornix along the lateral vaginal wall to the bladder neck at the 2-o'clock and 10-o'clock positions.

    • Anterior vaginectomy is a U-shaped anterior vaginal wall incision on both sides of the bladder neck. Labia can be retracted laterally with suture ligatures. The dorsal venous plexus anterior to the urethra is controlled with suture ligature. The anterior vaginal wall is then divided and removed en bloc with the entire specimen.

    • The vagina is reconstructed by suturing the lateral walls together or by flipping the posterior wall forward in a clam-shell fashion. A vaginal pack soaked with Betadine can be left in the vagina postoperatively for 1-2 days.

    • Vagina-sparing cystectomy is well accepted in select patients based on tumor location. [22]

  • Radical cystectomy without urinary diversion is an option in anuric patients on hemodialysis.


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