Invasive bladder cancer is one of the most lethal malignancies we treat in urology. Although some debate the significance of a delay in treatment or positive surgical margins in the treatment of prostate cancer or small renal masses, few would debate these factors’ significance in bladder cancer. Studies have demonstrated that the timing of treatment, positive surgical margins, and number of lymph nodes removed all impact recurrence and/or survival in individuals with bladder cancer.
It’s also clear is that basic principles hold true for the technique of cystectomy regardless of the approach used. Although retrospective data have suggested that the robotic approach may offer improved convalescence, a recent randomized study found no difference in morbidity or pathologic outcomes, ie, positive surgical margins and lymph node yield (Eur Urol 2015; 67:1042-50). Therefore, the purpose of this article is to discuss important principles of radical cystectomy, whether performed using the open, laparoscopic, or robotic approach.
Staging and surgical planning
Since no two cystectomies are the same, it is important to adequately plan for surgery. One must review the patients’ prior operative reports in order to know tumor location, size, and bimanual exam findings. Review of the CT scan allows for the identification of borderline enlarged lymph nodes, presence of hydronephrosis, or suspected involvement of adjacent tissues/organs. If there is a question of extravesical disease, an MRI can provide information on the integrity of surrounding soft tissue. This information will allow the surgeon to determine how wide a dissection should be performed and whether the participation of other specialty surgeons may be required.
After access to the abdomen is obtained, either in an open or robotic fashion, setting up adequate exposure is critical to optimize surgical efficiency and minimize the risk of injury to adjacent structures. Sigmoid colon and small bowel adhesions to the bladder and pelvic sidewalls need to be dissected sharply and the bowel needs to packed into the upper abdomen and away from the operative field. This is achieved with either a self-retaining retractor in the case of open surgery or gravity (steep Trendelenburg position) in the case of robotic surgery.
Ureters are best identified where they cross over the common iliac arteries. Incisions in the peritoneum should be performed a few millimeters away from the ureter and dissection should be carried out widely, leaving tissue surrounding the ureters intact, ensuring the preservation of blood flow and minimizing the risk of subsequent ischemic urine leaks or strictures. The ureters are transected at the level of the detrusor muscle unless there is suspected malignant involvement, in which case ureters may be taken proximally.
Frozen sections of the distal ureters may also help determine the need for additional tissue removal. The finding of CIS at the distal margin requires the excision of additional ureter until a negative margin is achieved, or the length of ureter remaining would preclude anastomosis to the urinary diversion. Clipping the ureters keeps the operative field dry and allows dilation of ureters and facilitation of the later ureteral anastomoses (figure 1).
Preparation of the vascular pedicles
The space of Retzius should be developed laterally, the vas deferens clipped and transected near the internal inguinal ring, and the bladder mobilized completely off the pelvic side walls, exposing the endopelvic fascia bilaterally. The peritoneum in the pouch of Douglas is then incised and the rectum is dissected off the base of the bladder. This can be done under direct vision using the robotic approach, allowing for the cauterization of small vessels. Seminal vesicles are dissected to their tips and damage to surrounding tissues in this area should be minimized to avoid injury to the neurovascular bundles critical for the maintenance of erectile function.
At this point, the bladder is left attached to the prostate and vascular pedicles. With the exception of the superior vesicle artery coming off the internal iliac artery, the pedicle consists of numerous arteries and veins that are difficult to isolate and clip. A vessel sealer is thus an ideal tool for this portion of the operation. Furthermore, the size and depth of the “bites” allow for continuous reassessment of tissue planes, ensuring a wider dissection when indicated by the disease (figure 2).
Next, the endopelvic fascia is opened, the puboprostatic ligaments are transected, and Denonvillier’s fascia is opened posterior to the prostate, allowing the rectum to be dissected away from the prostate from base to apex. Prostatic vascular pedicles can then be taken similarly with a vessel sealer or in an athermal manner (eg, with clips) if a nerve-sparing dissection is performed.
The dorsal venous complex
Improper handling of the dorsal venous complex (DVC) can lead to significant blood loss; therefore, this portion of the surgery should be performed with care. First, the DVC is bunched and suture ligated with a strong suture (eg, >2-0 vicryl or V-Loc suture) that can be cinched and tied tightly (figure 3). The DVC can then be transected, leaving a clear margin on the anterior/apical prostate. Occlusion of the proximal urethra by suture, clip, or catheter prevents tumor spillage.
The urethra can then be transected sharply with preservation of urethral length when an orthotopic neobladder is planned, and a urethral margin may be sent when indicated (eg, when there is suspected involvement of the urethra based on tumor location, presence of extensive CIS, etc.). The specimen can then be removed in the open approach or bagged and later extracted when the robotic approach is used.
Pelvic lymph node dissection
When performed for malignancy, a radical cystectomy should always be accompanied by an extended pelvic lymph node dissection (LND). There is evidence that a complete LND improves staging and may also improve the prognosis of the disease (although the results of a randomized trial are not yet available). The extended pelvic LND should include external and internal iliac, obturator, presacral, and common iliac lymph nodes to the aortic bifurcation (figure 4). Although some perform the LND in conjunction with the cystectomy, most do it after the bladder has been removed, allowing for more working space and greater exposure of the pelvic vessels.
Significant lymphatic channels should be clipped or sealed in order to avoid lymph leaks or lymphoceles. Adequate exposure allows this to be performed safely; therefore, the retractor will need to be adjusted in the open approach.
The root of the sigmoid colon mesentery should be completely mobilized in order to properly access the presacral lymph dissection as well as the left common iliac artery to the aortic bifurcation. This also allows for the passage of the left ureter to the right side through a wide opening, thus preventing acute angulation of the ureter.
Surgical tips and tricks
Based on the author’s own experience performing radical cystectomy, here are some additional tips and tricks:
Having adequate exposure and traction of tissues is critical to the successful completion of the steps of the operation. Spending extra time adjusting the retractor or retracting arm in robotic cases will keep the surgeon on track and minimize the risk of injury to adjacent organs.
Whenever possible, use natural planes of dissection. For most of the operation, dissection should be carried through loose areolar tissue unless cancer is locally advanced or tissues are fibrotic from prior treatment or surgery. This will shorten operative time, lessen blood loss, and minimize inadvertent organ injury.
It is important to minimize blood loss during the operation. Keeping tissue planes free of blood will improve visualization and avoid errors during surgery. Before moving on to the next step, spending extra time achieving hemostasis is always a good idea. Furthermore, minimizing postoperative anemia may potentially avoid the use of blood transfusions and aid in convalescence.
It is important to emphasize that the basic principles of a cystectomy remain the same regardless of the surgical approach used. In the case of major abdominal surgery with a reportedly high perioperative complication rate, proper intra-operative technique and postoperative management far outweigh the effect of incision size. It is therefore not surprising that a randomized study comparing open to robotic cystectomy failed to demonstrate a significant difference in morbidity (Eur Urol 2015; 67:1042-50). Wide surgical resection of malignant tissue, respecting given tissue planes, and proper tissue handing are important no matter what tool is used to accomplish the operation.
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