Radical cystectomy for carcinoma bladder

Radical cystectomy, the removal of the bladder and surrounding tissues, involves several key steps. These include initial patient positioning and port placement for robotic or laparoscopic approaches, followed by dissection and mobilization of surrounding organs like the rectum and pelvic side walls. The surgeon then identifies and dissects the ureters, bladder, and prostate (in males) or uterus and vagina (in females), carefully controlling the pelvic vasculature. Finally, urinary diversion, such as an ileal conduit or neobladder reconstruction, is performed to collect and manage urine.
Detailed Steps:
Pre-operative Preparation: This includes anesthesia, catheter insertion, and

1. RADICAL CYSTECTOMY DR. SUSHMITHA K MCH UROLOGY 1 ST YR PG

2. SCHEME OF PRESENTATION Definition Stages Indications Preop optimization Open cystectomy Robotic and lap cystectomy Complications

3. Definition: MALE: B ilateral pelvic lymphadenectomy B ladder, peritoneal covering, perivesical fat, distal ureters P rostate, seminal vesicles, vas deferentia M embranous or entire urethra. (sometimes) FEMALE: Anterior pelvic exenteration B ilateral pelvic lymphadenectomy C ystectomy, urethrectomy H ysterectomy, salpingo -oophorectomy, and partial anterior vaginectomy.

4. Stages:

5. Indications:

6. Indications:

7. Preoperative optimization Cardiac optimization Pulmonary optimization Smoking and alcohol consumption cessation Antibiotic prophylaxis Thromboembolic prophylaxis Adequate hydration No role of bowel preparation Stoma site marking

8. Open Radical cystectomy

9. STEP 1 – Mobilize the urachus from the umbilicus

10. STEP 2 – Mobilize the bladder from the bowel

11. STEP 3 – Isolate and transect the ureters

12. STEP 4 – Complete lymph node dissection

13. STEP 5- Division of lateral vascular pedicle

14. STEP 6 – Separate bladder from sigmoid colon

15. STEP 7 – Complete posterior dissection and cut off bladder blood supply

16. STEP 8- Exposure of the posterior vascular pedicle of the bladder for ligation. Ligation and division of the posterior pedicle.

17. STEP 9 – Complete anterior dissection and isolate urethra

18. MALE RADICAL CYSTOPROSTATECTOMY Foley catheterization Midline incision Develop space of retzius Mobilize bladder from pelvic side wall Divide the urachal remnant Divide vas Divide posterior peritoneum expose ureters Mobilize ureter proximally to preserve periureteral blood supply Pelvic lymphadnectomy Divide endopelvic fascia Divide lateral vascular bladder pedicles Establish plane between rectum and posterior bladder wall Ligate dorsal vein Dissect neurovascular bundles off prostate bilaterally Incise urethra Divide posterior bladder pedicle

19. FEMALE RADICAL CYSTECTOMY Foley catheterization Midline incision Mobilization of bladder from pelvic side wall Divide urachus Ligate infundibulopelvic ligaments (ovarian artery) round ligaments Incise broad ligament to expose ureters and mobilize Pelvic lymphadenectomy Circumferential incise cervix Divide urethra Close vaginal defect

20. Identification of the vaginal cuff posterior to the cervix. Incision of the posterior vaginal cuff.

21. Posterior vaginal wall and defect at the level of the introitus after en bloc removal of the bladder in an anterior pelvic exenteration in the female patient. (B) Intraoperative photograph of the introital defect. (C) Coverage of the introital defect with a flap made from the posterior vaginal wall.

22. Circumferential division of the vaginal cuff from the attachments to the cervix. (B) Closure of the vaginal cuff and placement of the urethral anastomotic sutures. (C) Intraoperative photograph of the completed repair.

23. Complications Re operation (10%) Bleeding (10%) Sepsis and wound infection (10%) Intestinal obstruction or prolong ileus (10%) Cardio pulmonary morbidity Rectal injury (4%) Cx of urinary diversion Peri operative mortality – 3% Early complications (within 3 months of surgery) in 28%

24. LYMPHNODE DISSECTION

25. Robotic and lap radical cystoprostatectomy Evolving Morbidity – limited Operative time – comparable Long term oncologic outcomes – awaited

26. Technically demanding in laparoscopic procedures. Urinary diversion is usually performed extracorporeally. No difference in term of lymph node yield and complication rate. Increased operation time but blood loss reduced. No consensus on oncology outcome.

27. Surgical Positioning and Port Placement Two bedside assistants are used . Patient is placed in the dorsal lithotomy position Patient is placed in 30-degree steep t rendelenburg position

28. Indications and contraindications Indications: similar to open radical cystectomy Contraindications: I nclude extensive prior abdominal surgeries morbid obesity (positioning and ventilation issues) B ulky or locally advanced tumors .

29. Complications Intraoperative: Hemorrhage Rectal perforation Early: Wound hernia or Dehiscence Bowel obstruction Ureteral stricture UTI / Pyelonephritis stones Renal deterioration

30. Late: wound Infection Intra abdominal abscess Pyelonephritis Hemorrhage Urine leak / Fistula Bowel leak / Fistula Ileus Bowel Obstruction

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