Dissection of the ureters

See Figs. 25.1 and 25.2 .

Dissection of Right Ureter.

Distal clipping of right ureter, just above the vesicoureteric junction.

The position of the ureters beneath the peritoneum is variable, but entering the pelvis over the pelvic brim, they generally cross the bifurcation of the common iliac arteries. Incising the peritoneum over this point is a reasonable first step. Their localization may be more challenging on the left side than the right, due to adhesions from diverticular disease, requiring adhesiolysis, which may distort the underlying anatomy. Using the fourth arm to retract the sigmoid colon may be helpful, and once the peritoneum is opened, dissecting inferiorly medial to the pelvic side wall may also reveal their location. Once found, they are dissected distally toward the uretero-vesical junction, taking care not to dissect off the periureteral tissue which may cause devascularization, and increase the risk of subsequent ureteric stricture. To reduce direct ureteric manipulation, some surgeons will pass a silicone loop around the ureters, which can be pulled by the robotic instrument during dissection, rather than grasping the ureter itself. Once the uretero-vesical junction is reached, the ureters are divided between two Hem-o-loks, each with an attached stay suture. This makes their manipulation easier during the later conduit or neobladder reconstruction and uretero-ileal anastomosis. Routinely, the distal ureteric margins are sent for frozen section.

Dissection of the anterior rectal space

See Figs. 25.3–25.13 .

For men, it’s important to localize the course of the vasa before incising the peritoneum horizontally on either side of the midline posterior to the bladder in an inverted U shape. The fourth arm can be used to elevate the upper aspect of the incised peritoneum, and the seminal vesicles are dissected and vasa divided on each side. This opens up Denonvillier’s fascia between the posterior surface of the prostate and anterior rectum, which is further opened distally down to yellow pelvic fat toward the pelvic floor. In women, dissection of the cul-de-sac is done after a similar inverted U as men, 2 to 3 cm superior to the common iliac vessels. The details of non-organ- or organ-sparing dissection are discussed below, but the basic principle is to dissect between the uterus and posterior wall of bladder, down to the junction between uterus and vagina. Manipulating the uterus with the fourth arm may be helpful for this, as well as placing a sponge in the vagina to further delineate the anatomy. The vagina is opened, and the anterior wall of the vagina is taken with the cystectomy specimen.

Dissection of the lateral rectal space and control of the vascular pedicles

See Figs. 25.14–25.23 .

For men, the peritoneum is divided lateral to the umbilical ligaments to open up the Retzius space. This is dissected to the endopelvic fascia, which is opened to allow separation of the prostate from levator ani down to the prostatic urethra and dorsal vein complex at the prostatic apex. Most surgeons will keep the umbilical ligament and urachus intact until the end of this dissection to prevent the bladder from falling into the pelvis and obstructing the surgeons’ view. With the bladder under traction from the fourth arm, the superior vesical artery, inferior vesical artery and vesico-prostatic artery can be divided by a LigaSure or between Hem-o-lok clips. For women, the lateral dissection is similar, lateral to the umbilical ligaments, ensuring that the vascular pedicles are isolated, continuing down to the endopelvic fascia. Once the round ligament is divided, levator ani is separated from the lateral aspect of the vagina exposing the urethro-vesical junction. For both men and women, once down to the pelvic floor, the bladder can be elevated with the fourth arm, which gently stretches the vascular pedicle away from the rectum and external iliac vessels so it can be safely divided with a LigaSure instrument used by the assistant or by a robotic LigaSure. Further dissection of the anterior division of the internal iliac artery will isolate the inferior iliac vessels, that may be divided in the same way. For both men and women, during dissection of the lateral space, it is important to avoid injury to the obturator nerves.

Bladder mobilization and urethral transection

See Figs. 25.24–25.34 .

The catheter balloon is pulled down to the vesicourethral junction.

Circumferential dissection of the urethra with posterior dissection to separate the posterior urethral wall from the anterior vaginal wall.

Ligation of the urethra just distal to the vesicourethral junction prior to urethral transection.

Urethral Transection.

Completion of Urethral Transection With Division of Posterior Urethral Wall.

Dissection of Prostatic Apex and Division of the Dorsal Vein Complex (DVC).

Right Posterolateral Dissection of Prostatic Apex.

Anterior Urethral Wall Transection.

Tissue from urethral margin is sent for frozen section to determine eligibility for neobladder.

Posterior Urethral Wall Transection.

Double-clipped end of divided catheter to ensure no tumor spillage, seen in the cysto-prostatectomy specimen.

The lateral dissection is continued on either side of the bladder, down to the pelvic floor, following the pubic bones and opening the endopelvic fascia if it remains intact. This will allow further definition of the prostate and prostatic urethra in men, and the vesicourethral junction in women. Nerve- or organ-sparing technical variations are discussed below. The dorsal vein complex, more developed in men, can be ligated and divided with the pneumoperitoneum increased to 20 mm Hg to minimize bleeding. The dorsal venous complex (DVC) can be oversewn, especially for men, before completing the urethral transection by applying the largest Hem-o-lok with the catheter in place, which is then divided at the same time, to prevent spillage of tumor cells. At the time of urethral transection generally as much urethra is spared as possible.

Bladder drop

See Figs. 25.35 and 25.36 .

Oversewing of the Dorsal Vein Complex (DVC).

Division of the Urachus and the Bladder Drop.

The urachus and median umbilical ligaments are divided last, and the bladder is dropped completely from the under surface of the anterior abdominal wall distally down to the pubic symphysis. Most of this dissection may have already been done to facilitate the urethral transection. During the bladder drop, it is important to avoid injury to the inferior epigastric vessels.

ELND

ELND (see Chapter 27 ) is generally done after the cystectomy, before the bowel work. In principle, lymph node tissue is removed distally to the circumflex iliac veins, inferiorly to internal iliac vessels over the pelvic floor, laterally to the genitofemoral nerve over psoas, and proximally to the presacral area up to the aortic bifurcation. Venous injuries that occur during the dissection can often be managed with pressure and Surgicel, as suturing may exacerbate the injury and create a larger tear.

Specimen removal

See Figs. 25.37 and 25.38 .

Bladder drop with dissection of the bladder off the undersurface of anterior abdominal wall toward the pubic symphysis.

Cystectomy Specimen.

In neobladder cases, prior to proceeding, a sample is sent to frozen section from the urethral stump to determine urethral margin status.

The bladder specimen is placed into a large bag when it has been freed. Similarly right and left lymph node packets are placed in individual bags, and a method such as tying a knot in the string allows differentiation of right and left. All three bags are clipped, and depending on the need for biobanking, can be removed at the same time mid operation which requires dedocking, or upon completion of the procedure. When removing the specimen, care should be taken not to rupture the bags or injure the mesentery of the conduit which may be close by.

Urinary diversion

Prior to starting the urinary diversion part of the operation (see Chapter 26 ), and irrespective of any planned ileal conduit or orthotopic neobladder, the left ureter is transferred to the right side of the abdomen beneath the sigmoid mesentery taking care not to damage the underlying vessels. For the bowel work, again regardless of choice of urinary diversion, a robotic bowel grasper and Cadiere instrument are placed in the second and third arms respectively, and the fourth arm is removed to allow the GI stapler to be brought into the abdomen by the surgical assistant through the 15-mm trocar. The details of the uretero-ileal anastomosis with stent insertion and specific bowel reconstruction, as well as potential complications, are dealt with in the chapter on Urinary Diversion. ^{, ,}

Specific technique

Port placement, lysis of adhesions, and ureteric dissection are the same for both men and women, the techniques diverging with the posterior dissection. Before making the incision in the posterior peritoneum in men, it is helpful to localize the path of the vas deferens, tracking beneath the peritoneum from lateral to medial, toward the tips of the seminal vesicles. Once oriented, with the assistant retracting the peritoneum up, an 8-cm U-shaped incision is made in the peritoneum above the seminal vesicles, in the cul-de-sac above the rectum (see Figs. 25.7 and 25.8 ). The vertical limbs extend inferiorly and proximally toward the bifurcation of the common iliac vessels on each side. Dividing the vasa and dissecting the seminal vesicles exposes Denonvilliers’ fascia. Small vessels can be clipped, especially if nerve sparing (NS) is being undertaken as this avoids cautery which may injure the cell bodies and fibers of the pelvic plexus in close proximity to the seminal vesicle’s tips and bodies (see Figs. 25.9–25.11 ). Denonvilliers’ fascia is opened and a plane developed between Denonvilliers’ fascia (on the under surface of the prostate) and the anterior perirectal fat overlying the rectum, which limits the risk of rectal injury (see Figs. 25.12 and 25.13 ). As the dissection extends distally, the third arm may be used to lift the prostate and bladder by the seminal vesicles, to facilitate dissection toward the pelvic floor.

Marking out the horizontal incision at the beginning of the posterior dissection below the bladder.

Horizontal incision either side of the midline below the bladder at the beginning of the posterior dissection.

Posterior dissection demonstrating dissection of the left vas and seminal vesicles with minimal cautery, part 1.

Posterior dissection demonstrating dissection of the left vas and seminal vesicles with minimal cautery, part 2.

Posterior dissection demonstrating dissection of the right vas and seminal vesicles with minimal cautery.

Incision of Denonvilliers’ Fascia.

The posterior dissection then continues between the prostate anteriorly and the rectum posteriorly, toward the pelvic floor, ensuring fat is kept on the anterior surface of the rectum to limit the risk of rectal injury, part 1.

Incision of Denonvilliers’ Fascia.

The posterior dissection then continues between the prostate anteriorly and the rectum posteriorly, toward the pelvic floor, ensuring fat is kept on the anterior surface of the rectum to limit the risk of rectal injury, part 2.

Once the posterior dissection is complete, the next step is to develop the lateral pelvic space between the bladder and pelvic side wall. On each side, incisions are made lateral to the medial umbilical ligament, and the plane is developed distally with gentle blunt dissection and cautery, opening the space of Retzius to the endopelvic fascia and Cooper’s ligament (see Fig. 25.18 ). The bladder can be retracted up toward the upper part of the abdomen, to further open up the space, and it is important to keep the urachus and umbilical ligaments untouched, to prevent the bladder dropping down and obscuring the operative field. The vasa may be divided again to further open up the space, and the anterior division of the iliac artery is a helpful anatomical landmark. This gives rise to the inferior vesical artery which bifurcates distally into the urethral and capsular arteries, the latter of which may also have anastomotic feeders. If possible, the capsular arteries are preserved at the level of the upper lateral part of the prostate near the origin of the seminal vesicles, as they contribute to the neurovascular bundles, but the urethral artery is clipped and divided. Once the pedicles are clearly defined the umbilical/superior vesical and inferior vesical arteries are clipped with Hem-o-lok clips and divided or alternatively divided using the handheld or robotic LigaSure instrument (see Fig. 25.19 and 25.20 ). Once the pedicles are divided, the bladder can be dropped by dividing the medial umbilical ligaments and urachus and dissecting the distal aspect of the bladder off the under surface of the anterior abdominal wall, taking care to avoid injury to the inferior epigastric vessels. Laterally, the endopelvic fascia can be opened, and the lateral aspects of the prostate are mobilized off levator ani, continuing distally to the puboprostatic ligaments. Once the prostate is free, the dorsal vein complex is ligated and divided, a part of the procedure prostatectomists will be familiar with (as well as the proceeding apical dissection and urethral transection). For the DVC ligation, the pneumoperitoneum may be raised to 20 mm Hg and a common method is to pass an O Vicryl suture on a round needle underneath the vessels, above the urethra and distal to the prostate, then use cold cut scissors to divide the DVC (see Fig. 25.29 ). Once the DVC is divided, the urethra is transected beyond the prostatic apex and if orthotopic neobladder is the chosen modality of urinary diversion, the urethral transection aims to preserve maximal urethral length (see Fig. 25.30–25.34 ). A large clip is applied across the urethra with the catheter in place to prevent tumor spillage. Once the urethra has been cut, the specimen (bladder, prostate, and seminal vesicles) is placed into a large endo-catch bag. The pneumoperitoneum is dropped to check for bleeding and any open vessels may be oversewn with 3/0 Vicryl (see Fig. 25.35 ). If the specimen is to be removed intraoperatively, generally this is done once the LND is complete with both lymph node packets, through an extended camera port incision. The camera port incision is sometimes made larger for this purpose at the beginning of the procedure, using the Alexis gel port system, which allows passage of the camera trocar but prevents leakage of gas from the pneumoperitoneum.

Incision of the Peritoneum Lateral to the Right Medial Umbilical Ligament.

Robotic LigaSure of the Right Superior Bladder Pedicle.

Hem-o-lok clip and athermic division of the right prostatic pedicle at the base of the prostate.

For more details, see Figs. 25.7–25.13 and 25.18–25.35 .

High release and athermic dissection of the right lateral prostate fascia that contains putative accessory nerve pathways, part 1.

High release and athermic dissection of the right lateral prostate fascia that contains putative accessory nerve pathways, part 2.

High release and athermic dissection of the right lateral prostate fascia that contains putative accessory nerve pathways, part 3.

Nerve sparing

Erectile dysfunction is a common sequela of RARC that significantly affects quality of life long term. There is evidence that male nerve sparing (MNS) RARC improves potency postoperatively, as well as theoretically improving continence outcomes for those who undergo orthotopic neobladder by preventing denervation of pelvic floor and urethral sphincter musculature (see discussion below). Technically, much of the NS approach is similar with variations stemming from a detailed understanding of the neuroanatomy of the pelvic plexus and an understanding of the pathophysiology of neural injury. The pelvic plexus has a trizonal structure, with a prior landmark paper describing a surgical approach to nerve sparing in RP by Walsh and Donker. The trizonal structure is formed firstly by the proximal neurovascular plate, which is a structure shaped like a bilateral rectangular plate. It begins at the junction of distal ureter and vasa just beneath the peritoneal surface, and then passes anteriorly in close relation to the lateral and posterior aspect of the seminal vesicles. Secondly, there are the accessory nerve pathways, which are putative nerve fibers within the lateral fascia of the prostate on its anterolateral and posterior aspects. Finally the third aspect of the trizonal structure is the predominant neurovascular bundle, more of a classical nerve, also found within the lateral fascial layers of the prostate in a groove between the prostate and rectum. As described by Walsh, it has a somewhat variable course within this groove, especially distally near the prostatic apex. ^, It is important to note injury to the cell bodies of the nerves in the proximal neurovascular plate is irreversible, so that the distal nerve fibers will degenerate permanently, but injury to the nerve fibers only is potentially reversible. Bearing in mind the location of the pelvic plexus and its trizonal structure, the technical aspects of male NS RARC only differ from standard male RARC once the dissection reaches the seminal vesicles and beyond to the apical dissection and urethral transection. During the posterior dissection around the seminal vesicles, minimal cautery is used near their middle and tips, which are closely related to the cell bodies of the proximal neurovascular plate (see Figs. 25.7–25.13 ). Another approach is to divide the seminal vesicles close to the prostate, which avoids dissecting their bodies and tips at all. Moving forward to the pelvic floor, minimal cautery is used to open the lateral pelvic space, and from the base to apex of the prostate, the neurovascular bundles are dissected laterally within the lateral prostatic fascia after high release of the fascia on the prostate, in a tension- and energy-free manner. As much as possible the capsular arteries are preserved and titanium clips are applied to small penetrating arteries (see Figs. 25.21–25.23 , 25.29 , and 25.30 ). Toward the apex of the prostate, special attention is paid not to damage the neurovascular bundles posterolateral to the urethra at 2 and 10 o’clock, as well as minimizing trauma to the adjacent tissues to prevent damage to accessory pudendal arteries and small branches of the pudendal nerves (see Fig. 25.30 ). There are two technical variations on this NS approach including nerve and seminal vesicle sparing (SVS) cysto-prostatectomy as well as capsule sparing cystectomy. For the SVS technique, dissection of the prostate is performed retrogradely within the intrafascial plane, without excising the vasa or seminal vesicles which will also spare all aspects of the pelvic plexus. ^, The capsule sparing technique involves precystectomy prostate biopsies and transurethral resection of prostate to exclude incidental prostate cancer, followed by RARC with preservation of prostate capsule, seminal vesicles, vasa and capsule of the prostate, also preventing any intraoperative injury to the pelvic plexus. ^, The NS approach also continues during the ELND, with sparing of the lymph nodes medial to the ureters at the bladder pedicle to prevent injury to the hypogastric nerves.

For more details, see Fig. 25.7–25.13 , 25.18–25.23 , and 25.19–25.35 and Video 25.1 .

Specific technique

As stated above, port placement and ureteric dissection are similar for male RARC and female anterior exenteration (see Figs. 25.1 and 25.2 ). In females, the posterior dissection also begins with a U-shaped incision of the peritoneum in the cul-de-sac above the rectum, the straight limbs of which extend proximally on each side to the bifurcation of the common iliac vessels. The fourth arm is used to place the uterus under traction and allow access to the plane between the posterior bladder and the uterus and vagina. In order to fully mobilize the uterus, the infundibulopelvic ligaments are identified and can be divided by LigaSure instrument or after application of Hem-o-lok clips or sutures. The round ligament and pedicle of the ovaries are dealt with in a similar fashion, as is the uterine artery pedicle. This allows the uterus to be retracted proximally, exposing the junction between the uterus and vagina more easily, which may be further identified by pushing a sponge into the vaginal cavity. Analogous to NS in the male, it is important to limit cautery and traction of the autonomic nerves that run distally adjacent to the lateral walls of the vagina. For the technique of pelvic organ preserving (POP) RARC, see below (see Fig. 25.3–25.6 ). The next step is to develop the bladder dissection and space lateral to the medial umbilical ligaments, and with the round ligaments already divided, this identifies the vascular pedicles (see Fig. 25.14–25.17 ). The superior vesicle artery is clipped and divided with Hem-o-loks or LigaSure instrument, and the bladder placed under traction by the fourth arm. This lifts the bladder away from the external iliac vessels to more easily identify the branches of the anterior division of the internal iliac vessels, which can be individually clipped and divided. In the absence of POP, the key to the hysterectomy, bilateral salpingo-oophorectomy, and vaginal dissection is fourth arm position and manipulation of the uterus. The bedside assistant will also contribute by moving the sponge stick in the vagina. This will help localize the posterior fornix of the vagina, and a horizontal peritoneal incision is made over this. The incision is then extended distally along the anterolateral wall, so that the anterior wall of the vagina is removed with the specimen. Once again, care is taken not to injure the autonomic nerves, and as the dissection proceeds distally to the pelvic floor, any vessels encountered can be clipped and divided. Once reaching the pelvic floor, the endopelvic fascia is opened, taking care not to injure autonomic nerves near the arcus tendinous fascia pelvis. At this point, before the urethral dissection, most surgeons will now divide the medial umbilical ligaments and urachus and drop the bladder from the undersurface of the anterior abdominal wall down to the apical dissection of the vagina (see Fig. 25.36 and 25.37 ). This includes dissection of the pubovaginalis ligaments similar to the puboprostatic ligaments, and the dorsal vein complex. Manipulating the catheter clearly defines the vesicourethral junction, and the dorsal vein complex may be dealt with simply by cautery although a stitch through the dorsal vein may be used as for men (see Fig. 25.24–25.26 ). Further dissection of the periurethral tissue and anterior vagina is done to isolate the external urethral meatus prior to completing the urethrectomy. For procedures to include an orthotopic neobladder, the urethra is divided approximately 5 mm down from the bladder neck to conserve the sphincter mechanism as much as possible (see Fig. 25.27 and 25.28 ). The specimen is placed in a large endo-catch bag, and in some cases this may be removed through the vaginal opening, which is subsequently sutured closed with 3/0 V lok sutures (see Fig. 25.38 ). ^{, , ,}

Incision of peritoneum and initial dissection into plane between posterior bladder wall and anterior vaginal wall, part 1.

Incision of peritoneum and initial dissection into plane between posterior bladder wall and anterior vaginal wall, part 2.

Distal dissection into plane between posterior bladder wall and anterior vaginal wall, toward the pelvic floor, part 1.

Initial dissection into plane between posterior bladder wall and anterior vaginal wall, toward the pelvic floor, part 2.

Lateral dissection and dissection of left superior bladder pedicle, part 1.

Lateral dissection and dissection of left superior bladder pedicle, part 2.

LigaSure of the left superior bladder pedicle using the assistant handheld LigaSure.

LigaSure of the right superior bladder pedicle using the assistant handheld LigaSure.

For more details, see Figs. 25.1–25.6 , 25.14–25.17 , 25.24–25.28 , and 25.36–25.38 .

Organ sparing

One of the primary aims of surgical oncology is to maximize oncological outcome, while preserving functional outcomes as much as possible. In the same way that erectile dysfunction affects health-related quality of life (HRQoL) outcomes for men after RARC, female sexual dysfunction post RARC is common, especially for younger women. With this in mind, POP RARC with orthotopic neobladder has been used to improve both postsurgery sexual function and body image. The risk of POP is inadequate excision of the primary tumor, with the potential to leave microscopic disease behind. This may arise from inaccurate preoperative clinical staging, and potentially increase the chance of local recurrence. Nevertheless, a recent systematic review showed, in carefully selected patients, POP RC and neobladder had similar oncological outcomes to standard RC and better functional outcomes, both sexual and urinary, albeit with short-term follow-up. Moreover, maintaining body image and vascular and nerve preservation of the clitoris may facilitate a return to sexual activity in the postoperative period, and a minimally invasive robotic approach allows an expedited surgical recovery. Patient selection is crucial to preoperative planning for POP RARC to minimize the risk of local disease recurrence, and women with carcinoma in situ (CIS), clinical evidence of extravesical disease (cT3), hydronephrosis, possible node positive disease, or tumors located near the base of the bladder should not undergo POP RARC. From a technical point of view, for the conservation of genital organs, when approaching the vaginal dissection, traction is applied to the uterus with the fourth arm as before to highlight its junction with the vagina, made easier by the assistant using a sponge stick (see Fig. 25.3–25.6 ). The uterine and ovarian pedicles as well as the infundibulopelvic ligaments are left intact, and the plane between anterior wall of the vagina and posterior wall of the bladder are developed down to the pelvic floor, without incising the vagina. Taking care not to injure the autonomic nerves that are adjacent to the lateral vaginal wall is as important as in the non-POP approach, and the endopelvic fascia is preserved. The urethra is then dissected out circumferentially, with the catheter removed, and excised with the bladder before the whole specimen is placed in a large endo-catch bag (see Fig. 25.24–25.28 and 25.38 ). ^{, , ,}

See Fig. 25.1–25.6 , 25.14–25.17 , 25.24–25.28 , and 25.36–25.38 andVideo 25.1 .