Keywords

Introduction

Radical cystectomy (RC) with pelvic lymph node dissection (pLND) represents the cornerstone for treatment of muscle invasive bladder cancer, and refractory non-muscle invasive disease. However, RC remains a major procedure that poses considerable risks and perioperative morbidity [1,2,3]. In this context, much interest has been spurred in robot-assisted radical cystectomy (RARC) aiming at improving perioperative outcomes and enhancing patient recovery while providing superior visualization, magnification and ergonomics for the surgeons. Recently, RARC has been shown to provide equivalent long term oncologic outcomes to its open counterpart, and to be superior in terms of blood loss, transfusion rates and hospital stay [4].

Although anterior pelvic exenteration remains the standard of care for female patients with bladder cancer, recent data suggest that involvement of female reproductive organs is relatively uncommon (<8%) [5]. Removal of female reproductive organs adversely impact sexual function and quality of life. Sparing the female reproductive organs helps in maintaining the support of the pelvic floor, which may improve urinary function. Additionally, preservation of the anterior vaginal wall may decrease the incidence of fistula formation between the vagina and bowel or neobladder [6].

In this chapter we will discuss and demonstrate a step-by-step anatomic approach to RARC in females, both anterior pelvic exenteration and female organ-Sparing cystectomy.

Preoperative Preparation

Informed consent should be obtained from all patients undergoing RARC after thorough counseling about the risks, benefits and possible complications and consequences, including stoma management and the possibility of self-catheterization if a catheterizable reservoir is created. A comprehensive preoperative anesthesiology assessment that includes cardiac, renal and hepatic testing and correction of modifiable medical disease should be performed. Careful evaluation of the patient’s pulmonary function is vital considering the steep Trendelenburg position.

“Fast track” or enhanced recovery protocols (ERAS) have been incorporated in the preoperative, intraoperative and postoperative management to promote patient recovery and minimize the associated morbidity [7]. Screening patients revealed that a significant number of patients are malnourished. Improving the preoperative nutritional status of patients has been shown to reduce complications and enhance recovery in gastrointestinal surgery [8,9,10,11]. Smoking cessation prior to major surgery reduces perioperative complications and readmission rates [12, 13]. Despite the well-known benefits of physical exercise, the current evidence supporting the benefits of physical exercise prior to RC remains inconclusive to provide any recommendations.

Patients are safely allowed intake of solids up to 6 h and liquids up to 2 h before surgery [14]. Preoperative oral intake of a clear fluid rich in carbohydrates 2–3 h prior anesthesia reduces thirst, anxiety, catabolism and may promote postoperative muscle strength, and earlier return of bowel function [15, 16]. Omitting mechanical bowel preparation is largely supported by the colorectal surgery literature. However, non-digestible vegetables can be seeded into the peritoneum during construction of the urinary diversion, and vegetables should be avoided for 1 day before RARC [14].

Thrombo-embolic complications are not uncommon after RC [17]. Mechanical methods (as compression stockings and intermittent pneumatic compression devices) and low molecular weight heparin are important for measures for thrombo-embolic prophylaxis [18]. Broad-spectrum intravenous antibiotics are preferably administered 1 h before the start of the procedure.

Positioning and Port Placement

The patient is positioned in the Trendelenburg position (with feet at least 10–15° higher than the head) to displace the intestinal loops upwards, providing more working space. The abdomen is insufflated using the Veress needle or Hasson technique. After placing the camera port, all ports are placed under direct vision. Ports should be placed more cephalad to facilitate bowel maneuvering and performing extended pelvic lymph node dissection. A standard 6-port transperitoneal approach is used with an additional 12 mm short suprapubic port placed later to facilitate bowel anastomosis (Fig. 15.1).

Fig. 15.1
figure 1

Standard 6-port transperitoneal approach

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“Technique of Spaces”

‘Technique of spaces’ deconstructs the procedure into smaller measurable portions that keeps the surgeon focused and facilitates training. The spaces of dissection are the periureteral spaces, lateral pelvic spaces, retrouterine space, and retropubic space [19].

Peri-Ureteral and Lateral Pelvic Spaces

The ureter is identified by incising the posterior peritoneum above the iliac vessels, where the uterine artery is encountered crossing the ureter. Both structures are left intact until all other landmarks are identified. Ureteral identification may be more difficult on the left because of the possible inflammatory adhesions from previous diverticular disease. The fourth arm can be used to retract the sigmoid colon on the left side to improve exposure and facilitate dissection. The ureter is dissected distally toward the uretero-vesical junction (UVJ) maintaining adequate peri-ureteral tissue to prevent ischemia to the distal ureter.

Lateral pelvic space is identified by incising the anterior peritoneum lateral to the medial umbilical ligament, and the incision is extended towards the ipsilateral ureter. This space contains the round ligament (which extends from the deep inguinal ring to the uterus) and the infundibulopelvic ligament (which contains the ovarian pedicle, lies anterior and lateral to the ipsilateral ureter) (Fig. 15.2). Control of the ovarian pedicle is achieved by dissecting the peritoneum connecting the infundibulopelvic ligament with the internal iliac vessels. Then, any areolar tissue is swept from lateral to medial to maintain adequate soft tissue margin and avoid injury to the iliac vessels. The endopelvic fascia is identified and incised.

Fig. 15.2
figure 2

(a) The round and infundibulopelvic ligaments. (b) Ureter, uterus, ovary, internal iliac and uterine arteries

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After identification of all the landmarks, the ureter is clipped, and the distal margin is cut using scissors and sent for frozen section. The uterine and vesical blood vessels are divided.

Retro-Uterine Space

Once both lateral pelvic spaces are developed on either side, the posterior peritoneum remaining between the two ureters is incised across the midline, including the recto-uterine pouch (Fig. 15.3). Manipulation of an intravaginal dilator helps identifying the junction of posterior fornix with the cervical os. This is followed by blunt dissection in a sweeping manner of the posterior vaginal fornix from the Denonvillier’s fascia overlying the rectum. Care must be taken to preserve the pelvic plexus that descends on the lateral vaginal wall (which supplies the vagina and urethra, and therefore important for adequate sexual function).

Fig. 15.3
figure 3

Recto-uterine pouch

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Ligation of the Vascular Pedicles

After developing the aforementioned spaces, the fourth robotic arm is used to apply anterior retraction to the uterus. The right and left arms are used to manipulate the perivesical tissue to clearly define the vascular pedicles. An endo GIA stapler is used to divide the vascular pedicles (Fig. 15.4).

Fig. 15.4
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Endo GIA stapler is used to divide the vascular pedicles

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Retropubic Space (Cave of Retzius)

The bladder and the uterus are dissected from the anterior abdominal wall by incising the urachus and medial umbilical ligaments as cranial as possible in order to ensure an adequate soft tissue margin. The urethra is exposed and the indwelling Foley catheter is drawn out. The whole length of the urethra is excised if an ileal conduit was preoperatively planned (Fig. 15.5). Alternatively, if a neobladder was planned, a large clip is placed across the urethra to prevent antegrade urine spillage, and the distal urethral margin is sent for frozen section.

Fig. 15.5
figure 5

The whole length of the urethra is excised if an ileal conduit was preoperatively planned

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Development of Anterior Vaginal Space

Preservation of the anterior vaginal wall is important for sexual function and largely depends on preoperative oncologic planning. In order to preserve adequate length of anterior vaginal wall, traction is applied on the uterus using the fourth arm followed by careful dissection between the anterior vaginal and posterior bladder walls.

The specimen is put in an endo bag and can be extracted transvaginally (Fig. 15.6). The vagina is closed in a transverse fashion to avoid a narrow dysfunctional vagina.

Fig. 15.6
figure 6

The specimen is put in an endo bag and can be extracted transvaginally

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Pelvic Lymph Node Dissection

Pelvic lymph node dissection is an integral part of the procedure. It is crucial for adequate staging, removal of any possible micrometastatic disease, and identifying patients who may require adjuvant treatment. It has been shown that thorough lymph node dissection improves survival even in node negative patients. There is a growing body of evidence suggesting that extended lymph node dissection template, and lymph node count of more than 20 lymph nodes are associated with the highest benefit [20,21,22]. Adequacy of lymphadenectomy has been used as a surrogate for the quality of surgical performance [23].

One advantage of performing the lymphadenectomy after RARC is that it allows more freedom of movement within the pelvis. The fourth arm is used to retract the sigmoid medially away from the dissection area allowing access to the more proximal nodal tissue. All lymphatic tissue overlying he common, external and internal iliac vessels is removed. Dissection is extended to the genitofemoral nerve laterally, internal iliac artery medially, lymph node of Cloquet distally and proximally to the aortic bifurcation (Fig. 15.7). Judicious use of cautery is exercised control and seal the lymphatic channels while avoiding vascular injury.

Fig. 15.7
figure 7

(a) Before Pelvic lymph node dissection. (b) After Pelvic lymph node dissection

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The dissected nodal tissue is placed in an endo bag and can be extracted through the vagina incision or through extension of one of the ports incision. Care must be undertaken to avoid spillage of the endo bag contents.

Postoperative Care

Although gastric decompression may be beneficial in reducing postoperative nausea and vomiting, it has been shown that early removal of nasogastric tube in the recovery room after extubation is associated with reduced complications [24]. Alvimopan and chewing gums allow early return of bowel function and shorter hospital stay [25, 26]. Adequate pain control is crucial. Baseline treatment should include regular administration of acetaminophen. Epidural analgesia is very effective, but may hinder early mobilization [7].

Early mobilization has been associated with better cardiac and respiratory functions and psychological well-being, in addition to prevention of thrombo-embolic complications [27]. Early institution of an oral diet seems to enhance bowel function and decrease the time to first bowel motion and shorten hospital stay without increasing complications [28]. It has been also associated with improved cognitive function in the postoperative period [29].

There is no consensus on the optimal timing for stent or catheter removal [7]. It is our preference to remove the stents after 8–10 days in patients who had ileal conduits, and to remove the urethral catheter with the stents after 3 weeks in patients who had neobladders following a normal pouchgram.