V05-08: Peritoneum, nerve and prostate apex sparing extraperitoneal radical cystoprostatectomy (RC) and extraperitoneal orthotopic neobladder formation
Peritoneum preservation during RC and extraperitonization of orthotopic neobladder offered the advantage of reduction in the length of hospitalization, early recovery and less bowel related complications, according to several publications. Incontinence and impotence after RC and orthotopic urinary diversion are significant factors diminishing quality of life. Standard nerve sparing technique that is widely used during radical prostatectomy and cystectomy not always leads to the preservation of erectile function, while quality of life parameters are independent prognostic factors for overall survival. Therefore, farther improvements of RC surgical techniques are strongly needed. Our aim was to apply several, modified, sparing techniques in one single surgical procedure of RC aiming at reduction of postoperative bowel complications, improvement of continence and reduction of postoperative erectile dysfunction.
The video presents the surgical procedure for 58 years old man with muscle invasive bladder cancer, tumor located at the lateral bladder wall. The man is sexually active and willing the preservation of erectile function. He is strongly motivated for orthotopic neobladder formation
Retrograde RC was initiated aiming at maximal sparing of posterior bladder wall covering peritoneal tissue. After the anatomical transaction of dorsal vein complex, the prostatic fascia was incised as ventrally as possible, to achieve the maximum sparing of the part of prostatic fascia containing branches of neurovascular bundles; this also helped to spare very thin area of prostate apex. For maximal sparing of neurovascular bundles and its branches, the maximal sparing of the surrounding tissue was employed via careful dissection as far from neurovascular bundles as possible: using direct visual control; dissection exactly at the surface of the seminal vesicles. The peritoneal cavity is remaining closed until RC has been finalized. Orthotopic neobladder is created and complete extraperitonization of the neobladder is carried out. Peritoneal cavity is closed almost hermetically.
Simultaneous use of the several, modified, sparing techniques during the one single RC is achievable. This might lead to the better survival after RC via the reduction of postoperative bowel complications and improvement of quality of life due to better erectile function and continence.