Radical Cystectomy

Radical cystectomy proceeds as described elsewhere. Several specific points deserve attention:

1. Laparoscopic access: Pneumoperitoneum is obtained through a standard Veress technique. A primary 10-mm trocar is placed at the umbilicus. An additional four trocars are placed in a fan-shaped distribution. Two 10-mm trocars are placed at the lateral pararectal line 10 cm above the pubic symphysis, and two 5-mm trocars 2-3 cm medial and superior to the anterior-superior iliac spines.

2. Ureteral dissection: Ureters are clipped and transected close to their insertion into the bladder. This greatly facilitates subsequent identification and atraumatic laparo-scopic manipulation.

3. Two different colored 4-0 Vicryl holding sutures are placed at the distal ends of the ureters.

4. Vascular pedicle control: The vascular pedicles of the bladder and prostate are controlled with serial applications of an Endo-GIA laparoscopic stapler.

5. Specimen retrieval: Once the bladder is fully excised, it is placed into a laparoscopic retrieval bag. In female patients, the specimen can be retrieved immediately through an opening in the anterior vaginal wall. In male patients, the specimen bag can be placed aside during the next steps of the operation. Once the abdomen is incised for creation of ileal conduit, the specimen can then be removed.

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