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Pre/Post-Op Cystectomy Management

ERAS Preop

• Provide resources to understand disease and connect with others (BCAN)
• Correct anemia, nutritional deficiencies
• Encourage smoking cessation and alcohol reduction 4 weeks before surgery
• No need for mechanical bowel preparation
• Encourage preoperative carbohydrate loading
• Ingest solids up to 6 hours before surgery, clear liquids up to 2 hours before surgery
• Give preoperative lovenox, use SCDs
• Avoid intraoperative hypothermia
• Perform pre-op stoma marking

Surgical Risks/Expectations

• Pain
• Bleeding
• Infection (5-39%)
• Injury to organs
• Ileus (2-32%)
• Issues w/ diversion (up to 33%)
• Impotence (40%)
• Recurrence (see below)
• Readmission (10-30%)
• Mortality (3% - 4-6% if > 75yo)

Ileal conduit complications

• Urine leak: 2%
• Infection: wound infection (2-7%), abscess (2%), sepsis (3%), pyelonephritis (3-18%)
• Wound dehiscence: 3%
• Obstruction: ileus (6%), intestinal obstruction (3-5%), ureteral obstruction (2-6%)
• Stoma: hernia (2%), stenosis (3%)
• Metabolic: acidosis (13%), stones (7%), renal failure (7%)
• Conduit bleeding (4-10%)

Robotic Cystectomy

Prepping

1. General anesthesia, a-line, ceftriaxone
2. Postioning: either split leg or supine (depends on robot)
3. Tuck arms at sides
4. Prep from xiphoid to genitals
5. Trendeleberg 23deg, do not flex/rotate bed

Access

1. Place veress at umbilicus, insufflate
2. Ports: 8mm superior to umbilicus at midline (midline incision), 8mm robot ports x2 on patient's R side, 8mm robot port x1 on patient's L side, 12mm assist on lateral L side, 12mm assist superior and triangulated with midline and L robot ports
3. Robot instruments: bipolar forceps in Arm #1, camera in Arm #2, monopolar scissors in Arm #3, forceps in Arm #4

Visibility and posterior access

1. Identify and take down any physiologic adhesions holding bowel in the pelvis
2. Widely incise peritoneum posterior to bladder (1 instrument-length above rectum), open upwards as smiley-face
3. Identify and retract seminal vesicles anteriorly, develop space posterior to prostate up to the apex

Lateral dissections

1. Identify ureter at bifurcation of iliac vessels, open peritoneum overlying ureters
2. Isolate ureter (keep periureteral fascia intact), trace towards bladder, cut attachments at leading edge
3. Once ureter traced down to bladder, place clips x2 (proximal clip tagged), then divide between with cautery
4. Divide peritoneum lateral to the medial umbilical ligament (obliterated umbilical artery)
5. Enlarge the space, define the plane between perivesical fat and preperitoneal fat
6. Should not be able to identify bladder, iliac vessels, or obturator nerve if in correct planes
7. Connect peritoneal incisions together, divide vas with cautery once identified
8. Superior plane/dissection is completed when endopelvic fascia identified
9. For bladder/prostate pedicle, clip the medial umbilical ligament and other larger vessels prior to dividing, otherwise divide with bipolar and cautery, trace along prostate (do not dive into rectum)

Anterior dissection

1. Divide medial umbilical ligaments close to abdominal wall to drop bladder completely
2. Divide anterior prostatic attachments, then place DVC stitch transversely x2-3, use perineal pressure if needed
3. Place clip on urethra, divide distal to clip to completely separate specimen and prevent tumor spillage

Pelvic LND

1. Identify external iliac artery, split tissue over the artery and begin to peel medially
2. Continue peeling medially, peel off the internal iliac vein
3. Continue dissecting out of the obturator fossa, bipolar perforating vessels
4. Identify obturator nerve and separate from the tissue
5. Divide tissue from distal attachments and proximally near bifurcation
6. Remove lateral tissue off iliac artery and from overlying the psoas muscle up to genitofemoral nerve

Finish robotic portion

1. Apply hemostatic agents
2. Place specimens in a bag
3. Create window below sigmoid mesentery without getting into presacral space (stay on top of iliac bifurcation)
4. Bring left ureter through window to R side
5. Place drain through L side assist port
6. Undock robot, remove ports

Create the conduit

1. enlarge midline port, travelling to L side of umbilicus (away from stoma)
2. Remove specimens and place hemostats on ureters
3. Identify 20cm terminal ileum, at least 10-20cm proximal to ileocecal valve, mark ends with silk suture
4. Shine light through mesentery, create window with bovie, then enlarge with ligasure
5. Staple to divide proximal and distal ends
6. Cut off antimesenteric corner of bowel ends, staple together for anastomosis (ensure conduit is inferior)
7. Grasp open end with allis clamps x4, then staple across
8. Oversew end with vicyrl 2-0 popoffs
9. Place crotch stitch with silk 2-0 to reinforce anastomosis and suture inferior mesentery side to prevent internal hernias

Ureteroileal anastomosis

1. Incise ureter transversely with tenotomy scissors, then incise proximally to create a T incision
2. Line up with conduit, then cut out small window of serosa then mucosa at that site
3. Place 4-0 monocryl x2 at base of ureteral incision and attach to conduit, ensure knots are on outside
4. Take small ureteral bites (avoid strictures) and suture to conduit
5. Once ~75-80% closed, place stent proximally with wire, remove wire to create curl, then grasp with tonsil through conduit and bring out through the stoma, clamp with babcock
6. Finish anastomosis, leak test prior to tying knots

Stoma creation

1. Grab skin with kocher at marked location, excise a circle of skin and underlying tissue
2. Incise fascia in cross-shape, then pass tonsil through incision into abdomen
3. Grasp conduit with babock and bring out through stoma site
4. Place vicryl stitches x4 through skin, through proximal conduit serosa, then through conduit lip to evert stoma and hold in place, tie down once all 4 placed
5. Place extra stitches to secure stoma to skin
6. Place nylon suture to secure stents

Closure

1. Close midline incision fascia with #1 PDS nonlooped x2, meeting in middle
2. Staple skin incisions
3. Place ostomy device

Open Cystectomy

Prep and opening

1. Male positioning: supine with legs together, place ASIS over break and hyperextend abdomen
2. Female positioning: stirrups low lithotomy (cannot hyperextend abdomen)
3. Prep in abdomen and genitals, give cefazolin or equivalent antibiotic, have suctions x2, bovie and ligasure
4. Make midline incision from L of umbilicus down to pubic symphysis
5. Open down to fascia, incise fascia at midline
6. Develop space of Retzius, can split endopelvic fascia if able
7. Divide urachus superiorly with ligasure, tie with 0 silk stitch on pass to allow for retraction
8. Place bookwalter retractor, use short Rich for inferior wall, medium rich for superior wall, and narrow malleable for additional intestinal retraction

Ureteral identification

1. Find ureter at bifurcation of common iliacs on either side, if having trouble can identify psoas and track inferiorly
2. Isolate ureter with right-angle clamp and vessel loop (tagged), trace inferiorly taking care to maintain periureteral tissue
3. Once near bladder, clamp distal ureter with right-angle, cut with Metzenbaum scissors, and tie off stump with 2-0 silk tie
4. Cut distal ureteral margin and send for frozen
5. Tag lateral edge of ureter (in to out), silk on L side, chromic on R side
6. Optional: clip ureters to create iatrogenic dilation in anticipation of anastomosis

Male bladder removal

1. Dissect posteriorly to create space between bladder/prostate and rectum
2. Ligate pedicles using ligasure, feel below to ensure not on rectum
3. Tie off DVC with 0 vicryl on CT-1 in figure-of-8 fashion (x2)
4. Clamp urethra prior to removal and tie off with 2-0 vicryl on UR-6

Female bladder removal

1. Place sponge stick into vagina to define borders
2. Use cautery on 50 to cut through anterior vaginal wall
3. Track inferiorly, opening vagina and ligating bladder pedicles
4. Tie off DVC with 0 vicryl on CT-1 in figure-of-8 fashion
5. Close vaginal opening at midline with 2-0 vicryl in figure-of-8 fashion
6. Close lateral vaginal openings with 2-0 V-loc x2, going lateral to medial

Pelvic lymph node dissection

1. Identify bifurcation of iliacs
2. Take to external iliacs laterally, inguinal ligament distally, and obturator nerve/fossa medially
3. Tip: either clip small vessels and cauterize, or use ligasure to prevent lymphocele creation
4. Tip: when near the obturator nerve, use metzenbaum scissors instead of cautery
5. Place Floseal and fibrillar for hemostasis

Conduit creation

1. Pass right-angle under sigmoid mesentery to allow L ureter to pass underneath
2. Measure 15cm proximal to ileocecal valve, mark with long silk stitch
3. Measure 15-20cm proximal from this mark, mark with short silk stitch
4. Create mesenteric window and staple off proximal and distal ends with GIA
5. Important step: make sure conduit limb is inferior to planned intestinal anastomosis
6. Grasp blind ends and stitch antimesenteric side at base with silk stitch
7. Open antimesenteric corner with scissors of each blind end, pass in GIA stapler, and staple together to anastomose
8. Grasp open end with allis clamps and use TA stapler to close off, cut off end with scissors
9. Oversew the corners and middle with silk stitches
10. Close inferior mesenteric window with silk stitch

Ureteroileal anastomosis

1. Cut off distal end of bowel with scissors, flush with bulb syringe and drain with pool suction
2. Cut bowel serosa with tenotomy, then open mucosa with tenotomy
3. Place chromic stitch x3 to evert bowel mucosa
4. Cut ureteral end transversely to open, then incise longitudinally to open ureter (insert gerald forceps to dilate)
5. Place 4-0 monocryl stitch out/in on ureter and in/out on bowel x2, then tie (make sure tails on same side), then pass one tail around using right-angle clamp and tie together
6. Run one stitch up (start on ureteral side) then after 5-6 throws, tie and only cut the loop (tag the tail)
7. Place bander stent via distal conduit end, pass out incomplete anastomosis, then feed into ureter and hold in place with Debakeys and remove wire to curl stent
8. Run other stitch up, throw x5-6, then tie in same fashion as above
9. Use a third monocryl to close the remaining portion of the anastomosis
10. Leak test with bulb syringe
11. Repeat for other ureter

Ostomy creation

1. Cut out skin circle at previously marked location in RLQ
2. Find fascia, incise as a lambda and tag the bottom corner with a 2-0 vicryl going out/in (do not cut off needle)
3. Putting fingers through main incision and up through ostomy location, cauterize over fingers to open up peritoneum enough for two fingers
4. Pass babcock through ostomy incision, bring stents out, then bring out entire conduit, ensure it lays flat inside abdomen
5. Place horizontal stitch (using existing 2-0) through proximal intestinal serosa then tie down
6. Place 3-0 vicryl stitch (x3) through ostomy opening, proximal serosa (away from mesentery), then through skin, cut and tag, use the other half to place a stitch through just ostomy opening and skin (near mesentery) and tag this too
7. Once all stitches placed, tie down and place extra stitches at any visible openings
8. Use 4-0 chromic stitch through skin to hold stents together

Closing

1. Create window deep to LLQ fascia, make small skin incision and pass through tonsil to place Blake drain into deep pelvis, stitch into place with 2-0 nylon
2. Take flex out of bed (if present)
3. Close midline incision with 0 PDS looped x2, starting at apex and running towards center
4. Every 3-4 stitches, place #2 vicryl as a retention stitch
5. Close subQ tissue with 3-0 vicryl and close skin with staples
6. Apply ostomy device and dressings

Neobladder (via open approach)

Setting up urethral anastomosis

1. Tie off DVC as needed, isolating urethra
2. Sharply divide anterior urethra - place double-armed 4-0 monocryl sutures in to out in anterior urethra (clamp with curved hemostat), then place similar sutures in lateral urethra (clamp with straight hemostat)
3. Pull foley back and transect urethra completely, place stitches in posterior urethra (clamp with rubbershod hemostat)

Forming neobladder

1. Identify ileocecal valve, place silk stitch 10cm proximal, tie with airknot x1
2. Subsequently place airknot x2 at 22cm, airknot x3 at 44cm, and airknot x4 at 54cm from original knot (can use vessel loop with staple marked at 22cm at 10cm)
3. Create mesenteric windows, staple off proximal and distal ends, then reanastomose intestines superiorly to neobladder segment in normal fashion
4. Open distal end of segment, then open antimesenteric intestine with cautery over plastic suction tip (to protect intestine), do not open proximal 10cm (neobladder chimney)
5. Designate corners of open intestine: P^L and P^R for the proximal corners near chimney, D^L and D^R at the distal open end
6. Bring P^R and D^R together and anastomose with 3-0 vicryl stay stitch, use this to hold traction to place next vicryl stay stitch, continue until posterior edge of neobladder is closed
7. Starting inferiorly, run 2-0 V-loc suture along posterior edge until superior edge, maintain tail as a tag for traction
8. Neobladder should now be shaped like a U, bring bottom portion of the U up to the anastomosed edges (P^R and D^R), but offset the bottom towards the right side (away from chimney side)
9. Starting at new apex, place 3-0 vicryl interrupted stitches to approximate edges, then calibrate bottom of right side to 24Fr dilator (will use for urethral anastomosis)
10. Continue placing vicryls on left side, but do not close completely (will need opening to externalize stents

Ureteral anastomosis

1. Anastomose ureters in usual fashion
2. Place stent as normal, bring out through open left side of neobladder opening (temporarily)
3. Usually do not leak test (difficult to perform)

Neobladder closure and anastomosis

1. Place running V-loc starting at R apex and run to superior apex, then continue running to L side
2. Before closing, create small opening in neobladder and bring stents through (so that they are not exiting through anastomotic line), tie to neobladder with 4-0 chromic
3. Calibrate urethral anastomotic site to 24Fr, place imbricating sutures as needed
4. Tag neobladder opening at 3, 6, 9, and 12 o'clock with temporary vicryl stitches, tag with hemostats
5. Place posterior stitches (using already placed urethral stitches), re-clamp with rubbershod hemostats
6. Place 24Fr Rusch catheter via urethra and insert into neobladder
7. Place lateral stitches into neobladder (and clamp), then place anterior stitches - cut out traction stitches as they become no longer required
8. Gently bring neobladder down to urethra, then tie starting posteriorly and move anteriorly, inflate balloon
9. Create skin incision on L side and bring stents up through incision using tonsil, stitch to skin using 4-0 chromic

Postoperative management

ERAS Postop

• Encourage gum chewing and oral magnesium to avoid ileus
• Consider alvimopan (u opioid antagonist) starting preop
• Start feeding within 4hr after surgery
• Consider epidural for analgesia
• Optimize fluid management and avoid overload
• MgOx daily supplements may help speed up bowel recovery
• Encourage early ambulation
• Extended DVT prophylaxis (apixaban, enoxaparin) recommended x4 weeks after surgery

Neobladder management

• Flushes: start POD#2, usually 30mL BID (small capacity at the start), helps to prevent mucus buildup and clogging
• Mebeverine: antispasmodic agent (not available in US), can decrease risk of undesired bowel contractions, dosed 135mg TID, improved incontinence compared to placebo at 3 months (Hashem 2021)