optimal radical tumor excision is the maingoal of bladder cancer surgeries. anterior pelvic extenteration is often synonymof radical cystectomy in woman, including removal of bladder, urethra, ovaries, fallopiantubes, uterus and part of the vagina. such a demolitive surgery has dramatic implicationson patientâ€™s life style. however, preservation of the gynecologic organseither partially or totally is possible in
selected women with bladder cancer.sexual sparing rc combined with an orthotopic neobladder should always offered to sexualactive, relatively young woman affected by low stage clinical localized muscle invasivebladder cancer (t2b, n0,m0 or less), unifocal tumor away from bladder base/trigonum andwith free internal genital organs.
we report the technique of robot assisted radical cystectomy in female with preservationof genital organs. the abdominal access is obtained in a blindblade-less technique and a 3 robotic arm-configuration is adopted.it is mandatory to identify the ureter at its crossing with iliac-vessels in order todetect the proximal limit of dissection and to avoid unpleasant injury. dissection start along common and externaliliac artery psoas muscle and genitofemural nerve are identified.this represents the later border of dissection.
the distal limit is then reached and the cloquetlymphnode removed. the circumflex vein is spared.triangle of marseille, and emerging of lymphatic tissue from pelvic floor is exposed by detachingiliac vessel from psoas muscle. this procedure will avoid tearing of tissue and unpleasantbleeding. at the end of the procedure the hypogastricvessels ramification and bladder pedicle are easily understandable and the cystectomy canbe easily started. adequate periureteral tissue is preserved.ureters are carefully dissected down to the uretero-vesical junction at level of uterineartery crossing. ureters are divided between two hem-o-lokclips provided with stay sutures.
the distal ureteric margin is sent bilaterallyfor frozen section. analogous procedure is performed contralateraly.vascular pedicles are sealed and sectioned with aid of articulable vessel sealing forceps. peritoneum is incised and space between the uterus and the bladder dissected.a vaginal-spatula facilitates dissection along the vaginal wall. the anterior vagina is opened, and the plane between the vagina and the bladder developed.a limited portion of anterior vaginal-wall close to the trigone is resected en-bloc withthe bladder 1 cm above the bladder neck. dissection is performed along the antero-lateralparavaginal plane, no further dorsal than the 2 or 10 o'clock position, in an attemptto preserve the paravaginal fibers passing
to the urethra. bladder is taken down with monopolar cautery. the urethra is identified and dissected.bladder catheter is removed and a hemo-lok clip is placed to avoid tumor spillage beforeurethra transection. retrieval bag is inserted through the vaginaopening and bladder removed under vision. vagina is then closed in two continuous layers.the final view shows uterus, cervix and vagina, intact infundibulo pelvic and broad ligamentand uterine and vaginal artery. in conclusion sexual sparing cystectomy performedwith orthototopic neobladder offer intact
sexual females,body image, lower decrease of sexual functionand normal voiding function.
those elements play extremely importnat roleon patient's psychology, sexuality and potential fertility.robotic surgery is the perfect tool to perform such a complex minimally invasive technique.