Sexual Sparing Robot-Assisted Radical Cystectomy in Female: Technique Step-by-Step

Abstract

Introduction and Objective: Anterior pelvic exenteration is often synonym of radical cystectomy (RC) in women, including removal of bladder, urethra, ovaries, fallopian tubes, uterus, and part of the vagina. However, preservation of the gynecologic organs is possible in selected women. After 100 minimally invasive RCs (60 laparoscopic and 40 robotic), we describe the technique of “Sexual-sparing robot-assisted radical cystectomy” (RARC) in a female. Methods: Sexual sparing RC is offered to sexually active, relatively young women affected by low stage clinical localized muscle-invasive bladder cancer (≤T2b, N0, M0), unifocal tumor away from bladder base, and with free internal genital organs. We report the technique of RARC in a female with preservation of genital organs. Results: A four robotic arm configuration is adopted. A bilateral extended pelvic lymph node dissection is performed: the proximal limit is the ureter cross over the common iliac a.; laterally the genitofemural-n. and psoas m.; caudally Cloquet's node; and medially peritoneal sheet, umbilical a. and lateral edge of the bladder. Ureters are dissected down to the ureterovesical junction at level of uterine a. crossing. Ureters are divided and distal ureteral margins are sent bilaterally for frozen section. Vascular pedicles are sealed and sectioned with articulable vessel sealing forceps (Caiman Vessels Sealers; Aesculpa BBraun) or ultrasonic forceps (SonoSurg G2; Olympus). Space between the uterus and the bladder is dissected. A vaginal spatula facilitates dissection along the vaginal wall. The anterior vagina is opened and the plane between the vagina and the bladder is developed. A limited portion of anterior vaginal wall close to the trigone is resected en bloc with the bladder 1 cm above the bladder neck. Dissection is performed along the anterolateral paravaginal plane, no further dorsal than the 2 or 10 o'clock position to preserve the paravaginal fibers and nerves. The bladder is taken down with monopolar cautery. The urethra is identified and dissected. The catheter is removed and a clip is placed to avoid tumor spillage before urethra transection. Retrieval bag is inserted through the vagina opening and bladder is removed under vision. Vagina is then closed in two continuous layers. Conclusions: Sexual sparing RARC performed when possible with orthotopic neobladder offers intact body image and lowers decrease of sexual function and normal voiding function. Those elements play an extremely important role on patient's psychology, sexuality, and potential fertility. Robotic surgery is the perfect tool to perform such a complex minimally invasive technique. No competing financial interests exist. Runtime of video: 7 mins