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Surgery in Motion
Radical Cystectomy and Orthotopic Bladder Replacement in
Females
Udo Nagele *, Markus Kuczyk, Aristotelis G. Anastasiadis, Karl-Dietrich Sievert,
Jörg Seibold, Arnulf Stenzl
Department of Urology, University of Tuebingen, Germany
Article info
Article history:
Accepted May 3, 2006
Published online ahead of
print on June 21, 2006
Keywords:
Cystectomy
Neobladder
Urinary diversion
Bladder substitute
Female patient
1. Introduction
Morethan 15yearsago, severalcentersstartedtooffer
urethra-sparing cystectomy and orthotopic urinary
diversion also to female patients diagnosed with
bladder cancer [1–4]. Up to this point in time, removal
of the female urethra was considered an integral part
of cystectomy. It was argued that renunciation of a
urethrectomy would be associated with an increased
risk for the development of intraurethral tumor
european urology 50 (2006) 249–257
Abstract
Introduction: More than 15 years ago, several centers started to offer
urethra-sparing cystectomy and orthotopic urinary diversion for female
patients with bladder malignancies. Several studies have been published,
outlining both the anatomical and oncological aspects of such
an approach.
Methods: In this contribution, the main aspects regarding the surgical
technique of cystectomy and orthotopic urinary diversion in female
patients, including technical variations which have been derived over
the years, are presented.
Results and Conclusion: The video shows a detailed description of the
surgical technique, and the main steps of the procedure are demonstrated
in schematic drawings as well as in animations to facilitate
understanding. Emphasis is given on important anatomical and physiological
aspects, which have influenced the current surgical steps. Possible
sequelae on oncological and functional outcome, which play an
important role in the evaluation of this procedure, are also discussed.
# 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Department of Urology, University of Tuebingen, Hoppe-Seyler-Str.
3, Tuebingen 72076, Germany. Tel. +49 7071 2986615; Fax: +49 7071 2985092.
E-mail address: Udo.Nagele@med.uni-tuebingen.de (U. Nagele).
recurrences. In addition, because of specific complications
associated with the latter procedure, such as
fistulation to the vagina or postoperative micturition
problems either in the form of urinary retention or the
subsequent development of urinary incontinence,
orthotopic bladder replacement in females was not
introduced into the clinical routine as rapidly as in
male patients. After it was demonstrated that, with
respect to certain oncologic prerequisites, the urethra
could be safely preserved, we now have a better
0302-2838/$ – see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2006.05.037

250
understanding of the female continence mechanism.
In addition, with the establishment of several
technical modifications and the availability of a
broader spectrum of clinical experience, creation of
an orthotopic neobladder after a cystectomy can be
routinely offered to female patients as well. This
observation is outlined by several studies that have
focused on both the anatomic aspects and the
oncologic risks that have to be recognized and
respected during this surgical approach [5–13]. However,
whereas contraindications for the creation of
an orthotopic neobladder in females from an oncologic
point of view (e.g., tumor involvement of the
bladder neck and widespread carcinoma in situ) are
similar to those in males, functional deteriorations
such as sphincter insufficiency should be excluded by
a preoperative urodynamic evaluation. Consequently,
contraindications to orthotopic bladder
substitution are clinically relevant forms of stress
incontinence, high-dose preoperative irradiation,
intolerance to postoperative incontinence in preoperatively
continent patients and refusal of self-catheterization.
With regard to the latter considerations,
younger patients with a strong demand for physical
integrity who are motivated to cope with the functional
disorders that might result from an orthotopic
bladder replacement are good candidates for this
surgical approach. In the present contribution, we
outline the surgical technique of cystectomy and
orthotopic urinary diversion in female patients,
together with technical variations that have been
derived from our experience over the years.
2. Technical aspects
2.1. Patient preparation and incision
We do not routinely position the patients in a lower
lithotomy position; rather we place them on a normal
straight table unless they are extremely obese or have
a tumour possibly invading the pelvic floor.
Preoperatively, a transurethral catheter is
inserted.
Since the vagina will be opened during anterior
exenteration, it must be included in the sterile
preoperative prepping and should be accessible for
sterile inspection during the operation. The vagina is
marked with a large sponge or sponge stick soaked
in disinfectant.
The approach is through a lower midline or
Pfannenstiel incision. A modified Balfour retractor
with two blades to retain the bowel cephalad is used
for optimal exposure. The abdominal cavity is
palpated for adhesions and metastatic disease.
european urology 50 (2006) 249–257
2.2. Anterior exenteration in the female patient
2.2.1. Lymphadenectomy
To gain access to the pelvic lymph nodes, we may
leave the overlying peritoneum intact and dissect it
off the pelvic sidewall in toto, or we may incise the
peritoneum in an inverted V-shaped fashion starting
at the umbilicus. From there, the peritoneal
incision is continued downward along the medial
umbilical ligament towards the avascular plain of
Toldt.
The overlying round ligament will have to be
dissected to gain a good exposure to the external,
obturator and internal nodes, which are then
dissected. The ovaries do not have to be removed
routinely for oncologic reasons. In case of preservation
of one or both of them, only their distal
attachments mainly to the fallopian tubes are
dissected, allowing the ovaries to be rotated
laterally.
Lymphadenectomy should include the internal
iliac, the obturator fossa, the external iliac and
approximately half of the common iliac lymph
nodes (Fig. 1). Although the value of pelvic lymphadenectomy
for both staging and, under certain
circumstances, therapeutic purposes has clearly
been demonstrated, there is still an ongoing
debate about the extent, especially cranially. Recent
papers have demonstrated the low incidence
of positive lymph nodes above the aortic bifurcation
with microscopic pelvic lymph node involvement
Fig. 1 – Extend of pelvic lymphadenectomy in malignant
disease of urinary bladder (adapted from Rohen/Yokochi,
Color Atlas of Anatomy: A Photographic Study of the
Human Body; I. Gaku-Shoin, 1984).

Fig. 2 – Sympathetic nerve fibres crossing the left common
iliac artery (U: left ureter, CIA: left common iliac artery).
and practically no positive para-aortic lymph
nodes in patients with negative pelvic lymph nodes
[14]. On the other hand, the removal of lymphatic
tissue around the common iliac arteries medial to
the ureteral crossing leads to the destruction of the
sympathetic nerves supplying the inferior hypogastric
plexus (Fig. 2). A subsequent autonomic
dysregulation may result in micturition problems
[15].
We therefore limit our lymphadenectomy cranially
to the common iliac nodes up to the crossing
of the ureters on both sides. The external iliac node
dissection is limited laterally by the lateral portions
of the genitofemoral nerve and caudally by the
ligamentum lacunare, which branches medially off
the inguinal ligament. By extending the lymphadenectomy
distally to the ligamentum lacunare instead
of to the Cooper’s ligament, important lymph nodes
for staging of the urethra are included.
The internal iliac vessels, especially the internal
iliac artery, are always preserved, and only the
medial branches to the bladder and inner genitalia
are ligated. Some of the medial and distal portions of
these nodes may have to be removed together with
the cystectomy specimen later on.
We perform the lymphadenectomy before the
cystectomy. One of the reasons is that, after a
meticulous pelvic lymphadenectomy, it is easier to
dissect the branches of the internal iliac artery to the
bladder.
european urology 50 (2006) 249–257 251
2.2.2. Cystectomy
Most of the female patients undergoing cystectomy
for bladder cancer are in their sixth or seventh
decade, and therefore there is no debate about
removing the uterus en bloc with the diseased
bladder. Whether one or both ovaries should be
removed as well depends on several factors including
intraoperative inspection.
The internal iliac arteries should be left intact and
serve as a landmark. The superior and inferior
vesical arteries, as well as the uterine and lower
ovarian arteries branching off the internal iliac
arteries and their corresponding veins, are ligated
and dissected.
The ureters are dissected, clipped and divided
below the iliac bifurcation, and a portion is sent for
frozen section. Clipping the ureters for 60–90 min
and at times even longer did not cause problems in
any of our patients.
The peritoneum is incised in the Douglas cavity
just below the vaginal fundus, whose location is
made visible by the sponge (stick) in the vagina. The
vaginal fundus is opened circumferentially around
the cervical insertion. The uterus is lifted anteriorly
with either a strong stay suture or a Messieux clamp.
If the patient already had a hysterectomy, the
vaginal fundus is grasped with Allis clamps. In
transitional cell cancer of the bladder, the vaginal
fundus and the anterior vaginal wall down to the
level of the subsequent uretheral dissection are
removed for oncologic reasons (Fig. 3). The size of
vaginal tissue that may have to be removed,
however, is variable, and the entire vagina can be
Fig. 3 – Schematic delineation of the incision of the anterior
vaginal wall.

252
removed en bloc with the bladder specimen, if
necessary. However, for preservation of autonomic
nerves that originate from the pelvic plexus and run
along the lateral vaginal wall, the vagina is ventrally
and longitudinally incised from the fundus downwards
to the bladder neck in the 10 o’clock position.
However, this sparse resection of the ventral vaginal
wall should be performed only when oncologically
possible. The perivaginal tissue as well as the
vaginal wall is usually well vascularized, and
interrupted sutures or pressure coagulation prior
to dissection is advisable.
It is known that women treated with partial
urethrectomy (e.g., for complicated diverticula or
tumours) remain continent unless a major portion
of the middle third of the urethra is resected [17].
Fetal and adult cadaver studies have demonstrated
that the entire rhabdosphincter, which is innervated
by the pudendal nerve caudally, is located in the
caudal half of the urethra and merges approximately
halfway with the mid-layer of the proximal
smooth musculature [18]. Smooth muscle fibres of
the outer and inner layer, innervated by the
autonomous nerve system, however, are present
throughout the whole length of the urethra. An
increasing number of reports in recent years have
shown that a bladder substitution to the urethra is
possible in women with both benign and malignant
disease, yielding oncologic and functional results
similar to those of male patients.
When we attach the low-pressure intestinal
reservoir to the urethra, we must remove the entire
bladder neck and an additional short segment of
adjacent urethra. This technique seems to be a
prerequisite for volitional micturition, because the
neobladder can neither form the shape of a funnel
seen during voiding under normal conditions nor
can it overcome the passive resistance of a fulllength
urethra [15].
Delineating the bladder neck may be difficult in
some obese women. In these cases we increase
filling of the catheter balloon to 20 cc, insert the
catheter using a slight outward traction and outline
the bladder neck with two small sponge sticks
(‘‘peanuts’’) on either side of the balloon.
Once the bladder neck and approximately 0.5 cm
of proximal urethra are peeled from surrounding
tissue, the urethra is clamped with a strong Overholt
clamp just underneath the bladder neck to avoid
spilling of tumour cells and urine; the urethra is
detached below the clamp [19]. Identification of the
catheter balloon on the level of the bladder neck
helps to identify the conjunction between the
urinary bladder and the urethra. This procedure,
however, does not guarantee a complete resection of
european urology 50 (2006) 249–257
Fig. 4 – Schematic drawing of the transverse (clam)
reconstruction of the vagina and placement of urethral
sutures for an orthotopic neobladder.
the bladder neck in all cases. Therefore, by opening
the bladder on a side table, we usually make sure
that the bladder neck and a segment of the urethra
are on the specimen, and send the urethral margin
for pathologic evaluation.
We prefer to close the vagina in a transverse
(‘‘clam’’) fashion with running sutures, which
results in a wide vagina allowing a better inspection,
insertion of electrostimulation devices if needed
and vaginal intercourse (Fig. 4) [16].
2.2.3. Preservation of inner genitalia
When a direct invasion of the anterior vaginal wall
or the uterus, or a metastatic affection of the ovaries
can be excluded, the ovaries alone can be preserved
in premenopausal patients, or the ovaries and the
uterus can be preserved in very young patients who
wish to retain the ability to become pregnant.
According to our experience, resection of the uterus
together with cystectomy does not, however, result
in functional impairment of the orthotopic neobladder.
This finding is mainly due to the stabilization
of the junction between the neobladder and the
urethra by the omentum flap that is positioned
around this area. The initial steps to mobilize the
bladder are the same; only the branches from the
internal iliac artery to the inner genitalia, which are
usually easy to identify, have to be spared. The
peritoneum is incised in the uterovesical pouch, the
vagina is left intact and dissection is continued in the
well-vascularized plane between the bladder floor
and the anterior vaginal wall. The bladder neck is
carefully dissected. The specimen is then detached
approximately 0.5 cm below the bladder neck.

2.2.4. Preservation of autonomic nerves
The autonomic nerve branches for the smooth
muscle portion of the urethral sphincter originate
from the pelvic (hypogastric) plexus [18,20]. The
innervation of the voluntary sphincter system most
probably is provided by the branches of the
pudendal nerve [21], although it has been suggested
that the autonomic nervous system may contribute
as well [22].
Nerve fibres originating from the pelvic plexus
located dorsolaterally of the rectum have been
traced on their route to the bladder neck and urethra
to run dorsal to the distal ureter, underneath the
lateral vesical pedicle and along the lateral walls of
the vagina (Fig. 5) [8]. An anterior exenteration with
complete resection of the vagina with the caudal
margin below the bladder neck would therefore
result in the dissection of the majority of, if not all,
autonomic nerves to the female urethra. As a consequence,
a careful dissection of the lateral vaginal
walls, bladder neck and proximal urethra would
leave the majority of the plexus fibres to the urethra
intact, thus preserving the sphincter mechanism.
During pelvic lymphadenectomy, care is taken to
minimize dissection in the region of the upper
hypogastric nerve crossing the common iliac artery.
Special attention is then directed towards dissection
and resection of the inner genitalia. After mobilizing
the ovaries, tubes and uterus, only the vaginal fundus
and the anterior vaginal wall down to the level of the
subsequent urethral dissection are resected. The
dorsal half of the vaginal fundus is incised circumferentially
around the cervical insertion or scar from
a previous hysterectomy. The line of incision is
continued ventrally and caudally down to the level of
Fig. 5 – Schematic drawing delineating the autonomic
nerves to the bladder neck and urethra.
european urology 50 (2006) 249–257 253
Fig. 6 – Schematic drawing of proximal urethral dissection.
the bladder neck to include an approximately 2 cm
wide segment of the ventral wall of the vagina
adjacent to the bladder. If this incision is not
performed with pressure coagulation, a running
suture guarantees sufficient hemostasis along the
vaginal incision lines. The bladder neck and proximal
urethra are then carefully ‘‘peeled’’ out of the
surrounding connective tissue and fascia. Care is
taken to incise the endopelvic fascia medially, where
it leaves the bladder surface. After complete transection
of the anterior vaginal wall, the dissection of
the proximal urethra is performed by staying as
close to the urethral wall as possible to avoid damage
to the nerve fibres coursing to the remnant urethra
(Fig. 6). The suspensory fascial reinforcements of the
remnant urethra will not be compromised in a nervesparing
cystectomy, since care is taken to stay as
close as possible to the urethra proximally, and to
avoid any dissection caudal of the level of urethral
severing.
2.3. Orthotopic neobladder
After trying several different techniques over the
years, we have found the neobladder described here
to be ‘‘economical’’ with regards to bowel length,
efficient with regard to reflux protection of the
upper urinary tract and less time consuming than
other methods.
The authors of the largest series of continent
urinary diversions prefer a re-configured lowpressure
ileal reservoir (‘‘wind chamber’’ effect),
according to the principle of the Goodwin cup patch

254
technique (‘‘cross-folded U’’) [23,24]. Goodmediumterm
results with acceptable ileum-related morbidity
continue to be reported among those using the ileal
low-pressure reservoir [23]. Mild acidosis is common
postoperatively and can be controlled with orally
substituted sodium bicarbonate. The absorptive
capacity decreases 8-fold in the long run, resulting
in less reabsorption and metabolic problems [25].
2.3.1. Preparation of the ureters for urinary diversion
Postoperative ureteral anastomotic stricture is a
common complication in urinary diversion. One
avoidable complication is ischemia of the distal
ureter. Knowing the vascular supply with its
common variations [26] and preserving the periureteral
adventitial tissue—even below the level of
ureteral dissection—might cause less ischemia and
strictures. The left ureter is transposed underneath
the mesosigmoideum to the contralateral retroperitoneal
space with care taken to both yield
maximum length and avoid kinking. This manoeuvre
should be done with special care to avoid for
example distal ischemia, twisting of the ureter or
extrinsic obstruction attributable to scarring. Both
ureters are spatulated and conjoined to a ureteral
plate with a running suture.
2.3.2. Reservoir construction
Forty centimeters of terminal ileum located approximately
20 cm oral to the ileocecal valve are then
isolated. The ileal tube is arranged as a ‘‘U (Fig. 7).
Ileal reanastomosis is performed with a running PDS
suture. The mesentery is closed separately.
Starting 2–3 cm from the endings, a running
seromuscular suture approximately 8 cm long at
the mesenterial insertion forms a so-called ileal
trough (Fig. 8). The ileum is detubularisized antimesenterically
over its entire length. The line of
incision is curved medially towards the mesentery at
the area of the future ureteral orifices (Fig. 9). The
conjoined ureters are placed into the ileal trough,
sutured to the distal end of the trough and buried by
closing the ileal flaps over both ureters, forming a
serosa-lined extramural tunnel (Fig. 10A and B). This
form of afferent reflux prevention is chosen because
of its low stricture rate [27]. Two 8F mono-J stents are
placed into the ureters. The rest of the ileal plate is
closed with a running Vicryl suture and is then crossfolded
(Fig. 11). The ureteral stents are brought out
through the neobladder separately. The cross-folded
ileal plate is closed with running seromuscular suture
lines to create the reservoir (Fig. 12). Although it has
not been demonstrated that antireflux ureteral
implantation is necessary, we are convinced that it
helps to avoid an anatomic and/or functional
european urology 50 (2006) 249–257
Fig. 7 – U-shaped ileal segment.
Fig. 8 – Forming of the ileal trough with an 8 cm long
seromuscular sutureline.
Fig. 9 – Marked line of incision is curved medially towards
the mesentery at the area of the future orifices.

Fig. 10 – (A) Prepared ileal plate with configurated ileal
trough. (B) Implantation of the conjoined ureters.
impairment of the upper urinary tract, especially in
younger patients. In addition, the technique of
ureteral implantation during pouch construction as
described herein makes instrumentation of the upper
urinary tract much easier. The latter becomes
Fig. 11 – Creation of the reservoir by crossfolding of the ileal
plate.
european urology 50 (2006) 249–257 255
Fig. 12 – Constructed neobladder with the urethra
anastomosed to the most caudal portion.
necessary in case of tumor recurrence in the region
of the upper urinary tract or in case of stone
formation. When compared with alternative techniques,
the latter points represent the main advantages
of the type of neobladder that is described herein.
We have observed that caudal migration of the
pouch into the pelvis may result in intestinal folds
that cause intermittent obstructive valves at the
ileo-urethral anastomosis. Therefore, the urethra is
anastomosed to the neobladder at its most caudal
portion. With the use of the index finger, the most
caudal portion of the neobladder is identified and
incised before completely closing the pouch.
Six anastomotic sutures are placed at the 1, 3, 5, 7,
9 and 11 o’ clock positions of both the urethral stump
and the neobladder neck. A 20F–22F silicone catheter
is inserted.
Under the surgeon’s vision, the anastomotic
sutures are tied in a tension-free fashion, resulting
in a watertight anastomosis.
An advantage of the technique shown here is an
uretero-ileal anastomosis that allows access to the
upper urinary tract with catheters or ureteroscopes
if it becomes necessary in subsequent years.
The watertightness of the neobladder and its
urethral anastomosis is tested with saline solution.
At the end of the procedure, a J-shaped omentum
flap is created and brought down around the bottom
part of the pouch and its urethral anastomosis to
prevent formation of both an ileal valve and an
urethrovaginal fistula. The flap is secured to the
pelvic wall. Alternatively, the pouch can be fixed on
the level of the pelvic floor with one or two sutures on
the left and right side, respectively, the latter running
through the ileal bladder and the pelvic floor
musculature. Thus, obstruction caused by ileal folds

256
and a pouchocele descent can be avoided. In addition,
the urethra–intestinal junction is secured [15].
Both mono-J ureteral catheters are brought out
through the lower abdominal wall, where they can
be led into a single stoma bag after 3–4 days. Pelvic
drains are inserted before wound closure. Ureteral
catheters are removed after approximately 8–9 days,
and the 20F–22F urethral catheter after 14 days, if a
previous pouchogram shows no extravasation. The
skin is closed with an intracutaneous suture.
3. Conclusion
Literature from recent years increasingly confirms
the initial preliminary results of urethra-sparing
cystectomy and orthotopic urinary diversion in
females. Removing the bladder neck and a small
portion of the adjacent urethra will not compromise
the oncologic outcome [28] in the majority of women
with bladder cancer, and the removed tissues can be
satisfactorily used for orthotopic reconstruction of
the lower urinary tract (Figs. 13 and 14). Diurnal and
nocturnal continence rates in more than 82% and
72% of patients, respectively, clean intermittent
catheterization in approximately 12% after 6
months, and stress incontinence grade I in the
remainder are results that justify the use of
orthotopic neobladders as the procedure of choice
in a large number of female patients.
We now know that urinary continence of any
bladder substitution can be maintained despite
removal of the bladder neck and the adjacent
proximal urethra. In our anatomic studies as well
Fig. 13 – Disease specific survival after urethra-sparing
cystectomy and bladder substitution to the remnant
urethra.
european urology 50 (2006) 249–257
Fig. 14 – Progression free survival rates in 102 woman
undergoing urethra-sparing cystectomy and orthotopic
intestinal bladder reconstruction.
as those of others, no prominent sphincteric
structure was present either in the female bladder
neck or in the cranial urethra. The bulk of the
striated intrinsic sphincter (rhabdosphincter) is
located in the mid to caudal third of the urethra
and will not be removed with proximal urethrectomy,
as described above. The sphincter’s innervation
via the pudendal nerve will not be compromised
during the surgical procedure.
Over the years, it has been possible to further
improve postoperative functional results by (1)
leaving the posterior and lateral vaginal walls intact
when performing a nerve-sparing anterior exenteration,
which can be achieved by carefully dissecting
out the bladder neck and the proximal urethra; (2)
removing 0.5–1 cm of the cranial urethra en bloc
with the cystectomy specimen and obtaining a
frozen section of the whole urethral circumference;
(3) using previous experience with low-pressure
reservoirs in male patients; and (4) preventing
complications related to a downward migration of
the pouch by using either a J-omentum flap or stay
sutures between the pouch wall and the surrounding
pelvic structures.
Appendix A. Supplementary data
Supplementary data associated with this article
can be found, in the online version, at doi:10.1016/
j.eururo.2006.05.037 and via www.europeanurology.
com. Subscribers to the printed journal will find the
supplementary data attached (DVD).

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