Technique of en bloc resection of the membranous urethra and bladder during robot‐assisted radical cystectomy in patients without simultaneous urethrectomy

Abstract

Introduction Prophylactic urethrectomy is often performed simultaneously with radical cystectomy (RC) in patients who are not selected for neobladder creation for urinary diversion. However, the indications for prophylactic urethrectomy are still controversial. Here, we introduce the ideal urethral dissection technique during robot‐assisted radical cystectomy (RARC) in patients without simultaneous prophylactic urethrectomy. Materials and Surgical Technique At our hospital, RARC is performed using a da Vinci surgical system with the operating table tilted to 20°. After lymph node dissection and bladder mobilization, periurethral dissection is commenced. A notable point of our technique is en bloc resection of the bladder and membranous urethra using a continuous intracorporeal approach. First, while applying traction on the isolated bladder in the cranial direction, we carefully and gradually dissect the urethral smooth muscle from the external urethral sphincter with electrocautery scissors. Next, we ligate the membranous urethra with suture material as far from the prostate as possible. Then, we cut the urethra as far from the prostate as possible after ligation of the urethra with a Hem‐o‐lok clip just beyond the apex of the prostate. Using this method, we are able to remove at least 1.0 cm of the membranous urethra en bloc with the bladder. Finally, we suture the pelvic floor, including the levator ani muscle, in two layers using 3–0 V‐Loc and 2–0 V‐Loc sutures. Discussion We believe this technique allows separation of the residual urethra from the abdominal cavity and enables safe performance of secondary urethrectomy.

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“…For cases in which urethrectomy is not performed, recently, urethral dissection is performed using the technique we reported. 10 For female patients, our approach entailed the removal of the bladder, urethra, uterus, and anterior vaginal wall as a unified procedure. Vaginal reconstruction was intentionally omitted.…”

“…If the patient's preoperative general condition was not favorable, the urinary diversion was performed with the ureterocutaneostomy, or urethrectomy was omitted. For cases in which urethrectomy is not performed, recently, urethral dissection is performed using the technique we reported 10 . For female patients, our approach entailed the removal of the bladder, urethra, uterus, and anterior vaginal wall as a unified procedure.…”