Cystectomy – Technical Considerations in Male and Female Patients

Abstract

Simple and radical cystectomy for the treatment of benign and malignant bladder disease goes back to the late 19th century. The technique has changed over the last century due to increasing surgical experience, improvements in medical technology and pharmacology, an evolving technique of urinary diversion and an increase in patients demand for post-operative quality of life.

Approximately two decades ago the orthotopic bladder substitution became popular in male patients, whereas in female patients the use of an orthotopic neobladder to a remnant portion of the female urethra started only a decade ago and still does not include the majority of female patients undergoing cystectomy. The major goal of cystectomy for malignant disease in the pelvis is the oncological outcome. Without compromising tumour resection, however, functional results, i.e. continence, volitional voiding, potency and sexual intercourse play an increasingly important role for this type of surgery. This is especially important for a bladder confined disease which has a better long-term tumour outcome, but on the other hand the use of radical surgery for these stages is still debated in favour of more conservative bladder sparing forms of treatment with less favourable outcome.

The technique of radical cystectomy and lymphadenectomy both in male and female patients with regards to preservation of the urethra is outlined. In addition technique of sparing autonomic nerves both to the membranous urethra and the penis or the external and internal female genitalia is described. Surgical variations based on recent anatomic and clinical findings are presented and discussed with regards to the best functional outcome in male and female patients.