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BACKGROUND

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Initial reports of cystectomy are attributed to Bardenheuer et al of Cologne in 1887, with the first female cystectomy being performed by Pawlik in Czechoslovakia around the same time. The modern steps of the radical cystectomy with pelvic lymph node dissection were described by Whitmore and Marshall in 1962.1 Further refinements have taken place over the years, with Schlegel and Walsh describing the nerve-sparing approach in 1987.2 With the advent of minimally invasive surgery, the first laparoscopic radical cystectomy (LRC) was described by Parra et al in 1992,3 and, in 2003, Menon et al4 demonstrated the feasibility of robotic-assisted radical cystectomy. Both of these new techniques have proven to have oncologic equivalency when compared with the open technique. In addition, the minimally invasive approach offers improved perioperative outcomes (lower blood loss, shorter hospital stay, and morbidity), although long-term outcomes have shown only small benefits with limited follow-up.5

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INDICATIONS AND CLINICAL APPLICATIONS

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The most common indication for cystectomy worldwide is invasive bladder cancer in the form of urothelial carcinoma, or squamous cell carcinoma, as is more common in areas with endemic schistosomiasis infection.6 In addition, bladder cancer involvement of reproductive organs has been shown to occur in 7.5% of females, with the vagina (3.8%) and cervix (0.7%) being the most commonly involved.7

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However, in the setting of gynecologic malignancy involvement of adjacent pelvic organs, such as the bladder, is less common. The most common scenario is cervical cancer, with involvement of adjacent organs occurring in fewer than 5% of North American patients.8 Cystectomy for gynecologic malignancy is a treatment often done for recurrent disease with about one-half of the patients having undergone previous treatment, either chemotherapy or radiotherapy. Less common indications for cystectomy include intractable hematuria, end-stage bladder secondary to radiation injury, neurologic disease, or refractory fistula disease.

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ANATOMIC CONSIDERATIONS

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The bladder is an ovoid, muscular organ with a capacity of 400 to 500 mL. The bladder occupies the anterior pelvis and is juxtaposed to the posterior border of the symphysis pubis, separated only by the potential retropubic space of Retzius. The paired paravesical spaces laterally bound the bladder. The bladder and adjacent structures define the inner surface of the lower abdominal wall, which includes the median umbilical fold (urachus), the paired medial umbilical folds (obliterated umbilical arteries), and the paired lateral umbilical folds (inferior epigastric vessels). The internal anatomy of the bladder includes the base or trigone (defined by the internal urethral orifice and both ureteral orifices), a ventral wall, and a dorsal wall. The ventral and dorsal walls meet at the bladder apex, where the urachus begins its course toward the umbilicus. In women, the bladder base rests on the anterior cervix and proximal anterior vagina. As such, radical cystectomy in the female patient includes removal of the bladder and surrounding fat, the uterus and adnexa ...

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