Radical cystectomy with an ileal conduit

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Access + stoma site The stoma site is marked with the patient standing, over the rectus muscle and clear of skin folds, scars and the belt line, so the appliance sits where the patient can see and manage it. The abdomen is then opened through a midline incision or by the robotic approach, and the bladder is assessed for resectability before the dissection commits. Marking before induction means the mark reflects the standing anatomy the appliance must live with, not the anatomy of a supine, anaesthetised abdomen.
   where it bites: a stoma sited on the ward with the patient supine is the complication that outlives the operation: parastomal hernia, leakage and appliance failure all follow a bad site.
2. Ureteric division Both ureters are identified where they cross the common iliac vessels at the pelvic brim and freed with their strip of adventitia, divided between clips well clear of the bladder, and the distal ends sent for frozen section where the indication demands it. The crossing is dissected with the iliac vessels in view and clips applied only under direct vision, because the ureter lies directly on the iliac vein at this point. Division at the brim, rather than low over the bladder, gives clean margins and enough length for the ureters to reach the afferent limb without tension later.
   where it bites: the ureter crosses the iliac bifurcation directly over the vessels; traction that avulses the ureter or a clip applied blind bites the iliac vein.
3. Posterior plane The peritoneum is incised behind the vasa and seminal vesicles and the plane is developed directly onto Denonvilliers' fascia, then swept down to the apex with the rectum in view throughout. The plane is avascular and drops almost without bleeding when the layer is right, and fat or bleeding means the plane has been lost, so the dissection returns to a clean area and re-enters under direct vision. In the female the same plane runs behind the uterus and vagina, with the anterior vaginal wall taken en bloc where the disease demands and the vault repaired as a planned part of the case.
   where it bites: the plane is avascular until a wrong-layer entry puts the instrument on the rectal wall; previous radiotherapy or a posterior tumour thins the margin to nothing.
4. Lateral pedicles The lateral bladder pedicles are divided along a line from each divided ureter down toward the apex, stepping sequentially through the bladder blood supply from its internal iliac branches, with an energy device where the approach allows and clips beside structures that must not be exposed to heat. Each step is taken with the obturator nerve in mind as it runs in the same lateral gutter, so bites are shallow and applied only to tissue that has been skeletonised. Working from the pelvic brim downward in a fixed order keeps the field organised and prevents a pedicle stump being missed until it bleeds.
   where it bites: the obturator nerve shares the lateral gutter with the pedicle; the clip that is too deep takes the nerve with the pedicle.
5. Apex + dorsal venous plexus The posterior attachments are divided and the urethra is freed at the apex, with the dorsal venous plexus ligated and controlled before the urethra is cut, so the last attachment of the specimen comes away without a venous tear. The catheter is withdrawn before the cut, and the specimen side of the urethra is clipped or tied as it is divided so nothing spills from the bladder into the pelvis. The urethral margin is sent where a neobladder is contemplated, because a positive margin changes the reconstruction. If the plexus tears it retracts into the pelvic floor, and the response is pressure, exposure and then a haemostatic suture, never blind diathermy into a pool.
   where it bites: the plexus retracts into the pelvic floor when torn; the save is a haemostatic suture, never blind diathermy into a pool.
6. Lymphadenectomy The node template is cleared to match the disease and the patient, running from the aortic bifurcation or the common iliacs down to the inguinal ligament and including the obturator and presacral packets as indicated. Each packet is swept off the vessels as a complete block with clips on lymphatic channels, and the obturator nerve is kept in view along the floor of the gutter. Presacral veins and obturator vessels bleed in awkward corners, so the template is cleared with the same discipline and exposure as the cystectomy itself, never as a rushed afterthought.
   where it bites: presacral veins and the obturator vessels bleed in awkward corners; the template is cleared with the same discipline as the cystectomy.
7. Ileal conduit + stoma A segment of ileum is selected on a healthy mesentery with a good arc of mobility and enough reach to bring the conduit to the marked stoma site without tension, then bowel continuity is restored and the mesenteric window is closed. Both ureters are joined to the afferent limb over stents, and the distal end of the conduit is brought out through the rectus at the pre-marked site and matured as a spouted bud. The bud is checked for a healthy pink colour before the drapes come down, because a dusky bud is revised now, in theatre, while salvage is easy.
   where it bites: a segment chosen under tension or on a marginal mesentery is the setup for ischaemia, retraction and stenosis of the whole conduit.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance