Operative note 28 Advanced
Cystoprostatectomy, keyhole - 10 steps
What it does: bladder and prostate out, keyhole. Diversion after.
- Ureters divided near the bladder, with a cuff. Frozen section the ends. Do not strip ureter fat. Scarring follows.
- Peritoneum opened between the ureter stumps. Vasa + vesicles stay with the specimen. Denonvilliers' fascia cut across, into pale fat. (That fascia = the sheet between bladder and rectum.)
- Bladder pedicles divided (stapler or harmonic) along the inner side of the external iliac vein. Find the obturator nerve first.
- Bladder dropped off the wall. Urachus with it.
- Endopelvic fascia opened. Dorsal vein complex stitched, right to left.
- Urethra divided. Catheter out. Clip the proximal urethra (no spill). Nerve bundles kept or taken.
- Specimen bagged, sealed.
- Drop the gas to 5 mmHg. Haemostasis check.
- Node dissection both sides. Bagged, labelled.
- Left ureter routed under the colon mesentery. Diversion built outside, via the port site.
- 2026 update: Robotic with internal diversion is standard in big centres. Open still fine. Steps translate.
- 2026 update: ERAS now: no bowel washout, early food.
From the UroRef Operative Quick Guide.