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Prior gynecologic surgery should be noted, and when oncologically sound, discussion regarding vaginal sparing in women who wish to remain sexually active should be undertaken. Detailed preoperative medical evaluation and optimization, counseling regarding urinary diversion together with an enterostomal therapist, comprehensive metastatic evaluation, and mitigation of thromboembolic complications remain important aspects in women.
Availability of a sponge stick for intravaginal manipulation during dissection and Babcock forceps for retraction of the uterus are notable additions to the instruments required for radical cystectomy in men. Refer to the Chapter 48 for further details on preoperative planning for radical cystectomy. To permit access to the vagina, the lower extremities are placed in a frog-legged position with the knees wellsupported.
Alternatively, the patient may be placed into a low dorsal lithotomy position. The skin is prepped from the nipples to the midthigh, including a thorough vaginal prep. After draping the abdomen, including maintaining access to the vagina, insert an Fr urethral catheter. Clip the catheter to the drapes for accessibility throughout the case. A primary right-hand-dominant surgeon should stand on the left side with the assistant on the right.
Make a lower midline abdominal incision from the symphysis pubis to just below or lateral to the umbilicus. Bluntly with a Kittner sponge stick but under direct visualization, open the space of Retzius and establish the potential space between the bladder and the pelvic sidewall and the external iliac vessels.
