ESOU 2019: Optimizing Functional Outcomes in Radical Cystectomy: Open Nerve-Sparing Radical Cystectomy

Prague, Czech Republic ( Dr. Arnulf Stenzl gave the third talk in this series about improving functional outcomes following radical cystectomy (RC), specifically open RC. Dr. Palau had given a similar talk but for robotic RC. Dr. Stenzl did note that videos were difficult with open surgery, so he would spend more time talking about anatomy. 

He again reviewed the basics of bladder cancer management. As background, it is well established that 20-30% of newly diagnosed bladder cancers are muscle-invasive (MIBC), and for these patients (and patients who progress to MIBC), the standard of care treatment is neoadjuvant chemotherapy and radical cystectomy (RC) with urinary diversion. Alternatives include trimodal therapy, though this is not yet considered a standard of care. RC is associated with significant detrimental effects on patient quality of life, urinary and sexual function, and has an impact on patient social and emotional health, body image and psychosocial stress. While most patients undergo urinary diversion with an incontinent ileal conduit, some patients (male and female) undergo continent neobladder formation.

The main nerve pathways of relevance to functional preservation are summarized below:
UroToday ESOU19 nerve pathways of relevance to functional preservation
He then spent much of the talk showing still frames of different sections of RC, with a focus on the neurovascular landmarks. I highlight some of his key points below.

1. Pelvic plexus – an important plexus to preserve. This lies medial to the ureter and near the seminal vesicle tips. When doing an extended node dissection, it is important to avoid injury to the plexus.
2. Periprostatic neurovascular bundle – he highlighted that while ~75% of the bundle is posterolateral to the prostate, approximately 25% is anterolateral and an effort should be made to preserve this as well.
UroToday ESOU19 Optimizing functional outcomes in radical cystectomy 2
3. As a result of this anterolateral bundle, which has some crossover in the midline, a high release of the bundle is important. In addition, one must be careful when transecting the DVC to not injure the bundle. 
UroToday ESOU19 Optimizing functional outcomes in radical cystectomy 3
4. Accessory pelvic arteries and vascular supply to the neurovascular bundle should be preserved if identified
5. In female patients, the rhabdosphincter is harder to preserve and identify. The autonomic nerves run on the anterolateral aspect of the vaginal wall and should be preserved if possible.

Presented by: Arnulf Stenzl, Director of the Department of Urology, University of Tübingen Medical School, Chairman of the Scientific Congress Office of the European Association of Urology, Tuebingen, Germany

Written by: Thenappan Chandrasekar, MD. Clinical Instructor, Thomas Jefferson University, Twitter: @tchandra_uromd, @TjuUrology, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic

Further Related Content:
Robotic Nerve-Sparing Radical Cystectomy
Prostate Sparing Approaches