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Media Gallery

Mobilizing the lateral peritoneum after transection of the vas deferens with preservation of the spermatic cord.
Pelvic lymph node dissection with removal of lymphatic tissue from the genitofemoral nerve to the obturator nerve and from the pelvic sidewall to above the bifurcation of the iliac vessels.
Mobilization of the distal ureters into the bladder, taking care to preserve vascular supply. The bladder is lifted to the left; the pouch of Douglas is seen between the bladder and rectum.
Exposure and ligation of the lateral pedicle, which extends from the internal iliac vessels over the distal ureter on its way to the bladder.
Opening the pouch of Douglas between the rectum and posterior bladder wall.
Pelvic ileal neobladder ready for anastomosis to the urethra.
The bowel segment of the Indiana pouch includes the entire ascending colon, a small portion of the transverse colon, and about 7-8 cm of the terminal ileum.
The colon has been opened on its antimesenteric border, and the terminal ileum has been plicated by application of the gastrointestinal anastomosis (GIA) stapler to reduce the lumen to approximately 16F. A 14F catheter is shown traversing the efferent limb. The ileocecal valve also has been bolstered with 2-0 absorbable sutures.
Dissection of the lateral pedicle extending from the internal iliac vessels over the distal ureters. These vessels can be ligated, allowing full mobilization of the ureter down to the bladder.
The posterior peritoneum has been entered, and the rectum is retracted to the right. The posterior plane between the bladder and prostate anteriorly and the rectum posteriorly can then be entered using a combination of sharp and blunt dissection; this defines the posterior pedicles.
The rectum is retracted down and to the left, and the articulating stapler is applied to the posterior pedicle. Three such applications of the stapler typically advance the dissection all the way to the lateral endopelvic fascia. The apex can then be addressed in a manner similar to a radical prostatectomy.
The ureters are anastomosed to the posterior wall of the pouch and are shown from behind the pouch. They are brought through the wall and sutured to the pouch with interrupted absorbable 4-0 sutures. An antirefluxing anastomosis has traditionally been recommended, using the LeDuc technique. Both anastomoses are stented.

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Table 1. Staging of Bladder Cancer

Disease Type	Stage	Characteristics
Superficial disease	Ta	Confined to mucosa
	T1	Involving lamina propria and muscularis mucosa
	CIS	Malignant cells still confined to the flat urothelial layer
Muscle-invasive disease	T2	Invasion of muscularis propria
	T3	Extension into perivesical fat
	T4	Invasion of pelvic sidewall or adjacent organs or metastatic disease

Table 2. Advantages and Disadvantages of Intestinal Segments Used for Urinary Diversion

Segment	Advantages	Disadvantages
Stomach	Can be used in patients with renal failure, hepatic failure, acidosis, and pelvic radiation; no mucus production	Hypokalemic hypochloremic metabolic alkalosis, hematuria dysuria syndrome due to acid irritation of the urothelium, concern for increased secondary malignancy
Jejunum	N/A	Hyperkalemic hypochloremic metabolic acidosis, hyponatremia, osteomalacia (avoid if at all possible)
Ileum	Familiarity to urologists	Hypokalemic hyperchloremic metabolic acidosis, vitamin B₁₂ deficiency, fat malabsorption, diarrhea, osteomalacia (not a good option following pelvic radiation)
Colon	Transverse colon can be used in patients who have had pelvic radiation.	Hypokalemic hyperchloremic metabolic acidosis, osteomalacia; most mucus production of all intestinal segments

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