Radical prostato-cystectomy for infiltrating bladder carcinoma using a combined abdomino-perineal approach

Radical abdomino-perineal cystectomy was used in 23 Pts with Tis to T4 bladder tumors, 12 of whom had previously been submitted to radical Radiotherapy (salvage cystectomy). The perineal approach greatly facilitated the prostatic dissection in 10 cases, in which it was considered extremely hazardous from the abdomen. There were two post-operative deaths from acute myocardial infection in patients over 70. Prolonged drainage of the perineal wound occurred in four Pts. Abdomino-perineal cystectomy is not a routine procedure and should be considered in two settings: in the case of salvage cystectomy when Radiotherapy - induced desmoplastic reactions make the dissection of the prostate from the rectum hazardous, and when urethrectomy is mandatory and the patients status requires an expeditious procedure. Although the early cystectomies for bladder carcinoma were performed using a combined perineo-abdominal or abdomino-perineal approach (Couvelaire 1948, Hinman 1939, Wilhem 1947), this procedure has fallen into disuse since the early 1950's in favor of the suprapubic approach. Nevertheless, the combined abdomino-perineal procedure offers three advantages: 1) better exposure of the urethra, prostatoseminal pedicles, and puboprostatic ligaments, 2) total urethrectomy can be done at the same time, 3) drainage through the perineal incision is excellent. These advantages are maximized when two surgeons operate simultaneously through the perineal and suprapubic incisions (Ameline 1948, Boccon-Gibod 1979, Boccon-Gibod 1984, Crawford 1980, Pascal 1974).