*5.2.1 Female (anterior pelvic exenteration)*

The technique starts with the section of the ovarian ligament following down this step will be also the start of the extended pelvic lymph node dissection reaching a better exposition of the ureter and later the bladder pedicles on the right side (**Figure 2**).

Once the lymph nodes are dissected medial to the ureter it can be visualized from the cross up over the iliac artery bifurcation, the ureter is perfectly identify and clip and transected then the lateral nodes are accomplished avoiding any injury of the hypogastric vessels and the obturator nerve preservation (**Figure 3**).

The common iliac artery bifurcation with-out the nodes shows the internal and external iliac arteries progressively dissected. The operative field view allows the identification of the bladder pedicles which are clipped or transected by ultrasonic device, the left ureter is clip and transected, lateral to this last one we follow the pedicle (**Figure 4**).

The same dissection is reproduced in the left side for the lymph node and the removed nodes are placed in an Endobag. It is then that both ureters are clipped and transected distally. In the case of uterus presence the pedicles are also clip by ultrasonic energy following the hypogastric artery to find the uterus branches. Because previously lymph node dissection and ureteral identification, uterus and vesical pedicles are easier to identify during exposition and dissection. Both pedicles are controlled and the lower plane of the bladder is follow by the anterior vaginal wall in assistance of a vaginal valve (**Figure 5**) [19, 20].

**Figure 2.** *Female ligament transection and lymph node.*

**Figure 3.** *Right ureter identification and lymphadenectomy.*

**Figure 4.** *Left ureter and pedicle identification.*

**Figure 5.** *Anterior wall of the vaginal plane and anterior bladder.*

**Figure 6.** *Urethra dissection and vaginal cavity.*

The dissection of the lateral surfaces of the bladder is extended, following the medial umbilical ligaments to the medial plane, the reflection of the endopelvic fascia is visualized and open it, the anterior urethra space is created and the urethra is clipped at the tip and transected safely, the specimen can be retrieval by the vaginal cavity (**Figure 6**) [21].
