Radical cystectomy is the surgical removal of the urinary bladder through an incision in the abdomen. Less commonly, all or parts of a cystectomy may also be done using a "laparoscopic" approach (multiple small incisions with placement of only a camera and small instruments, and not the surgeon's hands in the pelvic cavity). If this is the case, you will receive a supplement to this educational piece fully describing laparoscopic surgery.
Almost all cystectomies are performed for a diagnosis of bladder cancer, although there are rare instances in which other diagnoses necessitate removal of the bladder. Depending on variations in the procedure, the extent of the tumor, and an individual's particular anatomy, this operation can range from 4 hours to 8 hours or longer. In men, removal of the prostate, seminal vesicles (small organs that produce semen), and a portion of each vas deferens (tubes that transport sperm from the testicles to the urethra) is part of the operation. In women, hysterectomy/salpingo-oophorectomy (removal of the uterus, ovaries and fallopian tubes) is usually performed as well. In both men and women, multiple lymph nodes (small drainage glands) are sometimes removed to help determine the stage (extent of spread) of the cancer.
Because the bladder has been removed, it is necessary to create some form of substitution to receive urine produced by the kidneys. This receptacle is termed a "urinary diversion" and may be one of three types. There are advantages and disadvantages to each. By the time you are reading this, you will have discussed the pros and cons of each type with your surgeon and will have chosen one of the following:
- Simple Ileal Conduit: This is the most commonly performed diversion. The ureters(tubes that drain urine from the kidneys to the bladder) are connected to a piece of the small intestine (ileum). The end of that intestine is brought out to a hole in the skin. The urine will flow freely out to a small bag that adheres to the abdominal wall. This operation usually takes the least time to perform and may have the lowest complication rate.
- Continent Diversion: There are many variations of this type of diversion. A larger piece of small intestine and a piece of the colon (large intestine) are used. The hole in the abdominal wall is smaller and "continent". In other words, urine does not flow freely to a bag but rather remains in the intestinal pouch until the patient drains it himself. This is done several times a day by inserting a small catheter in the stoma (hole in the abdominal wall).This operation takes more time and is associated with more complications than an ileal conduit. The advantage is that the patient does not wear a bag.
- Continent Orthotopic Diversion: The other term for this is the "neobladder" which means, "new bladder". A large portion of the small intestine is used to create a pouch resembling a bladder.
It is sewn to the remainder of the urethra so that there is no stoma on the abdominal wall. Some patients are able to urinate and empty their neobladder, but most are not and are committed to placing a catheter in the urethra once to several times per day. While this operation might be the most cosmetically appealing, it has the longest operative time and is usually associated with the most complications.
As discussed previously, a cystectomy sometimes includes removal of multiple lymph nodes in the pelvis. If the lymph nodes are positive (contain cancer), then the operation is not considered curative. In this instance, chemotherapy might be considered for later treatment. In certain instances (that we discussed on your prior consultation), if during the surgery it is obvious that the nodes are positive, we may elect to not complete the operation and leave the bladder in place. When the tumor in the bladder is large and consequently causing problems (i.e. severe blood in the urine, pain in the pelvis, blockage of the kidneys, etc.), it might be better to remove the bladder for what we term "local control of the cancer". There are studies that demonstrate that multimodality therapy (the operation combined with other treatments such as chemotherapy or radiation therapy) may reduce complications of the disease and delay the progression of the cancer. To reiterate, there are instances that we may suggest this operation even when we know that there is a high likelihood that the cancer has already begun to spread beyond the bladder.
Radical cystectomy is an involved operation. Because anesthesia time can be long, we may send you for an updated general physical and note of "medical clearance" from your primary physician. This is precautionary and for your own protection.
As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood ("blood thinners, aspirin, anti-inflammatory medicines, etc."). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
We will ask you to completely clean out your small intestine the day before your surgery. You should plan a very light breakfast the day prior. Your lunch and dinner will consist of clear liquids (ones you can see through) only. At 5:00 p.m., you will administer an enema. Approximately one hour later, you will take a type of laxative. For the remainder of the evening, it is important to continue to drink plenty of clear fluids, but you CANNOT eat. You may drink up until midnight but not after and not in the morning of your scheduled surgery. Bowel preparation has many variations and your surgeon will choose the agents and the time of administration.
The duration of the operation is different for every patient, mostly reflecting difference in each patient's anatomy and the choice of urinary diversion. The general range is 4-8 hours or more. Your position on the table will be supine (flat on your back). The type of anesthesia used will reflect the suggestion of the anesthesiologist as well as contributions from your preferences as well as that of your surgeon. General anesthesia (complete sleep) is used in most cases, but a spinal might be acceptable in some circumstances.
After the abdominal cavity is opened, we will inspect the organs such as the liver and the lymph nodes that drain the bladder. The ureters are detached from the bladder and a small sliver is sent to the pathologist to ensure that the ends (that will be sewn to the diversion)contain no tumor cells. Next, the bladder, prostate, seminal vesicles and a portion of the vas deferens (in a male patient) are separated free from the surrounding tissue and removed. In women, the bladder is usually removed with the uterus, the fallopian tubes, and the ovaries. The urethra in women is removed entirely unless a neobladder is planned. In this case, the urethra is left in place so that the newly created bladder can be sewn to it.
Removal of the lymph nodes can be done at different times during the operation. If the nodes do not look or feel positive, some surgeons will wait until the bladder is removed to operate on the lymph nodes. If they are suspicious, and your surgeon would stop the operation if they are indeed positive (contain cancer), then they will be removed first and the operation would halt for a short time while the surgeon waits to hear from the pathologist (doctor who looks at tissue under the microscope). All of these circumstances will vary from patient to patient. Your surgeon will have discussed all of these possibilities prior to your operation.
After removal, the urinary diversion is created and the ureters (tubes from the kidneys) are attached to the diversion. Some surgeons will place stents (plastic tubes) in the ureters to assist drainage during the healing process. Other surgeons do not. One or several drains (tubes that help remove excess fluid or blood from the body) are usually placed and will remain or a few days or longer. If an ileal conduit was created, there might be a catheter in the small stoma temporarily to keep the diversion empty during the healing process. If a neobladder was created, there may be a catheter in the new urethra for a while during the healing process.
Another part of the operation in men that is occasionally discussed is the "nerve sparing procedure". We are referring to the nerves that control your ability to get erections. While carefully sparing the nerves is possible in some patients, in is not in others. Depending on your wishes, we may attempt to spare nerves on both sides, one side, or not at all. You should realize that sometimes a nerve sparing procedure does NOT mean that you will be able to achieve erections.
After the procedure, you will be in the recovery room until you are ready to be moved to a regular room. Depending on the particular circumstances, we may elect to admit you to an intensive care unit for closer monitoring.
Your urine will be coming out through a catheter and emptying into a bag. Catheters may remain for days or weeks until adequate healing has occurred. The urine may be crystal clear or appear bloody for a few days. You may have one or more drainage tubes attached to bags to empty the excess fluid accumulation in the body from the operation.
There will be a tube coming from your stomach and out of one side of your nose (put in while you are asleep) to keep fluid out of your stomach, intestines and colon. You may also have boots on your legs that inflate and deflate (intermittent squeezing) to prevent the formation of blood clots in your veins (deep vein thrombosis or DVT).
A typical hospital stay for radical cystectomy is usually one week, but may vary depending on your particular health status and your post-operative hospital course. It is important to get out of bed either the first or second morning and spend time in a chair. With assistance from a nurse or family member, you may usually walk on the second day. Your diet may begin as only liquids and should advance as you are tolerating it.
Upon discharge, you may have no dressing (bandage) on your incision. If you have an ileal conduit, you will be instructed on how to empty the urine bag and even switch it to a larger bag for overnight use when you are sleeping. With the continent diversions (those without a bag) you may receive instructions on how to catheterize if it is not too early to do so. Otherwise, you may still have a catheter and a drainage bag for a little while. It sounds complicated, but it is easy...we assure you.
You will be discharged with instructions for follow-up in our office. Other than your regular medications, we may give you an antibiotic, a pain medication, and a stool softener so that you do not strain to have bowel movements. Other medications will depend on your particular needs.
Expectations of Outcome
It is normal to feel a bit tired or weak for several weeks. We typically tell patients that they will be out of work for at least 4-6 weeks (up to 12 weeks is possible if your occupation requires strenuous activity) and that it may take several more weeks before you truly feel like yourself.
While we will be able to tell you about our findings during surgery, you must understand that the specimen will be evaluated by the pathologists. They carefully examine the entire specimen under the microscope. It may take one week before we have an official report to discuss with you. Of course you will be anxious, but we encourage you to be as patient as possible. Use that week to concentrate on your recovery.
Management of your urinary diversion (whether a bag or a catheterization) may seem awkward at first. Like anything else in life that you do often enough, you will soon become familiar with the procedure and develop a comfortable routine.
*Because of the organs removed, men will no longer be able to ejaculate any fluid if orgasm is achieved. In women, the vagina may be shortened or tight and sexual intercourse may be painful or even not possible. Women who are still menstruating should understand that they will be in menopause once the uterus and ovaries are removed.
Possible Complications of the Procedure
ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
- Blood Loss/Transfusion: There is always some blood loss expected. In some instances, blood loss necessitates a transfusion. Blood transfusion may be necessary in up to one third of radical cystectomy operations.
- Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. They will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with disorders of the immune system.
- Wound Infection: As with any incision, an infection can occur. This would present with redness, swelling, and/or drainage (white to yellow thick fluid) from the incision. Usually, these are managed with antibiotics and local wound care. In some instances, an area of the superficial (upper layer) incision needs to be opened for adequate drainage. An abscess is an infection collection in the body. It can present with the same symptoms such as fevers, chills, fatigue, and even discomfort and usually requires adrainage procedure. *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
- Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation (especially longer operations), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
- Inability to Remove the Bladder: Although uncommon, a patient's anatomy, excessive bleeding, an extensive tumor, or scarring from a prior procedure(s) may make it impossible for the surgeon to safely remove the bladder.
- Ileus or Bowel Obstruction: Because we operate on the intestines, they can go into prolonged spasm (ileus), or they may become completely blocked. Usually, replacement of the NG tube and observation are all that is necessary. Less commonly, repeat surgery is warranted.
- Strictures and Stenosis: Any opening in tissue can scar down and become blocked. The two places that this may occur are where the ureters (tubes draining the kidneys)are sewn to the new bladder or conduit. Sometimes, this results from a ureter not having enough blood supply. The other place this may occur is in patients who have a stoma on the abdominal skin. Whether it is the type that always requires a bag (the ileal conduit), or whether it is the type that gets catheterized, the opening can scar down over time. Treatment may include simple dilatation (spreading the area open), minimally invasive procedures, or even open surgery.
- Anastomosis Breakdowns: There are many new connections (anastomoses) in this operation. The ureters (tubes draining the kidneys) are sewn to a piece of intestine or colon. The intestine or colon are sewn to each other in different areas as well to form the urinary diversion (conduit, pouch, or neobladder). Sometimes, it is possible for these connections to leak urine. This problem is usually managed with observation if the leakage area has adequate drainage. If necessary, extra drainage can sometimes be added with only minor procedures. Persistent leaks may require special x-rays to locate the area allowing the fluid out. Once found, it may require open surgical correction if it does not stop over time.
- Bowel or Colon Infarction: As you recall, a portion of intestine and/or colon are used to make the urine pouch diversion. During the surgery, we ensure that the piece of intestine or colon used had a good blood supply. Hours, days, or even weeks after the operation, the blood supply may change for a variety of reasons and the tissue of the pouch does not survive. Repeat surgery to make a new diversion could be necessary.
- Impotence (Erectile Dysfunction): Just to reiterate, erectile dysfunction is not uncommon following this operation. Even if "nerve-sparing" is attempted, you may still not be able to get erections.
- Bladder Neck Contracture: *This only applies to the operation when a neobladder (choice #3 in the definition section) is performed. As mentioned, the new bladder is reattached to the remaining urethra (anastomosis). Sometimes, the area of the repair can scar down (weeks to months later) and restrict proper urine flow. Treatment may include simple dilatation (spreading the area open), minimally invasive procedures, or even open surgery. Unfortunately, the problem could recur in the future.
- Lymphocele: A lymphocele is a collection of lymphatic fluid (fluid that drains through the lymph nodes) that can accumulate in patients that undergo removal of lymph nodes. These collections can form in the abdomen or pelvis and may compress nerves (causing weakness in the leg) or blood vessels (increasing the risk of a deep veinthrombosis). Often, the first sign of a pelvic lymphocele is ankle and foot swelling on the same side of the lymphocele. Treatment ranges from observation (often a self-limiting process) to a minimally invasive drainage procedure. The need for an open procedure is far less common.
- Injury to the Rectum: The back of the bladder and prostate lie against the front of the rectum. Local extension of the cancer or inflammation from prior operations or biopsy may make it difficult to separate the two. Rectal injuries may occur and can usually be repaired quite easily and quickly. It is less common to need a major procedure such as a temporary colostomy (bag for stool). Sometimes, a general surgeon would be asked to assist with this procedure.
- Chronic Pain: Any patient can develop chronic pain in an area that was subject to surgery. The cause is not always forthcoming. While this usually resolves with time, consultation with a pain specialist may be necessary.
- Obturator Nerve Injury: The obturator nerve is located in the same area as some of the lymph nodes that are removed in this operation. Injury to this nerve would present with a specific problem with leg motion on that side (specifically close your legs together).
- Death: The incidence of death during or shortly after the operation is approximately1%. It is usually a result of an unexpected cardiac (heart) event or a pulmonary (lung)event. The rate may be higher in patients with significant medical problems.
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.
Delta Medix, P.C.