Radical cystectomy is the complete surgical remove of the urinary bladder. 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 tumour, and an individual’s particular anatomy, the duration of 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-oophrectomy (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 there are 2 main types in use. There are advantages and disadvantages to each.
- 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 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 many 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 rarely curative. In this instance, chemotherapy might be considered for later treatment. In certain instances (that we discussed in 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. However, with modern CAT scans, discovering “surprises” at the time of surgery is becoming far less common. When the tumour in the bladder is large and consequently causing problems (ie. 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”. Sometimes this is not possible and an ileal conduit diversion is performed, with radiotherapy and possibly chemotherapy used to treat the bladder which remains in place.
Because the operation is complicated, you may need to have a full cardiac assessment prior to the procedure.
On the day before surgery, you should only take clear fluids. You will be given instructions about completely cleansing your bowels with Picoprep as preparation for the urinary diversion. These instructions will be provided by the rooms and are also available on this website.
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 four to eight hours or more.
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 tumour cells. Next, the bladder, prostate, seminal vesicles and a portion of the vas deferens (in a male patient) are separated free from 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.
In most cases, the lymph nodes will be removed after the bladder is removed. However, if the nodes appear to look or feel suspicious, they may be removed at the beginning of the operation. They will then be sent for immediate analysis (frozen section). If there is evidence of cancer in the lymph nodes, signifying spread of cancer beyond the bladder, the cystectomy may not be completed, as discussed above.
After removal, the urinary diversion is created and the ureters (tubes from the kidneys) are attached to the diversion. We sometimes place stents (plastic tubes) in the ureters to assist drainage during the healing process. One or several drains (tubes that help remove excess fluid or blood from the body) are usually placed and will remain for a few days or longer. If an ileal conduit was created, there will be a bag over the stoma (hole in the abdomen). If a neobladder was created, there may be a catheter in the new urethra for a while during the healing process.
After the operation, 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 or emptying directly into a bag, depending on the type of diversion used. 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 7-10 days 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.
If you have an ileal conduit, you will be instructed on how to empty the urine bag and even switch it to a large 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.
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 four to six 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.
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. Indeed, the majority of men will not be able to achieve spontaneous erections after radical cystectomy. This is due to interference with microscopic nerve fibres around the prostate during the course of the operation. It is absolutely vital that no cancer is left behind after a radical cystectomy. For this reason, wide clearance is mandatory and microscopic nerve fibres that control erections are therefore usually sacrificed. However, erectile function can still be achieved with the aid of medications and other devices. 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
Because of the complexity of this procedure, a number of postoperative problems may occur. Despite this, the majority of patients recover very well from the surgical point of view.
Possible Early Postoperative Complications
- Wound Infection
As with any incision, an infection can occur. This would present with redness, swelling, and/or drainage from the incision. Usually, these are managed successfully with antibiotics and local wound care.
- 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.
- Ileus or Bowel Obstruction
Because we operate on the intestines, they can go into prolonged state of quiet (ileus), or they may become partially blocked because of the formation of adhesions. Usually, replacement of the NG tube and observation are all that is necessary. Of the ileus persists for more than 4-5 days, we may need to provide nutrition via the veins (total parenteral nutrition or TPN). Less commonly, repeat surgery is warranted.
- Anastomosis Breakdown
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. 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. Rarely, repeat surgery may be needed.
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 form in the pelvis and may compress nerves (causing weakness in the leg) or blood vessels (increasing the risk of a deep vein thrombosis). Often the first sign of a pelvic lymphocele is ankle and foot swelling on the side of the lymphocele. Treatment ranges from observation (most 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. Very rarely, 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 colostomy (bag for stool). If there is a history of radiotherapy to the bladder or rectum, a rectal injury is less uncommon. In this circumstance a permanent colostomy may be required. Sometimes, a general surgeon would be asked to assist with this procedure.
Incidence of death during or shortly after the operation is approximately 1%. 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.
Possible Delayed Complications
- 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 simply dilatation (spreading the area open), minimally invasive procedures, or even open surgical reconstruction.
- Urinary tract infections
Any form of urinary diversion confers a higher risk of recurrent urinary tract infections than normal urinary tract anatomy. Because they are so common, we usually recommend treatment only if the patient is symptomatic or if certain more dangerous organisms are isolated. It is also important to exclude the presence of kidney obstruction due to a stricture (see above) when a urinary tract infection is detected because this may predispose to the infection getting into the bloodstream.
- Metabolic problems
As a result of urine being in contact with bowel following urinary diversion, waste products and acids in the urine may be absorbed by the segment of bowel used for the diversion. In most cases, the kidneys are able to compensate for this but when kidney function is also affected, such waste products may build up in the system and lead to problems such as thinning of the bones.
- Parastomal Hernia
When an ileal conduit is formed, a small hole must be created in the abdominal wall in order to bring one end of the conduit out to the skin. The weakness in the abdominal wall immediately alongside this hole may enable bowel from within the abdomen to push through, forming a hernia. If this occurs, a formal hernia repair may be required.
Detailed instructions on follow-up will be provided to you before discharge from hospital. Please contact the office of Dr Sved as directed in the hospital. You may see him in his offices at RPA, Bankstown or Strathfield Private Hospital. In the long term, regular scans and urine tests will be required to monitor for possible cancer recurrence.