What is a cystectomy?
A cystectomy is a surgical procedure in which the bladder is removed for a variety of reasons. These indications most commonly are due to invasive bladder cancer but can also include benign conditions. There are several types of cystectomy that may be performed:
- Radical cystectomy: This is a surgical procedure in which the bladder and surrounding fatty tissues are removed with a wide margin. Adjacent pelvic organs are also removed. This includes the prostate in a man and the uterus, ovaries, and part of the vaginal wall in a woman. This surgery is primarily performed for invasive or advanced bladder cancer. The surgery may be done with an incision or laparoscopically with robotic techniques.
- Partial cystectomy: This is a surgical procedure in which part of the bladder wall is removed and the remaining bladder is preserved. There are limited indications for this type of procedure, as it does not provide as effective cancer control as a radical cystectomy. This, however, is a common procedure performed for some benign conditions of the bladder wall.
- Simple cystectomy: In this procedure, the entire bladder is removed; however, the surrounding fatty tissue and pelvic organs are preserved. This type of cystectomy is primarily performed for extensive benign lesions of the bladder which leave the bladder nonfunctional.
After the bladder is removed, the surgeon will then perform some type of urinary diversion to restore continuity of the urinary tract. This is most commonly performed with an ileal conduit which is a surgical procedure in which a small strip on the intestine is removed from the intestinal tract and then brought to the skin surface. The ureters from the kidneys are then surgically attached to this intestinal strip. This allows urine from the kidneys to enter this segment of the intestine and subsequently be delivered through the skin stoma into a urinary collection bag. (see other questions below)
There is a multitude of other types of urinary diversions which can also be performed based upon patient preference and disease states. Many of these diversions are designed to eliminate the need for an external drainage bag. In these surgeries, a larger strip of the intestine is used to create a urinary pouch inside the body which then delivers the urine either through the urethra (intestinal bladder substitution or neobladder) or through a small stoma at the umbilicus through which the patient passes a catheter to drain urine intermittently throughout the day. Continent urinary diversions are best suited for patients with less extensive cancer and who are in better health, able to tolerate the more elaborate and lengthy surgery.
What are common symptoms following my cystectomy?
A cystectomy is a complex surgical procedure that can carry up to a 25% complication rate. Most of these complications are minor and can be effectively treated.
By the time you leave the hospital in 5-10 days, you should be ambulating independently with good pain relief using oral pain medication. It is common to have pain in the incision site for several weeks following any major surgery.
Because of the use of pain medication around the time of your surgery, constipation is a common problem. Patients are advised to monitor themselves for this problem and to use over-the-counter stool softeners and laxatives as needed.
Easy fatigue is very common following this surgery and can last for weeks to months depending on the patient’s baseline health, age, and overall endurance.
Poor appetite is sometimes present for 1-4 weeks and weight loss is common. You will gradually be able to eat more and return to normal weight, usually within a few months.
How do I manage my new stoma or bladder?
The urinary stoma refers to the small visible portion of the intestine used to drain the urine from your kidneys and into the external device. It extends above the skin by about a ½ inch and is usually located on the lower right side of the abdomen. An appliance with a central hole and attached collection bag is fitted over the stoma and while in the hospital a specialized nurse called an enterostomal therapist, will teach you or your caregiver how to place it, change it and care for it. A visiting nurse will also be arranged to visit your home to help teach and manage this process in the beginning. After a period of recovery and practice, most patients can do this easily and independently. Some are helped by their spouse, relative, or friend, and with time the appliance will stay attached and need to be changed about every 5 days. The bag has a valve at the bottom to drain the urine into the toilet when full.
Some patients will choose to have a new bladder(neobladder) constructed with a piece of their own intestine and attached to their urethra internally. You will be discharged with several tubes extending from the new bladder through the skin and into the urethra. You will be taught how to manage these tubes and a nurse will be arranged to visit you at home to help with these. Irrigation of the tubes(catheters) is necessary to remove the excess mucous made by the bladder, now made from intestines. After 10-14 days, once the suture lines are healed, you will return to the Dr’s office to have x-rays and tube removal. At this point, you will be allowed to urinate again with the urine now collecting in the neobladder. The sensation is different, and many patients are signaled to urinate by a fulness in the pelvis or a small amount of urine extending to the sphincter muscle. Urine control often returns quickly during the day but more slowly at night. Many patients will require a pad at night and may benefit from setting an alarm and timing the night urinations. With time urination becomes more normal and patients are quite pleased with the result.
When should I seek advice from my physician?
Contact your physician is you run a fever of 101 degrees Fahrenheit or greater consistently. Your physician will also need to know if you are having any difficulty with abdominal pain or bloating that is not improved with pain medication. If you develop nausea and vomiting that persists greater than 24 hours, you should also contact your physician. You can expect a learning curve regarding your appliance management and will likely get a bit wet with urine a time or two. This is normal. If you are having difficulty beyond a few weeks or if the stoma and surrounding skin doesn’t look normal to you then call the office for an appointment – sometimes you may be directed to the enterostomal expert that you met in the hospital.