For high-risk bladder cancer
This procedure is most commonly performed for high-risk (usually muscle-invasive), bladder cancer. On occasion, it may be carried out for non-malignant conditions such as refractory painful bladder syndrome, or a severely dysfunctional bladder.
The procedure and risks are essentially the same whether the bladder is being removed for cancer or not, except that in a cancer situation the lymph nodes are routinely sampled (this is not necessary for benign conditions).
The operation is carried out under general anaesthetic, usually combined with an epidural for postoperative pain relief, at Grace Hospital.
It is important to have a clear-fluid-only diet for 24 hours pre-operatively. This avoids the use of formal bowel preparation which is unpleasant and can lead to pre-operative dehydration. Clear fluids include thin soups without chunks of meat or vegetables and may include a glass or two of wine if desired. In addition, it is desirable, although not critical, that you have a bowel motion the night before, or the morning of, surgery and we will send you a microlax enema to help with this if required.
You will be sited for a stoma – ideally by the stoma therapists, prior to surgery. This needs to be done irrespective of the type of urinary diversion planned.
The operation is carried out via a midline incision below the umbilicus.
- In males, both the bladder and prostate are removed, as well as the lymph nodes which drain the bladder. Unless there are exceptional circumstances the urethra does not need to be removed.
- In females, the uterus and ovaries, as well as a part of the front wall of the vagina are removed with the bladder and the entire urethra. These other organs can be left in place in non-cancerous conditions. After the bladder is removed the ureters are joined to a piece of bowel and either an ileal conduit or neobladder is created (see below).
The procedure typically takes between 3 - 4 hours to complete (usually longer for females, where the advantage of a wider pelvis is offset by the need to do more). Although this would be an average operative time, the procedure may take substantially longer, especially if there are a lot of adhesions from previous surgery. We do not rush this fairly complicated procedure.
The wound is closed with subcutaneous dissolvable sutures. You will have a drain into the abdominal cavity and other tubes depending on the method of urinary diversion. You will have a drip in your arm to provide fluids intravenously.
Postoperatively, an hour or so is spent in recovery, then you return to the ward. Patients are usually fairly comfortable and able to receive visitors that afternoon. You will be allowed to have oral fluids as soon as you are awake.
You will be encouraged to get out of bed on the first postoperative day and you will gradually be able to increase your oral intake depending on how much ileus you get (see below). The drain is usually removed on the 2nd or 3rd day.
The average length of stay is between 8-10 days.
You will have support from the district nurses upon your return home.
Once the bladder is removed, the urine has to go somewhere and there are two options:
An ileal conduit where the ureters are joined to a segment of the small bowel (ileum), which is brought out onto the right side of the abdominal wall and acts as a stoma with a bag worn over this. The bag, or appliance, is worn under your clothes and has a tap at the bottom. Just like a bladder, it needs to be emptied when full.
An ileal neobladder. A 50cm piece of ileum is fashioned into a spherical shape with the bottom end sutured to the urethra. Voiding is carried out via the urethra by means of abdominal straining. Although this sounds attractive, it has its own particular set of issues (see below), and is not for everyone.
Both of these diversions require the placement of temporary ureteric stents which extend from the kidney and down through the area of anastomosis.
Risks and Complications
All surgical procedures are associated with some risk. Radical cystectomy is a large and complex procedure and there are a number of important potential complications besides the general risks of wound infection, blot clot formation, and pneumonia. There are particular risks that are gender-dependent and also related to the form of urinary diversion. All complications are more common if the procedure is carried out as salvage after prior radiotherapy.
The major important potential intraoperative complication is that of blood loss requiring transfusion. Improvements in technique and instrumentation have decreased the risk of transfusion from close to 100% 10 years ago to about 20% now. We always cross-match blood for this procedure so we have blood on hand if you need it. Whilst not strictly a complication, there is always a risk that the cancer is more advanced than anticipated and that it is impossible to complete the procedure. Modern imaging and the selective use of pre-operative chemotherapy have made this much less common, but it is obviously devastating to both the patient and surgeon on rare occasions when this occurs.
Ileus: This is where the bowel, as a result of being handled, decides to stop working. It is very common but not invariable. You stop passing wind (probably the only time in your life that you are actively encouraged to pass wind is during recovery following abdominal surgery), and your abdomen blows up like a balloon and becomes very tight and uncomfortable. This sorts itself out and lasts on average 48 hours, but it can take longer.
Anastomotic leak: This is where the join between the 2 halves of the ileum breaks down and bowel contents leak into the abdominal cavity. It is very rare, occurring in much less than 1% of patients, with the greatest risk being in the previously irradiated group. If you are unlucky enough to have this complication then emergency surgery will be required to sort out the problem.
Persistent urine leak: Again a rare complication (<1%), where the join between the ureters and the ileal segment is slow to heal. The risk is increased following radiation. It nearly always sorts itself out but you may need to keep the ureteric stents for longer than the usual 7 days.
Pelvic collection: This is an internal infection, usually of some residual hematoma in the pelvis. It occurs in around 5% of cases and is almost always resolved by instituting intravenous antibiotics and placing a drain to the area under local anaesthetic.
It is very common for men to lose their natural erections following this procedure. This is due to the proximity of the erectile nerves to the operative site. Nerve-sparing can sometimes be attempted, depending on the stage of cancer, but is often not successful. Fortunately, there are treatments available that will help with postoperative erectile dysfunction.
In women, the requirement to remove some of the vagina with the bladder can result in a change in vaginal shape. Interestingly, possibly contrary to what some might think, studies have shown that it is better to refashion a shorter, wider vagina, rather than a long and narrow one.
Post-operatively annual scans of the kidneys are performed to ensure they are not getting stretched up (hydronephrosis). If left untreated, this can lead to the functional death of the affected kidney. This problem may occur due to scarring at the site of anastomosis between the ureters and ileum and, rarely, due to cancer recurrence at this level.
Risks related to urinary diversion
This is a relatively simple diversion to create. The ureters are plumbed into the proximal end of a 15cm segment of the small bowel and the distal end is brought onto the skin surface at the site decided by yourself and the stomal therapist. Sometimes the blood supply of the segment is not long enough to allow the stoma to be placed at the desired location, although every effort is made to achieve this. The main concern with ileal conduits is leakage of urine around the appliance but in practice improvements in appliance technology and careful siting of the stoma have made this rare.
Another uncommon complication (<5%), is that of a parastomal hernia. This is due to a weakness in the abdominal wall surrounding the stoma and is usually easily repaired.
This sounds superficially attractive, who would want a bag when you could have a bladder where it is supposed to be, inside the body? But there is more to it than that. It is not that it is a much more difficult procedure technically; the primary issue is that the neobladder is made out of the intestine and it behaves as an intestine - it secretes mucous, absorbs whatever is contained within it and it has peristaltic activity. This leads to potential problems with:
Mucous blockage: This is not usually too big a problem in the long term. In the immediate postoperative period, you will need to flush your neobladder periodically to clear mucous whilst it is healing. Once everything is healed and the catheters are removed (at 3 weeks post-operatively), you are able to void the excess mucous through the urethra, and the amount of mucous produced generally decreases with time.
Malabsorption syndromes: Urine is used to rid the body of waste products; it is not supposed to be reabsorbed into the body. The neobladder, being made out of ileum, reabsorbs a substantial amount of urine. Acid reabsorption is a particular problem, especially in those with relatively poor renal function, and you may need to take oral bicarbonate (Ural sachets).
Nocturnal urinary leakage: Although it is usual to achieve daytime urinary continence, nocturnal incontinence is very common. This is because the ileum peristalses or moves during sleeping hours, the feeling of impending leakage is able to be detected and resisted when awake, but when asleep this is not possible and urine leaks out. Some patients are able to control this by training themselves to wake and void several times at night in order to keep their bladders empty.
Another issue is that voiding is achieved by contraction, not of the bladder itself, but by using the abdominal muscles. Women may have a problem being able to do this efficiently due to their pelvic anatomy and they have an increased risk (about 30%), of not being able to empty the bladder properly (or at all).