Bladder Surgery, Cystectomy

Overview

Bladder surgery also known as cystectomy, is a surgical procedure performed on the urinary bladder, which is located above the urethra and below the kidneys. There are a number of reasons why surgery may be necessary for the urinary bladder, which collects urine that the kidneys have filtered. It can be necessary to remove the bladder, or they might require reconstructive surgery.

The condition being treated determines the type of bladder surgery. Bladder cancer, cystocele (bladder prolapse), and urine incontinence (loss of bladder control) are among the conditions that may require surgery.

Types

Bladder surgery is the most common treatment for bladder cancer. Surgery may be combined with additional treatments including chemotherapy or radiation therapy, depending on the bladder cancer’s stage and progress. Several different types of procedures can be performed to treat bladder cancer. Among those methods includes:

• Segmental or partial cystectomy: A segmental cystectomy involves the removal of a portion of the bladder. Patients with a low-grade tumor that has only affected one section of the bladder wall may benefit from this procedure. They can urinate regularly following this procedure because only a portion of the bladder is removed. When a tumor is invasive, removing just a section of the bladder may be a possibility, but all available data points to the tumor being a single entity confined to a specific area of the bladder. The treatment results in a smaller bladder, but a large portion is preserved.
• Radical cystectomy: The bladder is removed entirely during this procedure. An abdominal incision is performed, and the bladder and surrounding organs are thoroughly inspected to assess the cancer’s condition and check for any signs that it has spread to other organs or structures. Any more afflicted organs are removed along with the bladder. This usually involves the excision of the seminal vesicles and the prostate in men. When a woman has a radical cystectomy, her uterus, ovaries, fallopian tubes, and a portion of her vagina are typically removed.
• Transurethral resection (TUR) with fulguration: During this procedure, a thin, illuminated tube called a cystoscope is passed into the urethra and into the bladder. Next, high-energy electricity is utilized to burn away the tumor or remove cancer using an instrument with a thin wire loop on the end. This is called fulguration.
• Urinary diversion: In addition to removing the bladder, the surgeon has to create a new method for the patient to store and release pee.  The patient’s potential urine diversion alternatives will be discussed by the surgeon.

These days, most bladder surgery are robotic, requiring the surgeon to make only a few minor incisions before placing ports to enable the use of robotic arms to complete the procedure. There aren’t many long-cut open surgeries. Surgical procedures include the following types:

• Anterior repair: In cases of severe cystocele (falling bladder or bladder prolapse), anterior (from the front) correction may be necessary. This kind of surgery involves tightening the tissue that divides the vagina from the bladder and making an incision (cut) in the vaginal wall. To increase vaginal support, the surgeon may also place permanent mesh grafts composed of biologic or synthetic materials
• Bladder exstrophy repair: When the bladder is inside out and attached to the abdominal wall, it is a congenital abnormality that this type corrects.
• Neobladder urostomy: An intestinal segment may potentially develop into a bigger “neobladder” or a little pouch. Urine is stored in the pouch or bladder, which is inserted into the space left by the bladder. Once more formed from their intestine, the tube ends in an abdominal stoma, in this case a valve enables the pouch to be emptied whenever desired. There are no bags involved. To enable regular urine drainage, the neobladder can be connected to the urethra.
• Urostomy:Reconstructive bladder surgery is sometimes required or requested for individuals who have lost their bladder. An intestinal segment is taken out and reattached to the ureters during an operation known as a urostomy. This causes urine to flow from the kidneys to a stoma (opening) close to the person’s belly button. A light, leak-proof bag is fitted to the stoma to collect urine. As needed, the bag can be emptied.

Reasons for undergoing the procedure

Bladder surgery may be required for the following condition:

• Bladder cancer that starts in the bladder or spreads there.
• Birth defects related to abnormalities in the urinary tract.
• Inflammatory or neurological conditions affecting the urine system.

Numerous factors, including the purpose for surgery, general health, preferences, and care requirements, all influence the sort of bladder surgery and reconstruction they receive.

Risk

Bladder surgery is a complex surgery and complications are possible. Patients who are over 60 or who were born as female are more vulnerable. The possible risks include the following:

• Infection
• Bleeding
• Blood clots in the legs
• Blood clots at the lungs or heart
• Poor wound healing
• Injury to surrounding tissues or organs
• Organ damage as a result of sepsis, the body’s reactivity to an infection

There are several consequences that could be life-threatening or necessitate hospitalization. The patient might require more surgery to resolve the complications.

Procedure

The types of procedures used to do bladder surgery are as follows.

• Open surgery: This method allows access to the bladder and pelvic through a single abdominal incision.
• Minimally invasive surgery: During minimally invasive surgery, the abdominal cavity is accessed by the surgeon making multiple small incisions in the abdomen through which specific surgical instruments are placed. Another name for this kind of procedure is laparoscopic surgery.
• Robotic surgery: One kind of minimally invasive surgery is robotic surgery. The surgeon uses robotic surgical instruments from a distance while seated at a console.

Before the procedure

 The patient should engage in a comprehensive discussion about their health and any relevant medical conditions with the surgical team, including the surgeon and anesthesiologist, as well as other healthcare professionals involved in their care.

To minimize the risk of bleeding during bladder surgery, it is advisable for the patient to discontinue the use of medications that could potentially increase bleeding tendencies. This includes stopping blood thinners or NSAIDs at least one week before the scheduled procedure. Additionally, certain blood pressure medications, herbal supplements, and antibiotics may have restrictions or modifications, so it’s crucial for the patient to consult their healthcare provider regarding any other prescribed medications that may need adjustment.

Prior to the surgery, the patient will be instructed to cease tobacco use and smoking. The use of tobacco products can elevate the surgical risks due to their detrimental effects on the immune system and their tendency to impede the healing process.

On the day before the surgery, the healthcare provider will likely recommend that the patient transition to a clear liquid diet, and further dietary adjustments may be necessary on the morning of the procedure itself. It’s also vital for the patient to arrange for someone to provide care and support during the post-operative period and throughout their recovery.

During the procedure

Every bladder surgery is handled differently. A distinct strategy or type of surgery is needed for each condition that is addressed with bladder surgery. Ensure that they comprehend and feel at ease with the information provided to them while discussing bladder surgery with their healthcare provider.

Patients are given general anesthesia to keep them sleeping. Once they are sleeping, the surgeon makes an incision in their abdomen, either a single, larger one for open surgery or multiple, smaller ones for robotic or minimally invasive procedures.

The bladder is removed by the surgeon from the surrounding tissues. The surgeon will also remove surrounding lymph nodes, which are a component of the immune system, if bladder cancer is the condition being treated. To determine whether cancer has spread to them, these will be examined in a lab.

The surgeon designs a urinary diversion, or new urine removal mechanism, following bladder surgery. This may consist of the following:

• Continent urinary reservoir: In order to form a pouch (reservoir) inside the abdomen, the surgeon uses a portion of the intestines during this procedure. The reservoir is linked to ureters and an abdominal wall stoma, just like the ileal conduit. Urine, however, is kept in the reservoir. They put a small tube, called a catheter, into the stoma to drain it.
• Ileal conduit: The surgeon creates a conduit (tube) by using a portion of the small intestine. Through the conduit, the ureters that were previously attached to the bladder are now joined. Urine flows into the conduit, leaves the body through a stoma (hole in the abdomen wall), and fills a pouch that is worn beneath clothing. The pouch constantly fills with urine and needs to be emptied and refilled on a regular basis.
• Neobladder reconstruction: The surgeon utilizes a part of the intestines and the tissues are reshaped into a spherical bladder. It is linked to the ureters and urethra and implanted in the same spot as the original bladder. Much like their original bladder, the neobladder enables them to urinate. For them to fully empty the new bladder, a catheter may need to be placed into their urethra.

After the procedure

Their adverse effects after general anesthesia might include dry mouth, nausea, vomiting, shivering, and sore throat. To alleviate their symptoms, they could be prescribed medicine.

The healthcare team may ask the patient to get up and walk frequently in the morning following surgery. Walking helps avoid blood clots and joint stiffness, enhances circulation, and encourages healing and the restoration of bowel function.

Recovery from a radical cystectomy is often delayed by the gradual restoration of normal bowel function. They will probably spend five to seven days in the hospital if they have an open operation. They could spend less time in the hospital recovering from a minimally invasive surgery.

Patient will receive written instructions regarding wound care and advice about when to call their care team or seek urgent treatment from a nurse or other healthcare provider before they leave the hospital. They will also contain care, cleaning, and device usage instructions, depending on the kind of urine diversion treatment that was done.

Outcome

Bladder surgery is a significant therapy that can extend a person’s life, but it may lead to permanent changes in sexual and urinary function that can affect their overall quality of life. However, individuals can adapt to these changes with time and support.

The recovery period after bladder surgery can vary widely depending on the specific procedure performed. For instance, a radical cystectomy involves the removal of the bladder, whereas a transurethral resection results in fewer alterations to the bladder or surrounding tissue during the surgery.

To evaluate the patient’s ability to urinate independently following the surgery, the healthcare provider will conduct a voiding test and provide guidance on managing catheters.

Following the procedure, the patient will need to schedule another follow-up appointment with their healthcare provider. It’s essential for the patient to report any post-operative issues they may have experienced. In some cases, a camera may need to be inserted into the bladder to assess for the presence of bladder cancer.

The patient is advised to seek medical attention if they develop the following symptoms after their surgery.

• Severe pain during urination.
• Unable to urinate.
• Fever (more than 100.4 degrees Fahrenheit).
• Blood in the urine.