Cystectomy

Overview

Cystectomy, also known as bladder removal surgery, is a complex surgical procedure involving the partial or complete removal of the urinary bladder, the organ responsible for storing urine in the body. This procedure is typically performed to address bladder cancer but can also be used to treat non-cancerous conditions affecting the bladder and urinary system. It involves the removal of the bladder, which is situated between the kidneys and the urethra, and serves as a reservoir for urine before its elimination from the body.

Reasons for undergoing the procedure

Cystectomies are predominantly carried out by surgeons for the treatment of bladder cancer. Nevertheless, they may also advise this surgical procedure to address congenital conditions, which are conditions present at birth, or other disorders impacting the urinary system.

Before the procedure

You will consult with a doctor prior to a cystectomy. They will take your vital signs (blood pressure, pulse, and temperature) and assess your general health. They will also discuss with you the surgical technique they plan to employ in order to remove your bladder. Your bladder may be removed entirely (radical cystectomy) or in part (partial cystectomy):

• Simple cystectomy. Your bladder will be removed by your surgeon, but no surrounding structures will be cut out. Nephrogenic bladder, radiation cystitis, urinary fistula, and severe interstitial cystitis are among the benign bladder disorders that are treated with this method.
• Partial cystectomy. Only a portion of your bladder is removed by the surgeon. In order to ascertain whether the cancer has progressed outside of your bladder, they will typically remove adjacent lymph nodes when doing a partial cystectomy to treat cancer. Little bundles of tissue called lymph nodes are responsible for producing immune system cells and filtering lymph fluid, a clear fluid that contains white blood cells and keeps your body’s cells wet. The bladder that is still inside of you is fixed by your surgeon.
• Radical cystectomy. The surgeon excises all lymph nodes in the vicinity as well as your urine. Surgeons generally always cut the vas deferens and remove the prostate and seminal vesicles from men and people Assigned Male at Birth (AMAB). In females and those Assigned Female at Birth (AFAB), the uterus, fallopian tubes, ovaries, and cervix are frequently removed by the surgeon. Occasionally, they also remove a portion of the vaginal wall.

Ensure that you inform your healthcare provider about all the prescription and Over-The-Counter (OTC) medications you are currently taking, including herbal supplements. Taking medications like aspirin, blood thinners, anti-inflammatory drugs, and specific herbal supplements can increase the risk of bleeding, so it’s essential to discuss these with your doctor before making any changes.

Additionally, it’s crucial to disclose any allergies you have, whether they pertain to medications, foods, latex, or skin cleansers such as iodine or isopropyl alcohol.

Your doctor will provide you with detailed instructions regarding dietary and fluid intake before your cystectomy. Typically, you should refrain from eating or drinking anything after midnight on the night before your surgery. If you need to take any medication, it should be done with a small sip of water as directed by your healthcare provider.

During the procedure

During the cystectomy, there are two primary surgical approaches:

• Open cystectomy: In this approach, the urologist makes a single long vertical incision, typically six to seven inches in length, extending from the belly button to the pubic bone. They access the bladder and surrounding tissues through this incision and perform the surgery manually.
• Minimally invasive (laparoscopic or robotic) cystectomy: This approach involves inflating the abdomen with carbon dioxide to create a working space. The urologist then makes five to six small incisions, each approximately half an inch or smaller, in the abdominal area. Long, thin instruments, including a camera, are inserted through these incisions. In laparoscopic surgery, the urologist directly uses these instruments for the procedure, while in robotic surgery, the instruments are attached to a surgical robot controlled by the urologist from a surgical console. Robotic surgery provides three-dimensional vision and precise movements.

After removing part or all of the bladder, the urologist performs reconstructive surgery to create a new way to store and remove urine from the body. The methods for urinary reconstruction include:

• Ileal conduit: The urologist disconnects a short section of the small intestine (ileum), with one end connecting to the ureters and the other end leading to an opening in the abdominal skin (stoma). An ostomy bag is used to collect urine from the stoma, typically located near the right side of the belly button.
• Continent cutaneous diversion: A reservoir is created using a portion of the small and large intestines to store urine. The ureters attach to one end of the reservoir, and the other end connects to a stoma on the abdomen. Patients must periodically empty the reservoir using a small drainage tube (catheter), eliminating the need for an external ostomy bag.
• Neobladder: A reservoir is fashioned from a segment of the small intestine, with one end connected to the ureters and the other end leading to the urethra. Patients with a neobladder may need to periodically empty the reservoir by using their pelvic and abdominal muscles. Some may require a urinary catheter for assistance.

The duration of a cystectomy surgery typically spans approximately six hours.

After the procedure

After a cystectomy procedure, medical professionals will suture your incisions and apply bandages for wound care.

The anesthesiologist will discontinue administering anesthesia, and you will gradually regain consciousness within a few minutes. However, you may still experience some grogginess.

Following this, you will be transferred to a recovery room where healthcare providers will closely monitor your awakening process and assess your overall well-being. Once you are fully awake, they will address your pain management needs, which may involve pain medication and various techniques.

The duration of your hospital stay after bladder removal surgery depends on the specific type of cystectomy you undergo. Typically, patients require a minimum of one day of hospitalization following a laparoscopic or robotic cystectomy. In contrast, an open cystectomy necessitates a longer hospital stay, which may extend to up to a week.

Throughout your hospital stay, healthcare professionals will keep a vigilant eye on your recovery progress, ensuring that you are beginning to heal and effectively managing any pain. If you require an ostomy bag, they will also provide guidance on how to attach, empty, and change it.

Risks

Cystectomy, like any major surgery, comes with inherent risks. These potential complications include:

• Bleeding
• Blood clots
• Infection
• Bowel complications
• Formation of scar tissue that can obstruct urine flow from the kidneys
• Organ damage
• Anesthesia-related risks
• Wound healing issues
• Accumulation of fluids at surgical sites (seroma)

During the recovery period, you may encounter changes in your appetite and alterations in bathroom habits, which could involve constipation, diarrhea, or a combination of both. After a partial cystectomy, the reduced bladder size might necessitate more frequent bathroom trips. It is also common to observe mucus in your urine. In the case of a radical cystectomy, your ability to urinate depends on the specific reconstructive procedure performed.

For some individuals assigned male at birth (AMAB), a cystectomy may lead to sexual side effects, potentially causing difficulties with achieving and sustaining erections.

Similarly, women and individuals assigned female at birth (AFAB) may experience sexual side effects. While sexual intercourse remains possible, it may be uncomfortable if part of the vagina is removed during the procedure. Nerve damage is another potential issue that could limit one’s capacity to become sexually aroused.

Outcome

The duration of your healing process after bladder removal can vary and may take several weeks to months for full recovery. The specific type of surgical procedure you undergo will significantly influence the pace of your recovery. Generally, individuals who undergo a partial cystectomy tend to recover more rapidly compared to those who undergo a radical cystectomy.

If you’ve had a cystectomy, it’s important to promptly get in touch with your healthcare provider if you experience any of the following symptoms:

• Indications of an infection, such as a fever, chills, or dark, cloudy urine.
• Persistent and severe nausea and vomiting.
• Excessive bleeding from the areas where you had surgery.
• Increasing redness, swelling, pain, or discharge from your surgical wounds.
• Notice black, brown, or dark purple skin discoloration around your stoma.
• Unmanageable pain that doesn’t respond to your prescribed medications.
• Difficulty urinating or problems with emptying your urine diversion.