Radical Cystectomy Surgery

Cystectomy is an operation performed to remove the bladder.

In men the removal of the whole of the bladder (radical cystectomy) typically involves the removal of the prostate and the seminal vesicles. In women radical cystectomy also involves the removal of the uterus, the ovaries and part of the vagina.

Because the bladder is removed during bladder surgery, a new urinary diversion needs to be created for the patient. This is a new way of providing for the storage of urine and its expulsion from the body.

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Generally, cystectomy is performed to treat invasive or recurrent non-invasive bladder cancer. Cystectomy can also be performed to treat pelvic tumours such as advanced colon, prostate or endometrial cancer and certain non-cancerous (benign) conditions.

In the urinary system there are the kidneys, the ureters, the bladder and the urethra. This system is responsible for expelling harmful waste from the body through the urine. Your kidneys, located at the back in the upper part of your abdomen, produce urine by filtering the waste and fluid in your blood. This urine then goes from your ureters to your bladder, where the urine is stored until it is eliminated at a suitable time.

Why Is Cystectomy Performed?

Your doctor may recommend cystectomy as a treatment option in the following situations:

• Cancer that begins in or near the bladder and grows in such a way as to involve the bladder
• Birth defects affecting the urinary system
• Neurological or inflammatory disorders affecting the urinary system

What type of cystectomy and reconstruction you need depends on various factors such as the reason for your operation, your general health and your preferences. Discuss your options with a urology specialist in order to determine which procedures are suitable for you.

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The Risks Brought by Cystectomy

Cystectomy is a complex operation involving the manipulation of many internal organs in your abdomen. For this reason cystectomy carries certain risks:

• Bleeding
• Blood clots
• Heart attack
• Infection
• Inflammation of the lung
• Rarely there can be death after the operation

Because cystectomy is an operation performed not only to remove the bladder but at the same time to create a urinary diversion, the operation involves additional risks such as the following:

• Dehydration
• Electrolyte abnormalities
• Urinary tract infection
• A blockage preventing food or fluid from passing through your intestines (bowel obstruction)
• A blockage in one of the tubes carrying urine from the kidneys (ureteral obstruction)

Some complications can be life-threatening. Another operation may be necessary to correct the complication. Be sure to ask your surgeon what additional risks there may be for your operation.

The Cystectomy Procedure in All Its Details

Preparation for Cystectomy

Before cystectomy, talk with your doctor about the medicines you use and your habits such as caffeine and alcohol. You may need to make changes in your medicines or avoid certain substances in order to help recovery after the operation.

If you smoke, the best thing you can do for your health is to quit smoking before the operation. Smoking is not only a risk factor for the development of bladder cancer, it also increases the risk of developing problems after the operation.

When you plan your operation, you will receive special instructions on how to prepare for the procedure. If you have questions about the instructions, be sure to speak with your surgeon.

Complete Removal of the Bladder (Radical Cystectomy)

During cystectomy, your surgeon removes the bladder and part of the urethra along with the nearby lymph nodes. 

In men the removal of the whole of the bladder (radical cystectomy) typically involves the removal of the prostate and the seminal vesicles. 

In women radical cystectomy also involves the removal of the uterus, the ovaries and part of the vagina. Your surgeon also creates a new way for urine to leave your body.

Your surgeon may recommend one of the following approaches for your operation:

Open surgery: this approach requires a single surgical incision in your abdomen to access the pelvis and the bladder.

Minimally invasive surgery: your surgeon makes a few small incisions in your abdomen for the placement of special surgical instruments to access the abdominal cavity.

Robotic surgery: during this type of minimally invasive surgery, your surgeon sits at a console and operates the robotic surgical instruments remotely.

During the Procedure

During the operation you are given a medicine that keeps you asleep (general anaesthesia). When you are asleep, an incision is created in your abdomen. A large incision for open surgery or a few small incisions for minimally invasive and robotic surgery.

Your bladder is then removed along with the nearby lymph nodes. Other organs close to the bladder such as the urethra, prostate and seminal vesicles in men, and other organs such as the urethra, uterus, ovaries and part of the vagina in women, may also need to be removed.

After your bladder is removed, the surgeon tries to reconstruct the urinary tract to enable urine to be expelled from your body. The aim of this procedure, which we call urinary diversion, is to facilitate the safe storage and timely expulsion of urine after your bladder is removed while preserving your quality of life.

Several options are available for this:

Ileal conduit: during this procedure the surgeon uses a piece of your small intestine to create a tube connected to the ureters that connects your kidneys to an opening in your abdominal wall (stoma). Urine flows continuously from the opening. A bag that you attach to your abdomen sticks to your skin and collects urine until you empty it.

New bladder reconstruction: a spherical pouch that will become your new bladder is created from your small intestine. For this pouch a slightly larger piece than the one used in the ileal conduit is required. The new bladder is placed in the same location inside your body as your original bladder. In this way urine can flow from your kidneys. One end of the new bladder is attached to your urethra in such a way as to allow you to urinate in a relatively normal way.

The new bladder is not a completely new, normal bladder. If you undergo this operation, you may need to use a catheter to help the new bladder empty better. In addition, some people experience problems of urinary incontinence after the operation.

Continent urinary reservoir: during this procedure a piece of your intestine is used to create a small reservoir in your abdominal wall. When you urinate, the reservoir fills and you use a catheter to empty the reservoir a few times a day.

With this type of urinary diversion you eliminate the need to attach a urine collection bag outside your body. However, you will need to use a long, thin tube (catheter) a few times a day to empty the internal reservoir.

After the Procedure

After the operation you may need to stay in hospital for up to five or six days. 

The intestines tend to be the last part to wake up after the operation, so you may need to be under observation in hospital until your intestines are ready to absorb fluids and nutrients.

After general anaesthesia you may experience side effects such as a sore throat, shivering, drowsiness, dry mouth, nausea and vomiting. These can last a few days but are temporary conditions.

Starting from the morning after the operation, your health team may ask you to get up and walk frequently. Walking supports the return of bowel function, improves your circulation and helps to prevent joint stiffness and blood clots.

For a few weeks after the operation you may feel some pain or discomfort around your incision or incisions. As you heal your pain will gradually improve.

Urinary Changes After Cystectomy and Return to Normal

If you have had an ileal conduit operation, there may be fluid drainage from your urethra for six to eight weeks after the operation. Generally the colour of the drainage changes slowly from bright red to pink, to brown and then to yellow.

With new bladder reconstruction you may have bloody urine after the operation. Within a few weeks your urine should turn a yellowish colour.

In both procedures you can expect to see mucus in your urine, because the piece of intestine used in the procedure will still produce mucus as it did in your intestines. Over time there should be less mucus in your urine, but it never passes completely.

Return to Daily Activities

For the first six to eight weeks after the operation you may need to restrict activities such as lifting, driving, bathing and returning to work or school. You will gradually regain your strength and your energy level will increase.

You should consult your doctor about when it is safe to resume sexual activities. You may be advised to wait approximately six weeks before sexual intercourse for correct healing to take place.

Results

Cystectomy has the potential for a great impact on quality of life. However, even so, you can lead a fairly normal life after cystectomy surgery.

Your artificial bladder made with new bladder reconstruction is small in size. It grows slowly in the first few months. At first you may need to urinate every few hours during the day. As time passes, you can increase the time between urinations to up to four hours.

You may experience sexual changes after cystectomy. For men, nerve damage during the operation can affect the ability to have an erection. This can improve over time. You can find out from your doctor whether nerve-sparing techniques can be used during the operation. However, even with nerve-sparing techniques, the return of erectile function can take some time. 

For women, changes in the vagina can make sexual activity less comfortable. Nerve damage can also affect arousal and the ability to reach orgasm.  If you experience sexual difficulties after the operation, do not rush, be patient and discuss your concerns with your doctor.

Make an Appointment With Urology Specialist Prof. Dr. Murat Binbay