Radical cystectomy is the surgical removal of the urinary bladder through an incision in the abdomen. Less commonly, all or parts of a cystectomy may also be done using a “laparoscopic” approach (multiple small incisions with placement of only a camera and small instruments, and not the surgeon’s hands in the pelvic cavity). If this is the case, you will receive a supplement to this educational piece fully describing laparoscopic surgery.
Almost all cystectomies are performed for a diagnosis of bladder cancer, although there are rare instances in which other diagnoses necessitate removal of the bladder. Depending on variations in the procedure, the extent of the tumor, and an individual’s particular anatomy, this operation can range from 4 hours to 8 hours or longer. In men, removal of the prostate, seminal vesicles (small organs that produce semen), and a portion of each vas deferens (tubes that transport sperm from the testicles to the urethra) is part of the operation. In women, hysterectomy/salpingo-oophorectomy (removal of the uterus, ovaries and fallopian tubes) is usually performed as well. In both men and women, multiple lymph nodes (small drainage glands) are sometimes removed to help determine the stage (extent of spread) of the cancer.
Because the bladder has been removed, it is necessary to create some form of substitution to receive urine produced by the kidneys. This receptacle is termed a “urinary diversion” and may be one of three types. There are advantages and disadvantages to each. By the time you are reading this, you will have discussed the pros and cons of each type with your surgeon and will have chosen one of the following:
It is sewn to the remainder of the urethra so that there is no stoma on the abdominal wall. Some patients are able to urinate and empty their neobladder, but most are not and are committed to placing a catheter in the urethra once to several times per day. While this operation might be the most cosmetically appealing, it has the longest operative time and is usually associated with the most complications.
As discussed previously, a cystectomy sometimes includes removal of multiple lymph nodes in the pelvis. If the lymph nodes are positive (contain cancer), then the operation is not considered curative. In this instance, chemotherapy might be considered for later treatment. In certain instances (that we discussed on your prior consultation), if during the surgery it is obvious that the nodes are positive, we may elect to not complete the operation and leave the bladder in place. When the tumor in the bladder is large and consequently causing problems (i.e. severe blood in the urine, pain in the pelvis, blockage of the kidneys, etc.), it might be better to remove the bladder for what we term “local control of the cancer”. There are studies that demonstrate that multimodality therapy (the operation combined with other treatments such as chemotherapy or radiation therapy) may reduce complications of the disease and delay the progression of the cancer. To reiterate, there are instances that we may suggest this operation even when we know that there is a high likelihood that the cancer has already begun to spread beyond the bladder.
Radical cystectomy is an involved operation. Because anesthesia time can be long, we may send you for an updated general physical and note of “medical clearance” from your primary physician. This is precautionary and for your own protection.
As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
We will ask you to completely clean out your small intestine the day before your surgery. You should plan a very light breakfast the day prior. Your lunch and dinner will consist of clear liquids (ones you can see through) only. At 5:00 p.m., you will administer an enema. Approximately one hour later, you will take a type of laxative. For the remainder of the evening, it is important to continue to drink plenty of clear fluids, but you CANNOT eat. You may drink up until midnight but not after and not in the morning of your scheduled surgery. Bowel preparation has many variations and your surgeon will choose the agents and the time of administration.
The duration of the operation is different for every patient, mostly reflecting difference in each patient’s anatomy and the choice of urinary diversion. The general range is 4-8 hours or more. Your position on the table will be supine (flat on your back). The type of anesthesia used will reflect the suggestion of the anesthesiologist as well as contributions from your preferences as well as that of your surgeon. General anesthesia (complete sleep) is used in most cases, but a spinal might be acceptable in some circumstances.
After the abdominal cavity is opened, we will inspect the organs such as the liver and the lymph nodes that drain the bladder. The ureters are detached from the bladder and a small sliver is sent to the pathologist to ensure that the ends (that will be sewn to the diversion)contain no tumor cells. Next, the bladder, prostate, seminal vesicles and a portion of the vas deferens (in a male patient) are separated free from the surrounding tissue and removed. In women, the bladder is usually removed with the uterus, the fallopian tubes, and the ovaries. The urethra in women is removed entirely unless a neobladder is planned. In this case, the urethra is left in place so that the newly created bladder can be sewn to it.
Removal of the lymph nodes can be done at different times during the operation. If the nodes do not look or feel positive, some surgeons will wait until the bladder is removed to operate on the lymph nodes. If they are suspicious, and your surgeon would stop the operation if they are indeed positive (contain cancer), then they will be removed first and the operation would halt for a short time while the surgeon waits to hear from the pathologist (doctor who looks at tissue under the microscope). All of these circumstances will vary from patient to patient. Your surgeon will have discussed all of these possibilities prior to your operation.
After removal, the urinary diversion is created and the ureters (tubes from the kidneys) are attached to the diversion. Some surgeons will place stents (plastic tubes) in the ureters to assist drainage during the healing process. Other surgeons do not. One or several drains (tubes that help remove excess fluid or blood from the body) are usually placed and will remain or a few days or longer. If an ileal conduit was created, there might be a catheter in the small stoma temporarily to keep the diversion empty during the healing process. If a neobladder was created, there may be a catheter in the new urethra for a while during the healing process.
Another part of the operation in men that is occasionally discussed is the “nerve sparing procedure”. We are referring to the nerves that control your ability to get erections. While carefully sparing the nerves is possible in some patients, in is not in others. Depending on your wishes, we may attempt to spare nerves on both sides, one side, or not at all. You should realize that sometimes a nerve sparing procedure does NOT mean that you will be able to achieve erections.
After the procedure, you will be in the recovery room until you are ready to be moved to a regular room. Depending on the particular circumstances, we may elect to admit you to an intensive care unit for closer monitoring.
Your urine will be coming out through a catheter and emptying into a bag. Catheters may remain for days or weeks until adequate healing has occurred. The urine may be crystal clear or appear bloody for a few days. You may have one or more drainage tubes attached to bags to empty the excess fluid accumulation in the body from the operation.
There will be a tube coming from your stomach and out of one side of your nose (put in while you are asleep) to keep fluid out of your stomach, intestines and colon. You may also have boots on your legs that inflate and deflate (intermittent squeezing) to prevent the formation of blood clots in your veins (deep vein thrombosis or DVT).
A typical hospital stay for radical cystectomy is usually one week, but may vary depending on your particular health status and your post-operative hospital course. It is important to get out of bed either the first or second morning and spend time in a chair. With assistance from a nurse or family member, you may usually walk on the second day. Your diet may begin as only liquids and should advance as you are tolerating it.
Upon discharge, you may have no dressing (bandage) on your incision. If you have an ileal conduit, you will be instructed on how to empty the urine bag and even switch it to a larger bag for overnight use when you are sleeping. With the continent diversions (those without a bag) you may receive instructions on how to catheterize if it is not too early to do so. Otherwise, you may still have a catheter and a drainage bag for a little while. It sounds complicated, but it is easy…we assure you.
You will be discharged with instructions for follow-up in our office. Other than your regular medications, we may give you an antibiotic, a pain medication, and a stool softener so that you do not strain to have bowel movements. Other medications will depend on your particular needs.
It is normal to feel a bit tired or weak for several weeks. We typically tell patients that they will be out of work for at least 4-6 weeks (up to 12 weeks is possible if your occupation requires strenuous activity) and that it may take several more weeks before you truly feel like yourself.
While we will be able to tell you about our findings during surgery, you must understand that the specimen will be evaluated by the pathologists. They carefully examine the entire specimen under the microscope. It may take one week before we have an official report to discuss with you. Of course you will be anxious, but we encourage you to be as patient as possible. Use that week to concentrate on your recovery.
Management of your urinary diversion (whether a bag or a catheterization) may seem awkward at first. Like anything else in life that you do often enough, you will soon become familiar with the procedure and develop a comfortable routine.
*Because of the organs removed, men will no longer be able to ejaculate any fluid if orgasm is achieved. In women, the vagina may be shortened or tight and sexual intercourse may be painful or even not possible. Women who are still menstruating should understand that they will be in menopause once the uterus and ovaries are removed.
ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.