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CYSTECTOMY

ABOUT CYSTECTOMY

Cystectomy is a procedure to completely remove the bladder.

After the bladder is removed, the flow of urine is usually diverted into a segment of bowel which is brought out onto the skin on the abdomen as a stoma. This is known as an ileal conduit.

Alternatively, sometimes it is possible to create a new bladder out of a segment of bowel, which is connected to the urethra. This is known as a neobladder.

WHY IS CYSTECTOMY REQUIRED?

Cystectomy is usually performed to treat aggressive life-threatening cancer of the bladder.

Occasionally cystectomy is performed for non-cancerous problems, such as when the bladder has been severely damaged, for example by interstitial cystitis or radiotherapy.

WHAT DOES CYSTECTOMY INVOLVE?

Before the operation you will be seen by a specialist nurse who will talk with you about how to manage a stoma bag.

You may be asked to have a low residue diet or to use a medication to clean out the bowel in the days leading up to the procedure. You may also be given an enema to clean out the bowel on the morning of the procedure.

Cystectomy is performed under general anaesthetic (completely asleep).

Cystectomy can be performed as an open procedure or a keyhole procedure using the Da Vinci robotic surgical system. If an open procedure is performed, we make an incision in the middle of the abdomen from the pubic bone to the level of the belly button. If a robotic procedure is performed, we make multiple small incisions on the abdomen, with one larger incision above the belly button through which we pull out the bladder.

We completely remove the bladder. In men the prostate gland and seminal vesicles are usually also removed. In women the uterus, Fallopian tubes and ovaries are sometimes also removed. Sometimes the urethra is also removed.

If the operation is for cancer, the lymph nodes surrounding the bladder are usually also removed.

If we are creating an ileal conduit, a 15cm segment of small bowel is separated from the rest of the small bowel to make the conduit. One end of the conduit is joined to the ureters (tubes draining the kidneys). The other end of the conduit is brought out on the skin on the abdomen to form a stoma. Urine drains continuously via the stoma into a stoma bag. The remainder of the small bowel is joined back together.

If we are creating a neobladder, a 40cm segment of small bowel is separated from the rest of the small bowel. This segment is refashioned into a reservoir which can hold approximately 150 to 250mL of urine. The neobladder is connected to the urethra and ureters. This allows you to pass urine via the urethra. The remainder of the small bowel is joined back together.

Your wounds are closed with stitches or staples. One or more drainage tubes are placed coming out of the abdomen. Where the ureter (tube from the kidney) is joined onto the bowel, a splint known as a ureteric stent is placed to allow the join to heal. There is one stent placed in each ureter.

If you have a neobladder, a catheter is placed through the urethra and also through the front wall of the abdomen.

WHAT IS THE RECOVERY AFTER CYSTECTOMY?

You may spend the first one or more nights after the procedure in the intensive care unit (ICU). You will usually be in hospital for one to two weeks after the procedure.

You will not be able to eat normally for the first few days after the procedure because the bowel slows down. Once the bowel starts working normally you can slowly return to eating.
You will be encouraged to sit out of bed, slowly walk around the ward and chew gum to encourage the bowel to start working again. If your bowel takes a longer time than normal to start working, you may temporarily require an infusion of feeding solution into the veins.

Because the bowel slows down, vomiting is very common after the procedure. Sometimes it is necessary to place a tube down your nose into your stomach to drain your stomach contents to stop vomiting.

A number of measures are taken to reduce the risk of developing life-threatening blood clots in the legs after this procedure. You will need to wear compression devices on your legs which regularly pump up and down for several days after the operation. This can make it hard to sleep. You will need to wear compression stockings on your legs the whole time you are in hospital. You will be given an injection of a blood thinning medication while in hospital. You may be asked to continue giving yourself this injection at home for up to four weeks after the operation.

You may have an epidural infusion into the back which numbs you from the chest down after the procedure. This will be removed after one to three days.

The drains coming out of the abdomen will be removed while you are in hospital. This can be done on the ward and doesn’t require an anaesthetic.

The stents coming out of the ureters may be removed while you are in hospital, or at your first outpatient appointment. This can be done in the outpatient department and doesn’t require an anaesthetic.

If you have an ileal conduit, you will be taught how to manage the stoma bags before discharge from hospital.

If you have a neobladder, the bladder is flushed with water several times a day via the catheter. You or a carer will be taught to flush the bladder, so you can do this at home after discharge from hospital. The catheters in the neobladder will be removed three to four weeks after the procedure. This can be done in the outpatient department and doesn’t require an anaesthetic.

If you have stitches they will dissolve and do not need to be removed. If you have skin staples they will be removed one to two weeks after the procedure.

You will be given instructions on when you can remove the dressings on your wounds. You can shower with the dressings on. Once the dressings are removed you can get the wounds wet in the shower. Avoid soaking in a bath or swimming until your wounds have been reviewed at your first outpatient appointment.

In men, it is very common to get swelling of the penis and scrotum after this procedure. It will take several weeks to settle down.

You will not be able to drive for four to six weeks after the procedure.

You will not be able to return to work for at least six weeks after the procedure.

You will not be able to exercise of do strenuous activities for six to eight weeks after the procedure.

It is very common to feel tired and need to nap during the day after the procedure. It will take three to six months for this to improve.

WHAT ARE THE RISKS OF CYSTECTOMY?

Risks during the operation (excluding anaesthetic risks) include:

Occasional (1/10 – 1/50)

  • Major bleeding requiring a blood transfusion.
  • If you are having a robotic cystectomy, sometimes it is necessary to convert to an open operation.
  • If you are having a neobladder, sometimes it isn’t possible to make a neobladder and it is necessary to make an ileal conduit instead.

Rare (1/50 – 1/250)

  • Injury to the rectum (the last part of the large bowel) requiring formation of a colostomy (bringing the bowel through to the skin on the abdomen and requiring a second bag) to allow time for the bowel to heal.
  • Injury to another organ.

Risks shortly after the operation include:

Common (1/2 – 1/10)

  • Prolonged slow-down of the bowel known as an ileus.
  • Pneumonia (chest infection).
  • Wound infection.
  • Urine infection.
  • Leak of urine from the join between the ureters and the bowel, or from the neobladder.

Occasional (1/10 – 1/50)

  • Death within 30 days of the procedure (~1/20).
  • Blood clots in the legs or lungs.
  • Bleeding after the operation requiring another procedure to fix and/or a blood transfusion.
  • Collection of pus (abscess) in the abdomen or pelvis requiring another procedure to correct.
  • Collection of tissue fluid (lymph) in the abdomen or pelvis, sometimes requiring another procedure to correct.
  • Leak from the join in the bowel (~1/20) requiring another procedure to correct.
  • Severe swelling of the penis and scrotum in men.
  • Breakdown of the wound(s), possibly requiring another operation to correct.
  • Blockage of the bowel requiring another operation to correct.

Long term risks include:

Very common (most patients)

  • Men will be infertile and will not ejaculate after the procedure.
  • Most men will no longer be able to get an erection after the procedure.
  • Women will be infertile after the procedure if the uterus is removed.
  • In women the vagina will be shorter than before the procedure. Sex after the procedure may be painful.

Common (1/2 – 1/10)

  • The cancer may return after the procedure. The risk of this will depend on the final results from the bladder and lymph nodes which will be tested after the procedure. If the cancer returns and spreads through the body, it is incurable, and most people will die in less than two years.
  • In men it is common to incidentally find prostate cancer when the prostate is removed. Occasionally this requires further treatment.
  • Scaring at the join between the ureter and the bowel can block the kidney. This may require another procedure to correct.
  • Recurrent urine infections.
  • Kidney stones.
  • Worsening kidney function, sometimes leading to kidney failure requiring dialysis.

Occasional (1/10 – 1/50)

  • Swelling of the legs (lymphoedema)
  • A hernia may form in one of the incisions. This may require another procedure to correct.
  • Scar tissue (adhesions) may form around the bowel causing blockage. This may require another procedure to correct.

Long term risks specific to an ileal conduit include:

Common (1/2 – 1/10)

  • A hernia may form alongside the ileal conduit. This may require another procedure to correct.
    Occasional (1/10 – 1/50)
  • A problem with the ileal conduit requiring another procedure to correct.

Long term risks specific to a neobladder include:

Very common (most patients)

  • Incontinence of urine is very common. It should improve over 12 months. For some patients long-term incontinence is a problem, especially at night.
    Common (1/2 – 1/10)
  • Urinary retention (inability to pass urine) can occur, which may require you to pass a catheter into the bladder several times a day to empty the bladder.
  • Vitamin B12 deficiency requiring lifelong injections of Vitamin B12.
  • Changes in the acid and salt levels in the blood resulting in fatigue, nausea and osteoporosis. After a neobladder you will need to take a medication lifelong to reduce the chance of this happening.
  • A problem with the neobladder requiring another procedure to correct. Sometimes the neobladder needs to be converted into an ileal conduit.

    Occasional (1/10 – 1/50)

    • Scaring in the urethra, or at the join between the neobladder and the urethra, making it difficult to pass urine, usually requiring another procedure to correct.
    • Chronic diarrhoea due to removal of a large segment of bowel.
    • Rupture of the neobladder due to overfilling, usually requiring an emergency procedure to correct.
WHAT ARE THE ALTERNATIVE TREATMENT OPTIONS?

A combination of chemotherapy and radiotherapy is an alternative to cystectomy for cancer. It is not as successful at curing aggressive bladder cancer and is usually only recommended if you are unable to have surgery due to other medical issues.

WHERE CAN I FIND MORE INFORMATION ABOUT CYSTECTOMY?