Bladder removal surgery (cystectomy)

The bladder is a hollow organ in the pelvic region that stores urine before it is expelled. Cystectomy is a complex surgery primarily undertaken to treat muscle-invasive bladder cancer, also known as advanced bladder cancer, or to treat recurrent non-muscle-invasive bladder cancer.

Muscle-invasive bladder cancer occurs in about 25% to 30% of all cases of cancer found in the bladder. This cancer has spread beyond the lining of the bladder, invading its muscle wall and may also have metastasized to surrounding organs.

In cystectomy, a part or whole of the bladder is removed, including surrounding tissues and organs that are affected by cancer. Sometimes, cystectomy is also performed for benign disorders that affect the bladder and the urinary system.

Cystectomy is performed mainly for treating bladder cancer. Some of the other conditions in which cystectomy may be required are:

• Bladder problems or bleeding from things like radiation, chemotherapy, or injuries
• Cancer which has affected the bladder, such as other pelvic cancers like advanced colon cancer, prostate cancer, endometrial cancer
• Interstitial cystitis (IC): a chronic bladder problem characterised by persistent pain and frequent urge to urinate. When IC does not respond to other treatments, cystectomy is an option.
• Problems with nerve-muscle control of the bladder
• Bladder Diverticula: outward pouch from the bladder wall
• Endometriosis that has spread to the bladder
• Developmental abnormalities of the bladder

Sometimes when cancer has advanced and can’t be contained, cystectomy is undertaken to remove only the bladder for relieving blockage that hinders the flow of urine.

Some of the contraindications of cystectomy are:

• Metastatic disease, other malignancies in the urinary tract, prostatic invasion
• Multifocal clinically isolated syndrome, a neurological condition
• Comorbidities and old age
• Prior radiation therapy
• Inflammatory bowel disease
• Liver failure or kidney failure
• Advanced-stage cancer
• Bleeding disorder: the tendency to bleed or bruise easily
• Stricture in ureters or urethra

The doctors evaluate the presence and status of the above factors for determining that cystectomy can be performed.

The surgery is performed by a Urologist. The surgeon asks for relevant medical history from the patient which includes the symptoms of the disease, medication history, and any comorbidities.

A general physical examination is conducted to see if the patient is fit for surgery. The abdomen is palpated (examined by touch) and tenderness around the bladder area is noted.

Investigations prior to surgery include:

• Radiological tests such as CT scan, PET scan, chest x-ray, etc. to determine the growth of the tumour and the extent of the tumour (Read more: What is the difference between a tumour and cancer?)
• Cystoscopy: a thin flexible tube with a camera at its end is threaded through the urethra to view inside the bladder
• Blood tests: CBC, liver function test, kidney function test and coagulation profile. Certain tumour markers are also tested for
• Urinalysis: to diagnose urinary tract infection and check for blood in the urine
• ECG
• X-ray of the chest

As per the doctor’s advice, the person may be asked to stay physically active such as walking every day. The patient is also advised to not smoke for at least 6 to 8 weeks before the surgery, as it can negatively affect the outcome of the surgery. medications for any pre-existing conditions may be stopped or altered as per the surgeon's orders.

Before the day of the surgery, the medical team may direct the person to have only a liquid diet for one or two days and to fast overnight. They may also require the person to use a bowel prep for cleaning out their intestines. IV fluids may also be recommended for maintaining hydration levels.

Cystectomy is a major surgery that requires a hospital stay for some days after surgery. Blood may be arranged from before in the adverse effect of bleeding. Before the surgery, the medical team would also discuss the risks and complications that may arise from the surgery.

On the day of the surgery, a final checkup is done by the surgeon's team. A written and signed consent of the surgery and its associated complications are taken from the patient and the relatives. the patient is then shifted into a major operating room.

The patient is asked to lie on his back on the operating table. A cannula is placed into the arm for administering medications during the surgery. A monitor is attached to track the vitals (heart rate, blood pressure and oxygen saturation). The anesthesiologist will then administer general anaesthesia.

Once the anaesthesia takes effect, the surgery team will prepare the site for the surgery by cleaning it and placing sterile surgical drapes over the body. Thereafter, the surgeon will carry out surgery, for which any of the following two approaches may be used:

1. Open cystectomy

Incisions are made in the lower abdomen. The underlying tissue and muscles are separated. The surrounding lymph nodes are removed and also checked for cancer.

• In the case of partial cystectomy, the part of the bladder that contains cancer along with surrounding healthy tissue is removed, followed by stitching the bladder to close it.
• In the case of radical cystectomy, the blood vessels supplying the bladder are tied and cut. Thereafter, the bladder is separated from the ureters, the urethra and other surrounding tissues and removed. In men, the prostate, seminal vesicles and vas deferens are also removed, while in women the uterus along with fallopian tubes and ovaries, along with some part of the vagina if required are removed.

2. Laparoscopic Cystectomy

This is minimally invasive. In this approach, a small incision will be made below the belly button and a cannula will be inserted. Through this, the abdomen is filled with carbon dioxide to create a working space for the surgeon. Further incisions will be made to allow the insertion of necessary instruments for carrying out the surgery.

Using a laparoscope to visualise along with the instruments, the bladder (or part thereof, in case of partial cystectomy) will be removed along with surrounding organs along with neighbouring lymph nodes. Laparoscopic surgery has also witnessed the use of robots to achieve precision.  

Reconstruction

When radical cystectomy is performed, a passage is required to be constructed for urine to flow out from the body. For this, the surgeon may utilise any of the following three methods, depending on patient preference, the extent of the disease, the person’s anatomy and medical status (kidney function, age, overall health):

• Orthotopic neobladder: Out of a part of the intestine, usually the ileum (the last part of the small intestine), a sphere-shaped reservoir is created, which is placed inside the body and attached to the urethra. Functionally, the neobladder cannot completely replace the old bladder but can be emptied through regular catheterisation or by increasing the abdominal pressure. Over time, the catheter may not be required. 
• Ileal Conduit: Using the ileum, a tube is created which is attached to the ureters through an opening in the abdomen (stoma). Thus, the urine produced by the kidneys will pass through the ureters into the ileal conduit and out of the body through the stoma. For collecting the urine, the ileal conduit is attached to a pouch (urostomy bag) worn on the abdomen.
• Continent cutaneous urinary reservoir: Using sections of the intestine, a small internal pouch is created to hold the urine, which is drained via the stoma using a catheter. Thus, there is no need to wear an external bag.

Upon completion of the surgery, the incisions are closed using stitches or staples and a drain is left in the abdomen as an outlet for blood and fluid. The entire surgery takes 4 to 6 hours depending on the technique involved.

In almost half the cases, a person experiences certain complications during cystectomy. These may be mild but can turn severe if not properly addressed.

• Excessive Bleeding
• Reaction to anaesthesia, such as a sore throat or wheezing
• Blood clots or pulmonary embolisms
• Infection
• Damage to nearby organs
• Bowel obstruction
• Fluid build-up in the belly

After the person wakes up from the anaesthesia and is stable, they spend a few hours in the recovery room. For about a week, the patient will be required to stay in the hospital. The person will receive IV fluids and begin with a liquid diet, gradually returning to a regular diet. 

Chest physiotherapy may be initiated twenty-four hours later to prevent chest infection. To prevent deep vein thrombosis, simple movement of the legs and some mobilization is encouraged. Once the drainage is minimal, the abdominal drain will be removed. Analgesics for pain relief and antibiotics for preventing infection will be given. The patient will also be demonstrated coughing and breathing techniques to help keep the lungs clear and prevent pneumonia.

Before discharging, the doctor considers hydration, pain, bowel function and mobility to conclude that the patient is ready to go home. In case complications like nausea, bowel shut down or infection is present, the hospital stay might be extended. Upon discharge, detailed instructions on recovery at home are specified. In the first one or two weeks, some pain and swelling are common in the first 1 to 2 weeks.

Instructions for home recovery include:

• Taking care of the wound and periodically checking it for signs of infection
• Avoiding strenuous activities, heavy lifting
• Drinking plenty of water
• Not driving a vehicle until the doctor confirms
• It is recommended to avoid bathing for two weeks post-surgery.
• Eating 5 to 6 small meals per day
• Taking medicines as per instruction which includes antibiotics and analgesics and medications for pre-existing conditions if any
• Walking a few times daily and gradually increasing the pace and distance
• Avoiding any strain while passing stool. The doctor may also prescribe a stool softener for this.
• Following the instructions on managing the catheter, urostomy bag
• Performing pelvic floor exercises

There will be follow-up visits with the doctor for the removal of stitches, catheters, etc. In case of cancer, periodical check-ups such as cystoscopy will also be carried out to ensure that the person is cancer-free.

It takes time to adjust to living without a bladder and using the newly constructed mode for urinary diversion. The person might experience:

• Leaking of urine
• Difficulty sensing when to urinate with a neobladder
• Erectile dysfunction and inability to have an orgasm
• Loss of sexual sensations
• Pouch stones

The person should watch out for the following symptoms and check with their doctor in case these continue:

• Nausea and vomiting
• Redness, swelling, heavy bleeding, or discharge from the incisions
• Signs of infection, such as fever and chills
• Excessive pain, not getting controlled with medicine
• Inability in urinating, cloudiness or pus in the urine, or a bad odour to the urine

Complete recovery may take about four to six weeks, though in the case of open surgery the period of recovery could extend. For the person who has undergone radical cystectomy, additional treatments such as chemotherapy or radiation may be given.

Cystectomy is a major surgery which is largely used for treating bladder cancer when other methods have not been effective. Regardless of the approach followed, complications are common and need to be managed as per the doctor’s instructions. Full recovery may take a few months. However, bladder cancer is known to recur, so regular check-ups are necessary.