Radical cystectomy involves removing the bladder and the pelvic lymph glands, along with the prostate and seminal vesicles in men, and the uterus, ovaries and anterior vagina in women. It is the gold standard treatment for muscle invasive, non-metastatic bladder cancer. The operation is performed through an incision from the belly button to the pubic bone, and commonly takes between three and five hours.
With removal of the bladder, the urine draining from the kidneys must be diverted in some way. This usually takes the form of either an ileal conduit or a neobladder. Studies show that patients report a similar quality of life for the various types of diversions.
An ileal conduit is a short segment of bowel that is isolated from the rest of the gut. Both ureters, the tubes draining urine from the kidney, are attached to one end of the conduit. The other end of the conduit is brought to the skin as a stoma. The ileal conduit requires a patient to wear a bag on the skin to collect urine, which is then emptied when it gets full.
Before Your Surgery
Certain medications increase the risk of bleeding and need to be stopped prior to surgery. You should tell your surgeon about all prescription medicines, over the counter medicines, vitamins, and herbal supplements that you are taking. Some patients, such as those with artificial heart valves or high blood clotting risk, will need to take blood-thinning injections whilst coming off their tablet medications.
After Your Surgery
When you wake from anaesthesia you will have a bag over the stoma, which will be connected to a larger drainage bag to collect your urine. You will one or more drain tubes in your abdomen, which will be removed after a few days. You will have dressings over the incisions in your abdomen, and a drip in your arm.
As this is a major operation you may need to stay in the intensive care unit (ICU) for the initial few days after surgery.
You may have a nasogastric tube, which passes through your nose and down into your stomach to drain gastric secretions and allow your bowel to rest. This is usually removed after 2-3 days and you will start having sips of fluid, then slowly increasing to a normal diet.
You should expect some discomfort from the wounds. You will initially have pain control via an epidural catheter or intravenous patient controlled analgesia (PCA). By the time you are discharged you will be able to manage your pain with tablet painkillers.
You will not have anything to eat or drink for a few days, but your body will manage with the fluids you are receiving via the intravenous drip. Once your bowels start working you will be commenced on oral fluids and then eventually a regular diet.
Your stomal therapist will provide education and resources to help you manage your stoma after you go home.
Many patients will be ready to go home one week after surgery, however some may require a longer time in hospital to recover.
Resuming Normal Activities After Cystectomy
No driving for a minimum of 4 weeks after the operation. Avoid heavy lifting, bending, stretching, or straining activities like mowing the lawn for up to four weeks after your surgery. You may resume walking or light exercise immediately after your procedure. Ask your surgeon when to recommence blood-thinning medications. It may take several weeks before you feel well enough to return to work.
Specific Risks and Side Effects of Cystectomy
- Bleeding requiring a blood transfusion.
- Wound or intra-abdominal infection or abscess requiring drainage and prolonged antibiotics.
- Lymphocele, a collection of lymphatic fluid that occurs after lymph node dissection, occurs in less than 10% of cases. It may occasionally cause pain or become infected, requiring a minor drainage procedure.
- Anastomotic leak refers to either leakage of urine from the join between the ureters and the ileal conduit, or leakage of bowel content from the join between the reconnected segments of bowel. Urine leakage requires prolonged placement of an abdominal drain. Leakage of bowel context is extremely rare, but if it occurs it will require open surgical exploration.
- Bowel obstruction may occur due to the formation of intra-abdominal adhesions after surgery, and may require surgical correction.
- In men, impotence due to removal of nerves in close proximity to the bladder and prostate.
- Loss of ejaculation in men due to removal of the prostate and seminal vesicles, the organs that produce the seminal fluid, and cutting of the vas deferens.
- In women, infertility as a result of removal of the uterus. Shortening or narrowing of the vagina may lead to painful intercourse.
- Injury to major nerves travelling through the pelvis, causing weakness or altered sensation in the leg, is very rare.
- Rectal injury is very rare and tends to occur in situations where there has been prior major surgery or radiation to the rectum.
- Related to the ileal conduit:
- Metabolic problems.
- Recurrent urinary tract infections.
- Kidney stone formation as a result of metabolic changes.
- Strictures or narrowing of the ureters requiring stents or revision surgery.
- Stoma complications including narrowing, retraction, blockage and hernia formation, which may occur after several years and require revision surgery.
- Diarrhea as a result of a shortened gut.
- Anaesthetic complications, such as heart attack or stroke.
- Infection, for example of the urinary tract, chest, or other sites.
- Clots forming in the legs (DVT), which may then pass to the lungs.
- Allergic reactions to drugs, antiseptics, or wound dressings.
- The risk of death relates to the patient’s general health and the complexity of the surgery, and may arise due to either anaesthetic or surgical complications. The average risk of death after radical cystectomy is 2%.
When to contact your surgeon
- If you experience fevers, sweats, shakes, nausea or vomiting after you go home, or if you feel generally unwell.
- Your urostomy bag has stopped draining urine.
- Any unusual or prolonged pain not relieved by regular pain relief.