Bladder Removal Surgery

Overview

Cystectomy) Bladder Removal Surgery) is a difficult surgical procedure in which the urinary bladder is partially or completely removed by a surgeon.

Bladder removal surgery is most commonly used to treat invasive bladder cancer. Cystectomy is occasionally performed by doctors for benign abnormalities of the bladder and urinary system.

To remove the bladder, your surgeon will use one of many procedures, or surgical approaches. Your doctor will undertake reconstructive surgery after removing some or all of the bladder. Reconstruction develops a new mechanism for your body to store and eliminate pee.

What is the Main Function of the Bladder?

The urinary system, which comprises the bladder, urethra, ureters, and kidneys, aids in the preservation of chemical balance in the body by storing and eliminating waste materials. The bladder, a muscular chamber in the lower abdomen, serves as a reservoir for pee. Urine is transported from the kidneys to the bladder via two small tubes known as ureters. During urination, urine is expelled from the bladder via another tube called the urethra.

What are the Indications for Bladder Removal Surgery?

Cystectomy is done for the following conditions:

• Cancers, which include:
  • Bladder cancer that spreads to the muscles yet stays in the bladder.
  • Other types of pelvic cancer, such as advanced colon, prostate, or endometrial cancer, need the removal of the bladder along with other organs.
    
    
• Non-cancerous conditions, which include:
  • Severe interstitial cystitis that does not respond to other treatments.
  • Developmental abnormalities of the bladder.
  • Bladder diverticula (outpouchings within the inner wall of the bladder).
  • An abnormal connection (fistula) between the colon or the vagina and the bladder.
  • Localized endometriosis of the bladder. Endometriosis of the bladder is when the tissue that normally lines the uterus occurs in other organs, in this case, in the bladder.
  • Other conditions like pheochromocytoma, schwannoma or endocervicosis involving the urinary bladder
  • The presence of symptoms like severe blood loss in urine due to cavernous hemangioma or other conditions

Types of Bladder Removal Surgery

Our surgeon may remove part of your bladder (partial cystectomy) or the full bladder (radical cystectomy).

• Partial cystectomy: Only a portion of the bladder is removed during a partial cystectomy. To establish whether cancer has progressed beyond the bladder, adjacent lymph nodes are typically removed as well. Lymph nodes are tiny tissue bundles that filter your body's lymph fluid and create immune system cells. The surviving bladder is healed and remains in the body.
• Radical cystectomy: Surgeons remove the whole bladder as well as nearby lymph nodes during a radical cystectomy. In males, surgeons usually always cut the vas deferens and remove the prostate and seminal vesicles (parts of the male reproductive system). In women, doctors frequently remove the uterus, fallopian tubes, ovaries, cervix, and, on rare occasions, a portion of the vaginal wall.

Surgeons perform bladder removal surgery using one of two different surgical approaches:

• Open cystectomy: Your surgeon accesses your bladder and the tissues around it with one long incision in your abdomen. The surgeon’s and assistant’s hands enter the body cavity to perform the operation.
• Minimally invasive (laparoscopic or robotic) cystectomy: To make room for your surgeon, the abdomen is initially insufflated with carbon dioxide. To accomplish the surgery, very small incisions are created so that lengthy tools may be introduced into the body cavity. The hands of the surgeon and assistant do not enter the body cavity. The surgeon and assistant use these devices directly during laparoscopic cystectomy. The tools are attached to a surgical robot so that the surgeon may control them via a surgical console during a robotic cystectomy. By offering three-dimensional vision and boosting tool dexterity, the surgical robot improves the surgery. 

How Should I Prepare Before Bladder Removal Surgery?

The surgeon will review the tests performed to diagnose your disease, which requires a cystectomy, and to stage the malignancy in the case of bladder cancer. These might include:

• Under a microscope, the urine sediment is examined for the presence of cancer cells.
• Cystoscopy is a technique in which a thin tube is sent into the urethra to see the inside of the bladder and collect a sample of any abnormal or suspicious region for examination.
• Imaging studies are being conducted to identify the size and extent of the growth, as well as the presence of dissemination to local lymph nodes and distant areas.

Routine tests: You will have to undergo routine tests before the procedure. Routine tests which are done before any surgery include:

• Blood tests like hemoglobin levels, blood group, and liver and kidney function tests.
• Urine tests, urine infection should be ruled out prior to the surgery with a urine culture if necessary.
• Electrocardiogram (ECG) to study the electrical activity of the heart. In older patients, a detailed assessment of the heart may be required to make sure that they are fit for surgery.
• Chest x-ray.

Type of Anesthesia: The procedure is performed under general or epidural anesthesia. You will be unconscious throughout the process and will be unaware of what is going on.

Pre-operative Check-up: The above-mentioned routine tests are ordered a few days before the procedure. Aspirin and other blood thinners should be avoided for about a week before the surgery. To ensure adequate recovery, patients are encouraged to stop smoking. A day or two before surgery, bowel preparation with laxatives and a clear liquid diet may be recommended. A day before the procedure, admission is necessary.

The Day before Surgery: An enema is administered the previous afternoon or evening before the surgery along with gut-sensitive antibiotics.

Fasting before Surgery: Overnight fasting is essential, and intravenous fluid may be required on occasion to keep you hydrated. Sedation is sometimes necessary for a good night's sleep prior to surgery.

Shift from the Ward or Room to the Waiting area in the Operating room: An hour or two before the surgery, you will be shifted to the operating room waiting area on a trolley. Once the surgical room is ready, you will be shifted to the operating room.

Anesthesia before Surgery: The anesthetist will inject medications into you via an intravenous line and induce you to breath gases through a mask, putting you to sleep. Once you are sleeping, a tube will be put into your mouth and windpipe to provide anesthetic gases to alleviate discomfort and make you comfortable during the procedure. 

What Happens During Bladder Removal Procedure?

• During open radical cystectomy: Your abdomen and groin will be sterilized with antiseptics and draped to reveal just the surgical site once the anaesthetic has taken effect. You will be lying on your back for the open operation. A central midline incision will be made below the belly button on your abdomen. The muscle and underlying tissue will be separated. The blood veins that feed the bladder will then be tied and severed. The bladder will then be delivered out, separated from the urethra, ureters, and other surrounding structures. The prostate, seminal vesicles, and vas defers will also be removed in males, while the uterus, tubes, ovaries, and the anterior section of the vagina will be removed in women. Both sexes have their pelvic lymph nodes removed.
  
  
• During laparoscopic radical cystectomy: You'll be positioned with your legs apart and supported by stirrups. Pressure points will be well-padded, and stockings will be used to minimize blood stagnation in your legs. A little incision below your belly button will be made, and a cannula will be implanted. Through this cannula, carbon dioxide will be delivered into the belly to inflate it so that the surgeon can see the inside of your abdomen clearly. Additional incisions will be created to allow tools to pass through during the procedure. The bladder will be separated from the surrounding structures and gently removed using the laparoscope and equipment. The lymph nodes in the pelvis are also removed. If the urethra is affected by cancer, it is removed.
  
  
• During partial cystectomy, the diseased part of the bladder is removed and the defect is stitched up with absorbable sutures.
  
  
• During robotic surgery, the surgeon sits at a console and controls robotic arms, which carry out the surgery with precision.
  
  
• Urinary diversion:

The cystectomy surgery does not end with the removal of the bladder; a urinary diversion procedure is also required to provide a pathway for urine to exit the body. Urinary diversion methods include the following:

1. 1. Ileal conduit: A tiny portion of the ileum or small intestine will be removed. It will be knotted at one end and linked to a hole in the belly at the other (called stoma). The blind tube will then be attached to the ureters. Thus, urine produced by the kidneys travels down the ureters to the ileal tube before exiting the body via the abdominal hole. Because the tube has no method of stopping the continuous flow of pee, a bag must be connected to the abdomen to collect the urine. On a regular basis, the bag must be emptied.
   2.  Pouch reservoir: The ileum, the beginning of the large intestine, and the cecum, which is an expansion at the junction of the two, will be utilized to create an internal pouch in this treatment; the ureters will be joined to this pouch, and the pouch will open out via the abdominal stoma. The urine from the internal pouch must be drained on a regular basis using a catheter. This method eliminates the need to use an external bag.
   3. Orthotopic neobladder: This treatment also replaces the bladder with a section of the intestine, generally the ileum. The ureters will be attached to the top side of the ileal pouch, which will be connected to the urethra on the lower side. However, the replacement bladder, or 'neobladder' ('orthotopic' indicates that the component is grafted in a natural position), cannot fully replace the original bladder. The bladder can be emptied by raising abdominal pressure by contracting the muscles, or by catheterization on a regular basis.

After the procedure, the wounds are closed and a drain is placed in the belly.

Contraindications for Bladder Removal Surgery

There are no specific contraindications to undergoing a cystectomy. Cystectomy, on the other hand, should not be conducted on those who are not in good enough condition to endure a major surgical treatment. Individuals who cannot tolerate general anesthesia, as well as those with severe or improperly controlled co-morbidities such as diabetes, heart, lung, renal, or liver disease, fall into this category. Individuals who are very malnourished, have blood clotting issues, or have serious test abnormalities are also included. Individuals who are unwell or infected should also postpone surgery until they recover.

Individuals with serious heart and lung disease should avoid robotic-assisted or laparoscopic surgery. The placement and abdominal insufflation used during this kind of surgery create additional pressure on the chest wall, limiting lung function and the capacity to oxygenate the blood.

In the case of carcinoma in situ, a partial cystectomy is not recommended (CIS). Other contraindications for partial cystectomy include drastically reduced bladder capacity or cancer in or around the bladder trigone, which connects the urethra and ureters to the bladder.

After Bladder Removal Procedure

Waking up from General Anesthesia: Once fully awake from anesthetic effect, you will be shifted on the trolley and taken to the recovery room.

Recovery room: In the recovery room, a nurse will monitor your vitals and observe you for an hour or two before shifting you to the room or a ward.

Post-operative recovery: Following the surgery, you may be required to stay in the hospital for several days.

• When your bowel sounds return, you will be given intravenous fluids and allowed to drink liquids. You will be gradually transitioned to semi-solid meals, and then to solid foods.
• After 24 hours, chest physiotherapy can be begun to avoid chest infection.
• Once the outflow is limited, the abdominal drain will be removed.
• Deep vein thrombosis prevention, early leg exercise and mobilization can avoid deep vein thrombosis, which occurs when a clot forms in the deep veins of the legs, which can be fatal.
• Pain relievers and antibiotics may be prescribed.
  
  

Discharge from hospital:

• You will be discharged from the hospital after your wounds have healed and you can accept normal meals.
• Catheter drainage of urine will be necessary for at least one week following a partial cystectomy.
• You will be instructed on how to care for the stoma, urine bag, and catheter, as well as how to catheterize on a regular basis. Repeated bladder emptying may be necessary in the days following surgery, however this can be decreased over time as bladder capacity rises.
• You will need to limit your activity for six to eight weeks.
• You will need to see your doctor on a frequent basis, especially if you previously had cancer, to check for recurrence and to continue other types of treatment such as chemotherapy.
• In addition, you will have to be regularly monitored for proper function of the new urinary diversion created and for any complications that may arise.

Risks & Complications of Bladder Removal Surgery

Complications of cystectomy include the following:

Early complications:

• Infection, which can be prevented with postoperative antibiotics.
• Pain, for which painkillers are prescribed.
• Blood loss, which may even require blood transfusion.
• Chest infection (pneumonia), It can be prevented by administering painkillers, chest physiotherapy, and early mobilization.
• Wound complications, which include infection and wound dehiscence due to improper healing.
• Deep vein thrombosis, which can be prevented with early mobilization and low molecular weight heparin up to four weeks after cystectomy.
• Leakage at the sites of the intestinal surgery, or through the pouch at suture lines.
• Postoperative ileus, where the intestines fail to move following the surgery.
• Impotence in males, which can be avoided with a nerve-sparing surgery when possible. Females may suffer from sexual difficulties like problems with sexual arousal and ability to have an orgasm following nerve damage.
• Early menopause, it occurs in young women who have undergone radical cystectomy.
  
  

Late complications:

• Urinary tract infection, detected with urine routine and culture testing. Incisional hernia is an outpouching of the abdominal lining via the weak spot of the incision.
• Voiding problems in orthotopic neobladder, it might lead to urine retention or incontinence. Catheterization is commonly used to treat urinary retention. Incontinence becomes better with time; however, a pad may be necessary. Medication, collagen injection around the urethra, a urethral sling placed surgically to support the urethra, or an artificial urine sphincter can all be used to treat severe incontinence.
• Deceased renal function, this can occur for a variety of reasons, all of which require proper therapy as required.
• Bladder stone, which may be removed by endoscopic procedure (via a tube introduced into the bladder).
• Bowel obstruction, due to adhesions formed due to the surgery and may need repeat surgery.
• Recurrence of the cancer, which will be treated appropriately.

Conclusion

A cystectomy is a surgical procedure that removes the urine bladder.

A radical cystectomy is the surgical removal of the whole bladder. In males, this usually entails removing the prostate and seminal vesicles. In most cases, a radical cystectomy involves the removal of the uterus, ovaries, fallopian tubes, and a portion of the vagina.

After removing your bladder, your surgeon must devise a new route for pee to be stored and expelled from your body. This is known as urine diversion. Your surgeon will review the alternatives for urine diversion that may be right for you.

A radical cystectomy is used to treat bladder cancer that has spread to the muscle tissue or recurring noninvasive bladder cancer. Although it is infrequently utilized, a partial cystectomy is used to remove a malignant tumor from an isolated area of the bladder. A basic cystectomy, which involves removing only the bladder, may be used to treat noncancerous (benign) diseases.