Cystectomy, the surgical removal of the bladder, is a significant medical procedure performed when specific health conditions necessitate its removal. It can be a life-altering treatment for various severe diseases affecting the bladder.
Medical Reasons for Bladder Removal
Cystectomy is most commonly performed to treat bladder cancer, particularly when the cancer is invasive, high-grade, or has recurred despite previous treatments. Bladder removal may also be considered for severe non-cancerous conditions that have not responded to other forms of treatment.
These conditions include severe interstitial cystitis, a chronic condition causing bladder pain and pressure, when symptoms are debilitating and unresponsive to less invasive therapies. Chronic bladder dysfunction, such as neurogenic bladder caused by nerve damage, can also necessitate removal if it results in recurrent infections, kidney damage, or unmanageable incontinence. Additionally, congenital abnormalities affecting the bladder’s structure or function, like bladder exstrophy, may require its removal. In some instances, extensive radiation therapy to the pelvis can severely damage the bladder, leading to intractable pain, bleeding, or incontinence, making cystectomy a necessary intervention.
Surgical Approaches to Bladder Removal
Cystectomy can be either radical or partial. A radical cystectomy typically includes the bladder, nearby lymph nodes, and often surrounding reproductive organs, such as the prostate and seminal vesicles in men, or the uterus, ovaries, fallopian tubes, and part of the vagina in women. This comprehensive approach is primarily used for invasive bladder cancers. A partial cystectomy involves removing only the affected part of the bladder, preserving the remaining healthy tissue. This option is generally reserved for specific cases, such as solitary, low-grade tumors that have not deeply infiltrated the bladder wall, allowing for some preservation of natural bladder function.
Surgical techniques for cystectomy include traditional open surgery and minimally invasive approaches. Open surgery involves a single, larger incision in the abdomen to directly access the bladder. Minimally invasive techniques, such as laparoscopic or robotic-assisted surgery, utilize several small incisions through which specialized instruments and a camera are inserted. Robotic assistance offers enhanced dexterity, precision, and a magnified, three-dimensional view, which can lead to benefits such as reduced blood loss and a potentially faster recovery compared to open surgery.
Urinary Diversion Methods
After bladder removal, a new system is necessary to store and eliminate urine from the body. These alternative pathways are created through urinary diversion procedures, which are categorized as either incontinent or continent diversions.
Incontinent diversions involve continuous urine drainage into an external collection device. The ileal conduit is the most frequently performed type of incontinent diversion. In this procedure, a segment of the small intestine (ileum) is isolated; one end is connected to the ureters, and the other end is brought through the abdominal wall to form a stoma. Urine then flows continuously through this stoma into an external pouch worn on the abdomen.
Continent diversions are designed to store urine internally, allowing for controlled emptying. One such method is the continent cutaneous reservoir, where an internal pouch is constructed from a section of the intestine. A valve mechanism is created at the abdominal wall opening to prevent urine leakage, and individuals learn to insert a catheter periodically through the stoma to drain the urine from this internal reservoir. Another common continent diversion is the neobladder, or orthotopic bladder substitution. In this procedure, a new bladder-like pouch is fashioned from a segment of intestine and connected directly to the urethra. This allows for voiding through the natural urinary opening, though it often requires learning new techniques, such as using abdominal muscle pressure to empty the pouch, and may involve scheduled voiding to prevent overfilling. A neobladder does not possess the same nerve sensations as a natural bladder, meaning the feeling of fullness is different, and some individuals may experience nocturnal leakage.
Living Without a Bladder
Adjusting to life after bladder removal and urinary diversion involves learning new routines for managing urine elimination. For individuals with an ileal conduit, daily stoma care becomes a regular part of life, encompassing cleaning the skin around the stoma and changing the external pouch.
Patients with a continent cutaneous reservoir learn self-catheterization, a procedure performed several times daily to empty the internal pouch. Similarly, those with a neobladder learn specific techniques, often involving abdominal pressure, to effectively empty the newly constructed internal reservoir. Beyond the physical adjustments, there can be emotional and psychological considerations related to changes in body image and urinary function. Many individuals find support groups or healthcare professionals specializing in ostomy care or urological health beneficial during this adaptation process. With proper education, consistent self-care, and access to support networks, individuals can achieve a good quality of life after bladder removal.