Bladder removal, known medically as a cystectomy, is a major surgical procedure typically performed to treat muscle-invasive bladder cancer. The procedure involves removing the entire bladder, and often surrounding structures, such as the prostate and seminal vesicles in men, or the uterus, ovaries, and part of the vagina in women. Since the bladder is removed, the body requires a permanent change in the way urine is collected and eliminated. This operation necessitates a period of physical recovery followed by long-term adaptation to a new urinary system.
Immediate Post-Operative Recovery
The initial recovery phase begins in the hospital, focusing on managing surgical trauma and re-establishing normal bodily functions. Patients typically remain hospitalized for five to ten days. Pain management is a high priority, often starting with intravenous patient-controlled analgesia or an epidural catheter before transitioning to oral pain medication.
Restoration of bowel function is a significant early milestone, signaled by the passing of gas, which allows the diet to progress from clear liquids to solid food. Patients will have temporary medical devices, including surgical drains to remove excess fluid, and thin tubes called stents to keep the new connection between the ureters and the bowel segment open. Early and frequent walking is encouraged to prevent blood clots and encourage the return of normal bowel motility.
Understanding Urinary Diversion Options
The most significant consequence of bladder removal is the need for a urinary diversion, which replaces the bladder’s function of storing and eliminating urine. This reconstruction uses a segment of the patient’s own intestinal tissue to create a new pathway or reservoir. The choice of diversion method dictates the long-term lifestyle changes and self-care routines required.
Incontinent Diversion
One common approach is the Incontinent Diversion, most frequently performed as an ileal conduit. A short piece of the small intestine (the ileum) is isolated, and the ureters are connected to one end. The other end is brought out through the abdominal wall to form a stoma, which is a small opening. Urine drains continuously from this stoma into a urostomy pouch worn externally on the abdomen.
Continent Cutaneous Diversion
A second option is the Continent Cutaneous Diversion, such as the Indiana Pouch. This method creates an internal reservoir using a segment of the large intestine, where the ureters are connected. A stoma is still created on the abdomen, but a valve mechanism keeps the urine from leaking out. The patient must empty the internal pouch several times daily by inserting a catheter through the stoma.
Orthotopic Neobladder
The third and most complex option is the Orthotopic Neobladder, which aims to mimic the original bladder. A reservoir is constructed from a section of the small intestine and connected to the patient’s urethra. This allows urine to be passed naturally through the urethra, avoiding the need for an external stoma.
Voiding with a neobladder does not involve the same muscle contractions as the original bladder, requiring the patient to learn new techniques. Patients must use abdominal straining, such as the Valsalva maneuver, to empty the pouch. Nighttime leakage is common, and some patients may need to perform intermittent self-catheterization to ensure complete drainage.
Daily Life Management and Adaptation
Adapting to life after bladder removal involves mastering the specific care routines associated with the chosen urinary diversion method. Patients with an ileal conduit or a continent cutaneous diversion must learn meticulous stoma care to maintain skin integrity and manage collection or catheterization supplies. This involves regularly changing the external appliance or following a consistent catheterization schedule.
Neobladder patients focus on timed voiding and learning to empty the new reservoir completely to prevent infections and complications. Adequate hydration is required for all patients to keep urine clear and reduce the risk of urinary tract infections or stone formation. Dietary adjustments may be necessary, as the use of intestinal segments can lead to increased mucous production in the urine.
Resuming physical activity is gradual, but most patients can return to normal activities within eight weeks, though heavy lifting is restricted for longer. The procedure impacts sexual health; for men, nerve damage can cause erectile dysfunction, and for women, changes to the pelvic anatomy may require adaptation. Open communication with healthcare providers and partners about these physical and emotional changes is instrumental for adaptation.
Long-Term Monitoring and Follow-Up Care
Life after cystectomy requires continuous medical surveillance to maintain health and ensure the long-term success of the urinary diversion. Oncological monitoring is standard, involving routine imaging like CT scans of the chest and abdomen for several years to check for cancer recurrence.
Metabolic complications can arise because intestinal tissue, designed to absorb nutrients, is now in contact with urine. One common issue is hyperchloremic metabolic acidosis, an imbalance of electrolytes often corrected with oral sodium bicarbonate supplementation. Kidney function must also be monitored closely, as the diversion can affect the upper urinary tract and lead to a decline in renal health.
Vitamin B12 deficiency is a specific concern when the ileum, the part of the small intestine responsible for B12 absorption, is used for the diversion. Annual blood tests are recommended, as deficiency may not appear immediately. If B12 levels are low, lifelong supplementation, typically through injections or high-dose oral tablets, is necessary to prevent neurological complications.