A cystectomy is the surgical removal of all or part of the urinary bladder. This major operation requires significant adjustments to how the body manages urine. Its goal is to address serious bladder conditions by creating alternative pathways for urine to exit the body.
Conditions Requiring Bladder Removal
The most frequent condition leading to bladder removal is muscle-invasive bladder cancer, where cancer has invaded the muscle layers of the bladder wall. Radical cystectomy is a primary treatment to prevent its spread. Bladder cancer that is high-risk, aggressive, or unresponsive to other treatments, even if not muscle-invasive, may also necessitate removal.
Beyond cancer, other conditions can also lead to cystectomy. These include severe non-cancerous bladder dysfunction, such as interstitial cystitis unresponsive to other therapies, or certain congenital abnormalities. Chronic inflammatory conditions, nerve damage, or complications from other cancer treatments like radiation may also require removal.
Managing Urine After Bladder Removal
After bladder removal, a new method for urine management, known as urinary diversion, is established. The choice depends on factors like the patient’s overall health, manual dexterity, and the extent of the original disease. These diversions typically use a segment of the patient’s intestines to create a new pathway or reservoir for urine.
Ileal Conduit (Urostomy)
An ileal conduit is a common and reliable urinary diversion. A small segment of the ileum is isolated. The ureters, carrying urine from the kidneys, connect to one end of this intestinal segment. The other end is brought through an opening in the abdominal wall, forming a stoma.
Urine continuously drains from the kidneys, through the ureters, into the ileal conduit, and exits through the stoma into an external collection pouch. This pouch adheres to the skin around the stoma and requires regular emptying.
Continent Cutaneous Urinary Diversion
Continent cutaneous urinary diversions, such as the Indiana or Kock pouch, create an internal urine reservoir from a section of the intestine. An Indiana pouch, for example, uses portions of the large and small intestine. This internal pouch stores urine, preventing continuous leakage.
A small stoma is created on the abdomen, through which the patient periodically inserts a catheter to drain the urine. This method eliminates the need for an external collection bag. Patients learn to catheterize the pouch several times daily to keep it empty and prevent complications.
Orthotopic Neobladder
An orthotopic neobladder is a reconstructive surgery aiming for more natural urination through the urethra. A new bladder-like pouch is fashioned from a segment of intestine, usually the ileum, and connected to the urethra. Urine then flows from the kidneys, through the ureters, into the neobladder, and can be voided through the urethra.
Patients with a neobladder must learn new ways to empty it, often involving pelvic floor muscle relaxation and abdominal straining. While natural urination is the goal, some individuals may experience incontinence, especially at night, or difficulty fully emptying. In such cases, intermittent self-catheterization might be needed for full drainage. Training the neobladder to stretch, hold urine, and recognize fullness is a gradual process taking several months.
Adjusting to Life and Long-Term Care
Adjusting to life after bladder removal involves immediate recovery and ongoing management of the new urinary system. This includes physical healing, learning new routines, and addressing potential challenges.
The initial recovery typically involves a hospital stay of five to ten days, depending on the surgery type and individual recovery. Pain management is provided, and patients are encouraged to begin light activity, such as walking, soon after surgery to aid circulation and bowel function. Surgical incisions require care, and temporary drainage tubes or catheters are managed by the healthcare team.
Daily living adjustments are extensive, centered on managing the specific urinary diversion. Individuals with an ileal conduit learn meticulous stoma care, including skin cleaning and regular external collection pouch changes. Those with a continent pouch or neobladder learn self-catheterization techniques, performed daily to empty the internal reservoir. Diet and hydration might need modifications, and physical activity can typically be resumed gradually, with strenuous activities restricted for several weeks.
Potential challenges can arise:
Skin irritation around a stoma, particularly if the pouch seal is compromised.
Urinary tract infections, a common concern with all diversion types, requiring vigilance and prompt treatment.
Changes in bowel function, including constipation or diarrhea, due to the use of intestinal segments.
For those with a neobladder, issues like incontinence (especially nocturnal leakage) or difficulty fully emptying, which may require ongoing management and sometimes self-catheterization.
The psychological and emotional impact of bladder removal can be significant, including body image concerns and sadness. Support from healthcare professionals, family, and support groups is helpful.
Sexual health is also affected. In men, nerve-sparing techniques may preserve erectile function, but infertility is common if organs are removed. In women, removal of the uterus, ovaries, or part of the vagina can lead to early menopause and changes in sensation or comfort. Open communication with partners and healthcare providers is important to address these changes.
Ongoing medical monitoring is important for long-term care. Regular follow-up appointments with a urologist are necessary to ensure the urinary diversion functions well, monitor kidney health, and check for cancer recurrence. These appointments may include blood tests, imaging studies, and examinations to support health and address issues.