Radical cystectomy is a surgical procedure involving the complete removal of the urinary bladder. It is performed to address serious bladder conditions, particularly certain types of cancer. After bladder removal, a new method for storing and eliminating urine, known as urinary diversion, becomes necessary.
Conditions Requiring Radical Cystectomy
The most common reason for radical cystectomy is muscle-invasive bladder cancer (MIBC), where cancer has invaded the bladder’s muscle wall. This type of cancer has a higher likelihood of spreading, making cystectomy a standard treatment to remove the cancer and reduce further spread.
While bladder cancer is the primary indication, the procedure may also be considered for other severe, non-cancerous bladder conditions unresponsive to less invasive treatments. These include intractable interstitial cystitis, causing chronic bladder pain, or neurogenic bladder dysfunction due to nerve damage. In these cases, surgery manages debilitating symptoms and improves quality of life.
The Surgical Procedure
During a radical cystectomy, the entire bladder is removed, along with nearby lymph nodes. Lymph node removal helps determine cancer extent and guides further treatment.
In men, the prostate gland and seminal vesicles are also removed. For women, the procedure usually includes removal of the uterus, ovaries, fallopian tubes, and a portion of the vagina. The extent of organ removal can vary based on cancer spread and the patient’s condition. Surgery can be performed using traditional open techniques (single large incision) or minimally invasive approaches like laparoscopic or robotic-assisted surgery (smaller incisions). A radical cystectomy typically takes four to six hours.
Methods of Urinary Diversion
This is a critical part of the surgery, and several methods exist, each with different implications for the patient’s lifestyle. These diversions are constructed using a segment of the patient’s intestine.
One common method is the Ileal Conduit, also known as a urostomy. A small section of the small intestine (ileum) is isolated, and one end is brought through an opening in the abdominal wall, creating a stoma. The ureters, which carry urine from the kidneys, are then connected to this isolated intestinal segment, allowing urine to continuously drain out of the body into an external collection bag worn over the stoma. This is a straightforward and widely used method.
Another option is the Neobladder, which aims to create an internal reservoir for urine. A segment of the intestine, often the ileum, is reshaped into a pouch and connected to the patient’s urethra. This allows urine to be stored internally, and the patient can typically urinate through the urethra, similar to natural voiding, by relaxing pelvic floor muscles and using abdominal pressure. Patients with a neobladder learn to empty it regularly, often requiring self-catheterization if complete emptying is difficult.
A third method is the Continent Cutaneous Reservoir, sometimes referred to as an Indiana pouch. In this procedure, an internal pouch is created from a section of the bowel, often the large intestine, within the abdomen. The ureters are connected to this pouch, and a small opening (stoma) is created on the abdominal wall, usually with a valve mechanism to prevent leakage. Patients then periodically insert a catheter into the stoma to drain the urine from the internal reservoir, typically multiple times a day.
Post-Surgical Recovery and Adaptation
Recovery from a radical cystectomy involves immediate post-operative care and longer-term adjustments to a new way of life. Patients typically remain in the hospital for five to seven days following an open procedure, or potentially shorter for minimally invasive surgery. During this initial period, pain management is provided, and early mobilization, such as walking, is encouraged to promote healing and reduce complications.
Upon returning home, patients gradually resume their daily activities. Full recovery, including the ability to engage in more strenuous physical activities, may take two to three months, although many patients can return to lighter activities within six weeks. A significant aspect of adaptation involves learning to manage the new urinary diversion system. This includes understanding how to care for a stoma and change collection bags, or how to self-catheterize and manage an internal pouch. Regular follow-up appointments are scheduled to monitor the function of the urinary diversion and check for any potential cancer recurrence, ensuring ongoing health and well-being.