The surgical procedure for removing the urinary bladder is formally called a cystectomy. This major operation is performed when the bladder is diseased or damaged beyond repair, most commonly to treat muscle-invasive cancer. Since the bladder stores urine, its removal necessitates a second procedure, known as urinary diversion, to create a new way for the body to manage and excrete waste. Cystectomy is a complex surgery requiring careful planning and a lengthy recovery period.
Defining Cystectomy and Surgical Approaches
A cystectomy is performed in different ways depending on the extent of the disease and the patient’s overall health. The least extensive variation is a partial cystectomy, which involves removing only a section of the bladder wall. This approach is reserved for small, isolated tumors that have not invaded the muscle layer, allowing the remaining bladder to continue functioning.
The most common and extensive procedure is the radical cystectomy, which involves removing the entire bladder along with surrounding lymph nodes. The scope of this surgery differs between men and women due to anatomical differences. In men, the surgery typically includes the removal of the prostate and seminal vesicles.
For women, a radical cystectomy often involves removing the uterus, fallopian tubes, ovaries, and sometimes a portion of the vagina. Removal of these adjacent organs maximizes the chance of removing all cancerous tissue. The procedure can be performed through traditional open surgery or using minimally invasive robotic or laparoscopic techniques.
Medical Indications for Bladder Removal
The predominant reason for performing a cystectomy is bladder cancer, particularly when it has grown into the muscle layer of the bladder wall. This muscle-invasive bladder cancer requires complete removal of the bladder. Removal is also indicated when high-risk, non-muscle-invasive tumors, such as carcinoma in situ (CIS), do not respond to initial treatments like immunotherapy.
Beyond malignancy, a cystectomy may be necessary for severe, non-cancerous conditions that cause debilitating symptoms. These include severe radiation cystitis, where the bladder wall is damaged and bleeds uncontrollably following radiation treatment. Intractable interstitial cystitis, a chronic pain condition unresponsive to other therapies, can also lead to bladder removal.
The procedure is sometimes used to address severe neurogenic bladder dysfunction or congenital abnormalities. In these benign cases, a simple cystectomy, which removes only the bladder without surrounding reproductive organs, may be performed. The decision for removal is made when the bladder’s function is severely compromised or poses a significant risk to the patient’s life.
Methods of Urinary Diversion
Since the bladder is removed, a new pathway must be created to manage and eliminate waste after a total cystectomy. This procedure is called urinary diversion, and the options are categorized into two main groups: incontinent and continent diversions. The choice of method is based on factors like the patient’s health, kidney function, and personal preference.
Incontinent Diversion (Ileal Conduit)
The most common and simplest form of urinary diversion is the incontinent diversion, often created as an ileal conduit. This procedure uses a segment of the small intestine, the ileum, which is isolated from the rest of the bowel. The ureters, which carry urine from the kidneys, are connected to one end of this intestinal segment.
The other end of the ileal segment is brought through the abdominal wall to create a stoma, typically on the right side of the abdomen. Urine flows continuously out of the stoma, requiring the patient to wear an external pouch to collect the urine at all times. This method has a lower rate of long-term complications and is suitable for nearly all patients.
Continent Cutaneous Reservoir
A continent cutaneous reservoir, such as an Indiana Pouch, creates an internal storage pouch from a section of the bowel. This pouch holds urine inside the body, eliminating the need for a continuously draining external bag. Surgeons create a valve mechanism at the connection point to the skin to ensure the pouch is leak-proof.
The patient empties the pouch several times a day by passing a catheter through a small stoma on the abdomen. This diversion requires the patient to perform intermittent self-catheterization for life. While it offers greater freedom from external appliances, the surgical construction is more complex than an ileal conduit.
Orthotopic Neobladder
The orthotopic neobladder is the most complex form of continent diversion and aims to replicate the function of the original bladder. A new bladder is constructed internally using a segment of the small intestine. The ureters are connected to this new pouch, which is attached directly to the patient’s remaining urethra.
This allows the person to pass urine naturally through the urethra without requiring a stoma or an external bag. However, the neobladder lacks the original nerve connections, so patients must learn new techniques to recognize fullness and empty it using pelvic muscles and abdominal pressure. Many patients must still use a catheter periodically to ensure complete drainage, particularly at night.