Radical Cystectomy
A radical cystectomy is a cancer operation that involves surgical removal of the entire urinary bladder. This procedure is used to treat cancers that have invaded the bladder wall, and are demonstrating a tendency to be more aggressive. In men, this involves removal of the bladder, the prostate, the seminal vesicles, portions of the vas deferens, and occasionally the urethra. In women, this involves removal of the bladder, the uterus, the cervix, a portion of the vagina, and sometimes the urethra. This is a technically challenging operative procedure, and physiologically demanding on the patient. Several members of the Urologic Surgeons of Washington have extensive experience with this technique.
After the bladder has been removed, the surgeon needs to create a "new bladder" for the urine to pass from the patient's body. This is called a urinary diversion. There are many options that have been developed for urinary diversion after the radical cystectomy, and some of them are listed below. Preoperatively, all patients who are having a radical cystectomy are required to undergo a full bowel preparation, to clear the bowel of any contents, in preparation for creation of the urinary diversion. The bowel is then used to build the new "bladder" or urinary conduit.
URINARY DIVERSIOIN
The most common urinary diversions utilized today (and are performed by the surgeons in our group) include the following:
- An ileal conduit - this surgical technique uses a segment of the small bowel, to serve as a channel for the urine to flow from the ureters out to a new opening on your abdomen, called a stoma. Once the urine passes through the stoma, it collects in a plastic stoma bag attached to the skin. The bag needs to be emptied several times a day.
- A continent reservoir - there are many types of reservoirs that have been used over the years by Urologists. We use an Ileocecal reservoir (Indiana Pouch). This technique uses a portion of the large bowel, and a portion of the small bowel. The large bowel serves as the new storage container (bladder). The ureters are attached to the large bowel. The urine is stored for several hours in this bowel segment, and then drained through the small bowel portion, which has a very small opening in the abdominal skin (stoma). Periodically the patient has to pass a urinary catheter through the skin stoma, into the small bowel and finally into the large bowel. The urine is drained through the catheter into the toilet. The advantage to this approach is that most patients are dry between catheterizations, and do not need a urinary storage bag (stoma bag) to be worn on the outside of the body.
- A "neobladder" - this is a more highly specialized form of a continent reservoir (see above). There are several versions of this technique. We use the Studer neobladder, which requires approximately 60 cm of small bowel. The small bowel is reconfigured, the ureters are attached to the upper end of the new bladder, and the end down in the pelvis is attached to the remaining urethra. This allows the patient to pass the urine normally through their urethra. Sometimes people need to use a urinary catheter to drain the urine.
In preparation for the surgery, all patients require a formal bowel preparation to include a mechanical cleansing, and antibiotics. The cleansing of the bowels is absolutely required since the bowel will be used to create the urinary diversion or the "new" bladder. All patients will also have to give a blood specimen for type and screen.
For your upcoming surgery, you will be given a form with the date and time of surgery, and the time you should arrive at the George Washington University Hospital. Many patients park at a Metro stop and take the Metro train to Foggy Bottom/GWU, which is located in from of the hospital lobby. Alternatively, there is a parking garage on I Street, less than 1 block from the hospital.
On the day of surgery your surgeon will greet you in the pre-op area and answer any last minute questions that you may have. You will meet the anesthesia team, and several peri-operative nurses. You will also meet our resident house staff. These doctors will be involved in your hospital care, and you will most likely see them several times after your surgery has finished. It is a busy time, but your family will be able to stay with you for most of the preoperative time, until you are taken back to the operating room.
As with any major operation, there are risks associated with the performance of a radical cystectomy and urinary diversion. The risks of these operations include but are not limited to bleeding, infection, damage to the lung, pleura, liver, spleen, bowel, nerves, major vasculature, and major complications related to prolonged surgery and anesthesia (blood clots, heart attack, pneumonia, stroke and death).
Postoperatively, most patients are taken to the intensive care unit (ICU) for close monitoring. If things go well, transfer to the the main surgical ward occurs in the first couple of days. However, ICU care may be necessary for several days. Patients are typically in the hospital for 7 to 10 days after this particular operation. During this time you will meet with the enterostomal nurse who will work with you and your spouse, or significant other. She will help educate you on the proper care of your "new" urinary tract.
Upon discharge from the hospital, you will be given a prescription for pain pills and stool softeners. You may need to use the pain medication for several days, but we encourage you to quickly transition to Tylenol for pain control, and use the narcotic pain medication sparingly. While at home, if you experience a dramatic turn for the worse, such as increasing belly pain, nausea and vomiting, fevers (> 101 F) and chills, shortness of breath, chest pain, or unilateral leg swelling, you should return to the hospital emergency room (ER) right away for re-evaluation.
After surgery, you will also need to actively care for your newly formed stoma, and / or reservoir.
- Ileal conduit - the stoma bag will need to be changed every few days. During this time, the skin around the stoma and the stoma will need to be cleaned. The enterostomal nurse at GWUMC will meet with every patient to teach the proper care of the newly formed stoma.
- Continent reservoirs. These urinary diversions are more complex and require a larger commitment from the patient to maintain.
- Indiana pouch - post operatively the patient will notice a large tube coming through the skin from the reservoir (cecostomy tube), 2 smaller tubes coming through the skin (ureteral stents), a tube coming from the stoma (red Robinson), and a drain in the pelvis. The ureteral stents will stay in for 7-14 days. . The red Robinson will also be left in for 1-2 weeks. The pelvic drain is left in until the average daily output is minimal, and varies from patient to patient. The cecostomy is typically left in for 1 month. The cecostomy is used to irrigate the newly formed pouch on a daily basis, to clear any build up of mucous. The frequency of these irrigations will decrease with time, and should be discussed with the enterostomal nurse and urologist. Once the new reservoir is showing signs of proper healing, the ureteral stents are removed, and the red Robinson catheter is removed. The patient is then taught how to place a urinary catheter into the newly formed stoma to begin the process of draining the new bladder. Once the self-catheterization process through the stoma is successfully mastered, the cecostomy tube is removed.
- Studer neobladder - post operatively the patient will notice a large tube coming through the urethra (urethral foley), 2 smaller tubes coming through the skin (ureteral stents), a larger tube coming through the skin (suprapubic (SP) tube), and a pelvic drain. The ureteral stents will stay in for 7-14 days. The urethral foley will be left in for 2-3 weeks. The drain is removed when the drainage is minimal. The SP tube is typically left in for 1 month. The SP tube is used to irrigate the newly formed pouch on a daily basis, to clear any build up of mucous. The frequency of these irrigations will decrease with time, and should be discussed with the enterostomal nurse and urologist. Once the neobladder is showing signs of proper healing, the ureteral stents are removed, and the urethral foley catheter is removed. The patient is then taught how to clamp the SP tube, and void through the urethra. Early on, the patient may have some trouble voiding naturally, so the SP tube is left in place to serve as a temporary drainage port. Once the patient has successfully mastered the art of draining the bladder through the urethra (by valsalva, or urethral catheter), the SP tube is removed. Over time, the patient is taught how to irrigate the neobladder through the urethral foley catheter.
In follow up, the patient is monitored for recurrence of his cancer, through periodic examinations, radiographs, and lab tests. It is also important that various blood tests are checked to monitor the salt and acid/base balance in the body. Finally the patient needs to be aware that Vitamin B12 may become deficient over many years, and this too should be monitored.