Urinary bladder may be involved with cancer. Surgical removal of total/part of the urinary bladder is the first line of treatment for localized cancers involving urinary bladder following complete resection of the tumor transurethrally. Cystectomy is warranted in case the tumor has gone deep and penetrated the detrusor muscle layer of the bladder.
The surgery may be a Partial Cystectomy in which only part of urinary bladder along with the tumor is removed preserving the rest of the bladder or Radical Cystectomy in which entire urinary bladder is removed. Partial Cystectomy has a limited indication for a well-localized tumor situated at the fundus of the urinary bladder (that is the roof of the bladder). Most of the other patients with the organ-confined disease need radical cystectomy. However radical cystectomy may be offered for a metastatic disease which has refractory bleeding in urine or in advanced disease setting after completion of neoadjuvant chemotherapy.
Radical cystectomy also involves simultaneous removal of the prostate, seminal vesicles, and vas deferens in males and uterus with fallopian tubes in females. Since the function of the urinary bladder is the storage of urine, hence the surgery also involves the creation of a neobladder by using a portion of the small intestine or making a stoma that is joining both the ureters to a small segment of the small intestine (Ileal Conduit) and bringing this segment out on the abdominal wall. This segment is connected to a small plastic bag which is to be emptied periodically by the patient once it gets filled with urine.
Reconstruction with Neobladder
Neobladder made from a segment of the small intestine. Patient passes urine from the urethra as before
Reconstruction with Ileal Conduit and Stoma
Segment/Conduit of Small Intestine (Ileum) used to join both the ureters
A plastic appliance is worn over the abdomen that collects urine and needs to be emptied periodically
This surgery can be done open, laparoscopically, or robotically. The patient may choose any of the above depending on the finances available although not much difference exists in the oncological outcome with any of the techniques mentioned. The patient may need chemotherapy after the surgery depending on the final biopsy/histopathology report.
The patient usually needs to stay in the hospital for 7 to 10 days after the operation. Since this surgery is a major one special emphasis is made on the preoperative fitness of the patient including cardiological aspects. In the postoperative period, special care needs to be given to ambulation of patient, limb physiotherapy and deep breathing exercises to prevent lung complications and protein-rich nutrition once the patient starts accepting orally. The patient is taught the proper use of stoma appliance by stoma therapist to prevent any apparatus related malfunction. Initially, there might be some leakage from the bag and some fitting related issues but gradually the patient gets used to it.
Dr. Abhinav Jain, Associate Consultant – Urology, Kidney Transplant – Adult, Kidney Transplant Paediatric, Dharamshila Narayana Superspeciality Hospital, Delhi