Radical Cystectomy

Urinary bladder is a muscular sack which receives, stores the urine and release urine through the distal ( lower) urinary tract. Bladder cancer is a cancer which begins in the lining of the walls of the urinary bladder.

Radical Cystectomy is surgery (operation) performed to remove enlarged (overgrown) urinary bladder and surrounding tissues. Tissues surrounding urinary bladder include the prostate, the seminal vesicles and nearby lymph nodes. This procedure can completely cure cancer of urinary bladder that is localized ( restricted only to prostate gland).

Safety:

Radical Cystectomy is surgery (operation) as safe as any other traditional surgeries with minimal blood loss, pain, blood transfusion may be necessary. One to two weeks’ hospital stay.

Radical Cystectomy Length:

3- 4 hours.

Diagnosis:

Radical Cystectomy is recommended after the following diagnosis tests:

  • Urinalysis.
  • Urine cytology.
  • Cystoscopy
  • CT scan
  • KUB ( abdominal X-ray)
  • EKG (electrocardiogram)
  • CBC (complete blood count)
  • PT / PTT (blood coagulation profile)
  • Comprehensive Metabolic Panel (blood chemistry profile)

Preparation:

Certain medications to be specifically avoided pre surgery:

  • Aspirin.
  • Ibuprofen Motrin.
  • Voltaren, Plavix, Lovenox, Vioxx, Celebrex.
  • Arthritis medications: avoided since before a week of the surgery otherwise it can cause bleeding during the surgery.
  • The urine culture analysis should be negative.
  • In case of UTI Urinary Tract Infection, it should be treated before the surgery by prescribed antibiotics.
  • In case of severe lung/ heart conditions, it is advisable to exercise extra caution before and during the procedure

Radical Cystectomy Procedure:

  • Options of Surgery:
    Transurethral resection of the bladder (TURB).
    Radical cystectomy.
    Ileal conduit.
    Continent urinary reservoir.
    Orthotopic Neobladder.

Operative procedure that will be performed needs to be discussed at length with the patient. Surgeon should make it amply clear that sexual function is usually lost in both genders.

Radical Cystectomy is carried out under general anesthesia. The patient is kept lying down on the abdomen. Prophylactic antibiotics (Augmentin and Metronidazole) are administered intravenously after anesthesia. Patient then is catheterized with a 16 French Foley catheter to drain the bladder. A standard midline incision is used, skirting the umbilicus.

Conventional Radical cystectomy and orthotopic neobladder (ONB) includes pelvic lymphadenectomy and in addition, in the male patients, the urinary bladder is removed en bloc, with the parts of pelvic peritoneum, ureteric remnants, prostate and seminal vesicles along with a small piece of membranous urethra. In the female, the uterus, ovaries, fallopian tubes, vaginal vault and urethra are also removed. Continent Diversion entails suprapubic tube, urethral catheter, 2 ureteric splints, and 1 drainage tube.In addition, patients need to carry 4–5 urobags for 2-3 weeks after the surgery.

Alternatively, minimally invasive surgery (MIS), like laparoscopic radical cystectomy (LRC) and robotic radial cystectomy (RRC) have been suggested. Advantages of these procedure are- minimal blood loss, reduced pain, rapid recuperation, and acceptable cosmesis without large midline scar. However, limitations of MIS are- steep learning curve, long duration of surgery, high cost, besides dependence of ileal conduit over the ONB for continent diversion.

Radical Cystectomy Complications:

  • Bleeding.
  • Fever.
  • Constipation.
  • Infection.
  • Urinary leakage
  • Lymphatic leakage
  • Ileus
  • Delayed complications include (after 6 weeks):
  • Recurrent UTI
  • Parastomal hernia
  • Ureteric strictures – probably ischaemic
  • Stomal infarction – ischaemic
  • Stomal retraction
  • Stomal stricture
  • Acidosis
  • Bilateral hydronephrosis
  • Renal stone

Follow- up:

  • 24 hour surveillance.
  • Emergency Follow up:
  • Chest pain/ breathing difficulty.
  • Vomiting/ nausea
  • Worsening pain .
  • Large amounts of blood clots in the urine.
  • Difficult/ painful voiding and fully emptying the bladder.
  • Hospital stay for up to one week after radical Cystectomy.
  • During the operation, urinary catheter is inserted and few patients may be required to wear the catheter for some more days to a few weeks even after discharge from hospital.
  • Retaining catheter kept in skin after surgery should be there for some more days after discharge from hospital.

All above, treatments are finalized taking into consideration the overall health, severity, age and other ailments of the patient. Only a well experienced urologist should perform the above treatment.