Total Cystectomy:

This is an X-ray of a patient who underwent a cystectomy (removal of the bladder) followed by the creation of a new bladder. This is a specialized operation which is now available in Cambridge

What is Total Cystectomy?

Cystectomy is surgical removal of all or part of the urinary bladder. Total Cystectomy, also known as Radical Cystectomy is surgical is the removal of the entire bladder, nearby lymph nodes (lymphadenectomy), part of the urethra, and nearby organs that may have been invaded by the cancer cells. In men, the nearby organs that are removed are the prostate, the seminal vesicles, and part of the vas deferens. In women, the cervix, the uterus, the ovaries, the fallopian tubes, and part of the vagina are also removed. The ureters are disconnected from the bladder and urinary diversion is created.

What is Partial or Segmental Cystectomy?

Partial Cystectomy or Segmental Cystectomy is removal of part or segment of the bladder and is usually performed for the resection of stage I and II bladder cancer.

Some terms to remember -

• Cystoprostatectomy - In this procedure the urinary bladder and pelvic lymph nodes are removed along with distal parts of ureters, seminal vesicles, vas deferens and part of the urethra.
• Anterior Pelvic Exteneration - In this procedure the urinary bladder, pelvic lymph node, ureters, cervix, part of urethra, uterus, fallopian tubes, ovaries and part of the vagina are removed.
• Bladder Reconstruction / Urinary Diversion - Two techniques are usually used to divert the urine after Total Cystectomy:
  • Continent Cutaneous Urinary Diversion (CCUD) - A reservoir is created internally from a piece (15 - 20 cm) of your bowel which is attached on one end to the ureters and on the other end to the urethra. This is a method used to internally substitute your bladder and may allow you to urinate as before. In some cases it may require you to apply pressure on your abdomen or insert catheter to urinate. If part or all of your urethra was removed during Total Cystectomy, then the reservoir opens through a urostomy on your abdomen which needs to be catheterized to release the urine several times a day and during the night.
  • Incontinent Cutaneous Urinary Diversion (ICUD) - In this technique, an ileal conduit or channel is created using a piece of your small intestine that connects your ureters to a urostomy opening on your abdomen. The urine passes from the ureters through the conduit and out the urostomy into a plastic bag which is attached to your skin.

Who is an ideal candidate for Total Cystectomy?

If you have bladder cancer that has invaded the muscle layer and is locally invasive or if your cancer has come back after the initial treatment, then you are an ideal candidate for Total Cystectomy.

How do I prepare for Total Cystectomy?

Your surgical team will provide you with instructions about the care of the urostomy opening and the bag. Routine blood and urine analysis, CT of abdomen and chest x-ray will be requested by your physician on your pre-oparative consult. Inform your physician about your other health conditions and medications (including all the prescription, non-prescription medications, nutritional supplements i.e. vitamins, minerals and herbal products). Refrain from taking aspirin or Ibuprofen at least 2 weeks before Total Cystectomy. Stop smoking a few weeks before Total Cystectomy to prevent healing problems during recovery period. Do not eat or drink anything for at least 10 hours before the Total Cystectomy surgery. You will be instructed to be hospitalized the night before the surgery. You may be given an enema the night before to cleanse your bowel.

What does the procedure for Total Cystectomy involve?

Total Cystectomy is performed under general anesthesia and may take about 2 - 3 hours. An incision is made across the lower abdomen, the ureters are cut from the bladder, freeing it for removal. The bladder and associated organs i.e. prostate gland, seminal vesicles, vas deferens in men and the uterus, fallopian tubes, ovaries, and part of the vagina in women. A method of urinary diversion is created to remove the urine (as discussed above) after Total Cystectomy. The tissues and nerves around the prostate and bladder are dissected very carefully to ensure not to damage them (nerve sparing technique) during Total Cystectomy procedure. However, the nerves controlling erection of penis may be damaged during the surgery. In women, your surgeon will reconstruct your vagina after Total Cystectomy.

What is the recovery period like following Total Cystectomy?

Total Cystectomy entails surgery to the bladder as well as the bowel. You will spend the next couple of days in the Intensive Care Unit (ICU) under observation following Total Cystectomy. Your vital signs, circulation and respiration will be closely monitored. You will also be closely monitored for any immediate post-operative complications like excessive bleeding. There may be a stoma bag collecting urine that will need to be cared for. You will notice thin tubes coming out of the urostomy. These are called stents. They will be removed 7-10 days after your Total Cystectomy operation. There will also be a small plastic drain tube from your abdomen that will stay in place for about 5-7 days. You will experience some pain and discomfort which can be alleviated by the use of pain medication. Keep the operation area clean, avoid heavy lifting and sexual activity for 3 - 4 weeks. You will be able to get back to your normal activities in 2 months time following Total Cystectomy. You will probably be hospitalized for 8 - 10 days after Total Cystectomy procedure. Before going home you will be provided with a follow up regimen that will comprise of Cystoscopy and urinary exams every 3 months for at least 2 years, with regular CT scans of the pelvis and abdomen.

What is the outcome of Total Cystectomy?

The 5 year survival rate for people who have bladder cancer is 75%. Adjuvant therapy may be needed following a Total Cystectomy which may include radiation therapy, chemotherapy or biological therapy (immunotherapy).

B . R . A . N . D . of Total Cystectomy

Benefits of Total Cystectomy

The 5 year survival rate after Total Cystectomy, for people who have bladder cancer is 75%.

Risks of Total Cystectomy

• Bowel obstruction
• Perforation of bowel with peritonitis
• Injury to urethra and / or rectum
• Erectile dysfunction
• Alternatives to Total Cystectomy

Partial or Segmental Cystectomy

• Radiation therapy
• Chemotherapy

Now or Never

With improvements in surgical technique and instruments, the evolution of intensive care medicine, and the availability of new antibiotics, Total Cystectomy now is a relatively common procedure in most major medical centers.

Decision to have Total Cystectomy

With the advent of advanced techniques and equipment, surgical resection of bladder tumour via Total Cystectomy remains standard treatment for optimizing curative potential and minimizing the risk of recurrence.

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