Cystectomy

Cystectomy is a major surgical procedure to remove part or all of the urinary bladder. It is most often performed to treat bladder cancer that has spread into the bladder wall or is high-grade. Sometimes, it is also done for severe non-cancerous bladder conditions. This surgery usually involves creating a new way for urine to leave the body.

What is Cystectomy?

Cystectomy is a surgical operation that removes part or all of the urinary bladder, the organ that stores urine. The type of cystectomy depends on how much of the bladder needs to be removed. It is a significant surgery typically performed by trained surgeons to address serious bladder conditions.

There are two main types of cystectomy. A partial cystectomy removes only a portion of the bladder. This is an option if cancer is small and has not spread deeply into the bladder wall. The remaining part of the bladder can still store urine. A radical cystectomy involves removing the entire bladder. In men, this usually includes the prostate and seminal vesicles. In women, it often involves removing the uterus, ovaries, fallopian tubes, and part of the vagina. Because the entire bladder is removed, surgeons must create a new way for urine to exit the body, known as urinary diversion. This is a complex procedure requiring careful planning and execution by a surgical team (MedlinePlus, Mayo Clinic).

Why it's done

Cystectomy is primarily performed to treat bladder cancer, especially when the cancer is aggressive or has invaded the muscle layer of the bladder. It may also be necessary for certain severe non-cancerous conditions that cause significant pain or dysfunction and have not responded to other treatments.

The most common reason for a cystectomy is bladder cancer. This surgery is often recommended for muscle-invasive bladder cancer, meaning the cancer has grown into the bladder's muscular wall. It may also be used for high-grade non-muscle-invasive bladder cancer that has recurred or is widespread, where other treatments have failed to control the disease (Mayo Clinic). Less commonly, a cystectomy may be performed for severe, non-cancerous conditions. These can include birth defects of the bladder, chronic inflammation of the bladder (interstitial cystitis) that causes debilitating pain, or severe damage to the bladder from radiation therapy or trauma. In these cases, the surgery is considered when all other treatment options have been exhausted and the patient's quality of life is severely impacted (MedlinePlus).

How to prepare

Preparing for a cystectomy involves several steps to ensure you are as healthy as possible for surgery and to minimize risks. This typically includes medical evaluations, reviewing your medications, and making specific lifestyle adjustments as advised by your healthcare team.

Before your cystectomy, your doctor will order various tests, such as blood tests, urine tests, and imaging scans (like CT scans or MRIs), to assess your overall health and the extent of your condition. You will also meet with your surgeon and anesthesiologist to discuss the procedure and anesthesia options. It is crucial to inform your medical team about all medications, supplements, and herbal remedies you are taking, as some may need to be stopped before surgery, especially blood thinners (Mayo Clinic). You will receive specific instructions regarding diet and fluid intake before surgery. This often includes a period of fasting, meaning no food or drink, for several hours prior to the procedure. You may also be asked to perform a bowel preparation, which involves taking laxatives or enemas to clear your bowels. If you smoke, your doctor will strongly advise you to stop, as smoking can increase surgical risks and slow healing (MedlinePlus).

What happens during

During a cystectomy, you will receive general anesthesia to ensure you are asleep and feel no pain. The surgeon will make an incision to access and remove the bladder, either partially or entirely. If the entire bladder is removed, a urinary diversion procedure will be performed to create a new way for urine to leave your body.

The surgery can be performed using different techniques. Traditional open surgery involves a single, larger incision in the abdomen. Minimally invasive approaches, such as laparoscopic or robotic-assisted surgery, use several small incisions and specialized instruments. These methods may result in less pain and a quicker recovery for some patients, but not everyone is a candidate for them (Mayo Clinic). If you undergo a radical cystectomy, a urinary diversion will be created. The most common type is an ileal conduit, where a small piece of your small intestine (ileum) is used to create a tube that carries urine from your kidneys to an opening (stoma) on your abdomen. A small bag (urostomy pouch) is worn outside the body to collect the urine. Other options include a neobladder, where a new bladder is created internally from a section of intestine and connected to the urethra, allowing you to urinate more naturally, or a continent cutaneous reservoir, where an internal pouch is created that you empty periodically with a catheter (MedlinePlus, Mayo Clinic).

Recovery & timeline

Recovery from a cystectomy is a gradual process that typically involves a hospital stay of several days to a week or more. You will experience pain, which will be managed with medication, and your activity will be restricted initially. Long-term recovery involves adjusting to any new urinary diversion and slowly returning to normal activities.

After surgery, you will spend time in a recovery room and then be moved to a hospital room. You will likely have several tubes, including catheters to drain urine and possibly drains to remove fluid from the surgical site. Pain management is a priority, and you will receive medication to control discomfort. Nurses will help you get out of bed and walk short distances soon after surgery to prevent complications like blood clots (MedlinePlus). The hospital stay typically lasts 5 to 10 days, but this can vary. Full recovery at home can take several weeks to a few months. You will have restrictions on lifting heavy objects and strenuous activities. If you have an ileal conduit, you will learn how to care for your stoma and change your urostomy pouch. If you have a neobladder, you will learn techniques to empty your new bladder. Regular follow-up appointments with your surgeon and other healthcare providers are essential during this period (Mayo Clinic).

Risks & side effects

Like any major surgery, cystectomy carries potential risks and side effects, including general surgical complications such as bleeding, infection, and adverse reactions to anesthesia. Specific risks relate to bladder removal and urinary diversion, such as damage to nearby organs, bowel problems, and long-term changes in urinary and sexual function.

General surgical risks include excessive bleeding, infection at the surgical site, and complications from anesthesia, such as heart attack or stroke. There is also a risk of blood clots forming in the legs (deep vein thrombosis) or lungs (pulmonary embolism) (Mayo Clinic). Specific risks associated with cystectomy and urinary diversion include injury to nearby organs like the intestines, kidneys, or nerves. Bowel problems, such as a blockage or leakage, can occur. For men, radical cystectomy often causes erectile dysfunction. For women, it can lead to vaginal shortening or dryness, affecting sexual function. Urinary leakage or difficulty emptying the new bladder can also be long-term issues, depending on the type of diversion (MedlinePlus). Over time, some people with urinary diversions may experience kidney problems or metabolic imbalances. It's important to discuss all potential risks and side effects with your surgeon before the procedure to understand them fully (Mayo Clinic).

Success rate

The success rate of a cystectomy depends heavily on the reason for the surgery. For bladder cancer, success is often measured by how effectively the cancer is removed and controlled, which varies significantly with the cancer's stage and type. For non-cancerous conditions, success is typically defined by the relief of severe symptoms and improved quality of life.

For bladder cancer, a radical cystectomy aims to remove all cancerous tissue and prevent recurrence. The success of this goal is highly dependent on the stage of the cancer at the time of surgery. For example, early-stage, muscle-invasive bladder cancer generally has a better prognosis than advanced-stage cancer that has spread beyond the bladder. Survival rates vary widely, and your oncology team can provide specific statistics based on your individual diagnosis (Cochrane Library, Mayo Clinic). For non-cancerous conditions, such as severe interstitial cystitis or radiation damage, success is measured by the improvement in debilitating symptoms like pain and urinary dysfunction. While the surgery can significantly improve quality of life for many, it does not always completely eliminate all symptoms for every individual. Long-term follow-up is crucial to monitor for complications and ensure the best possible outcome (MedlinePlus).

Frequently asked questions

Will I always need to wear a bag outside my body after a cystectomy?

Not necessarily. If you have a radical cystectomy, a urinary diversion is created. An ileal conduit requires a bag (urostomy pouch) worn outside the body. However, other options like a neobladder or a continent cutaneous reservoir allow urine to be stored internally, meaning you would not need an external bag.

How long does it take to recover from a cystectomy?

Recovery from a cystectomy is a gradual process. You will typically stay in the hospital for 5 to 10 days. Full recovery at home, including returning to normal activities and feeling your strength return, can take several weeks to a few months, depending on the type of surgery and your overall health.

Can I still have sex after a cystectomy?

Sexual function can be affected by a cystectomy, especially a radical cystectomy. In men, it often causes erectile dysfunction. In women, it can lead to vaginal shortening or dryness. However, many people can resume sexual activity, sometimes with the help of medications, devices, or counseling. Discuss your concerns with your healthcare team.

What are the long-term changes to my life after a cystectomy?

Long-term changes depend on the type of urinary diversion. If you have an external pouch, you will learn stoma care. If you have an internal neobladder, you will learn how to empty it. You may need to adjust your diet and fluid intake. Regular follow-up appointments are essential to monitor your health and the function of your urinary diversion.

Will I need more treatment after cystectomy for bladder cancer?

For bladder cancer, additional treatments after cystectomy, such as chemotherapy or radiation therapy, may be recommended. This depends on the stage and grade of the cancer, whether it has spread, and your overall health. Your oncology team will discuss a personalized treatment plan with you.

What is a urinary diversion?

A urinary diversion is a surgical procedure performed after a radical cystectomy to create a new way for urine to leave your body. Since the bladder is removed, a new pathway is needed. Common types include an ileal conduit (external bag), neobladder (internal, allows natural urination), or a continent cutaneous reservoir (internal, emptied with a catheter).

Sources

• MedlinePlus — Cystectomy
• Mayo Clinic — Cystectomy
• Cochrane Library — Cystectomy