Cystectomy & Urinary Diversion
Figure 1: Bladder removal (radical cystectomy) and ileal conduit urinary diversion.
What are the indications for a radical cystectomy and urinary diversion?
Radical cystectomy and urinary diversion can be needed for a range of problems including:
Muscle-invasive bladder cancer.
Non-muscle invasive bladder cancer that has progressed despite intravesical treatments or where pathology shows very aggressive cancer
To control significant bleeding from large bladder cancer tumours
Occasionally for severe non-cancerous inflammatory bladder conditions
What pre-operative work up is needed?
Your urologist will organise any necessary urine and blood tests and imaging scans at your consultation prior to your procedure. You will need CT scans of your chest and abdomen. You may need special tests and scans to assess your fitness for surgery.
If you take any blood thinning medication such as aspirin, plavix (clopidogrel), warfarin or other anticoagulants, you should discuss with your urologist if these need to be stopped before your procedure.
You will also see a stomal therapist who will discuss stoma care with you and mark the stoma site. You will also see a bladder cancer specialist nurse to discuss aspects of your care. You will meet an anaesthetist to discuss aspects of your care pertaining the anaesthetic and pain control after the operation.
Please ensure you return any admission forms given to you to be filled out back to the hospital.
What happens on the day of the procedure?
You will generally be admitted to hospital the day prior to your surgery. You should have a low residue (low fibre) diet for 72 hours prior to your procedures (avoid high fibre cereals, bran, whole grains, fruits, seeds, nuts and raw foods and vegetables and cheese).
You will be given fasting instructions prior to your admission (avoid food for 6 hours prior to the procedure but water is ok until 2 hours prior). You should bring a list of your medications, any recent scans or reports with you to the hospital.
After you are admitted, your urologist will see you to discuss the surgery. An anaesthetist will see you to discuss the general anaesthetic and pain relief options such as spinal anaesthetic, patient controlled anaesthesia, wound catheters as well as oral mediations before you are taken to the operation theatre.
You will be provided with a pair of TED stockings to wear to prevent blood clots from developing and passing into your lungs. You may be given injections (e.g. heparin injection) to thin your blood to reduce risk of blood clots from developing. You may be administered laxatives to clear your bowel. If your iron levels are low, you may be given an iron infusion.
What does this procedure involve?
Figure 2: Ileal conduit urostomy.
Radical cystectomy involves removal of your bladder, prostate (men), uterus / ovaries (female) and local lymph nodes. The urine is then diverted into a section of bowel, which is brought to the skin surface as a stoma (ileal conduit, also known as a urostomy).
After a general anaesthetic and epidural or spinal anaesthetic to minimise any post-operative pain you will usually be given an injection of antibiotics before the procedure. Surgery will be performed through a midline incision in your lower abdomen. In men, the bladder, prostate, seminal vesicles (sperm sacs) and, if necessary, the urethra (waterpipe) will be removed. In women, the bladder, uterus, ovaries and the urethra (waterpipe) are removed.
The ureters (the tubes which drain urine from the kidneys to the bladder) will be stitched to a separated piece of small bowel and this will be brought out on the surface of the abdomen as a urostomy (ileal conduit). The two ends of the small bowel from which the urostomy has been made are re-joined.
The wound is closed with staples. One or more drain tube will be placed to remove any excess fluid. The procedure takes approximately 4 – 6 hours and you should expect to be in hospital for 7 to 14 days.
You will be encouraged you to get up and about as soon as possible to reduce risk of blood clots and help your bowel to start working again. You will sit out in a chair the day after the procedure and you will be shown deep breathing/leg exercises to do. We will encourage you to start drinking and eating as soon as possible. We normally remove your drains when they have stopped draining. You or a family member will be taught to inject you with a blood thinning medication, which you will take for 4 weeks from your procedure date.
The stomal therapist will ensure you are confident in managing your urostomy and bag changes.
Are there any risks or side-effects?
Pain at the operative site 50-100%
Infection in your wound or an abscess in your abdominal cavity 5-10%
Significant bleeding needing a blood transfusion 5-10%
Paralytic ileus (failure of your bowel to work) for several days causing nausea, bloating & vomiting, and requiring an intravenous drip and stomach drainage tube through your nose until it recovers
Need for return to theatre for re-operation due to bleeding, bowel leakage, urine leakage or bowel obstruction 5-10%
Hernia of the incision requiring further surgical repair 5-10%
Scarring, narrowing or hernia formation around your urostomy requiring revision 5-10%
Inability to ejaculate (or father children) because your sperm-carrying mechanism has been removed 100%
Inability to get an erection (impotence) 50-100%
Decrease in kidney function over time 20-30%
Diarrhoea/vitamin deficiency due to shortened bowel requiring specific dietary supplements or other treatment 5-10%
Rectal injury at the time of surgery requiring a temporary colostomy (bowel opening on your abdomen) 2-3%
Death within 90 days of surgery 3%
Anaesthetic or cardiovascular problems possibly requiring intensive care (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack) 10%
What can I expect after discharge when I get home?
You will be sent home with blood thinning injections and antibiotics. By the time you get home, you should be able to perform daily activities and manage your stoma bag. You will feel tired for several weeks. You should not engage in strenuous physical activity or driving for 6 weeks at least.
Your wound clips and the urostomy stents will be removed 14 days after the procedure.
If you have a fever, feel unwell, have unexpected abdominal pain, or start vomiting, you should contact your GP or come to the ED immediately
What follow-up will I need?
A follow-up appointment will be made for you 4 weeks after your surgery. You will need follow-up periodically with blood tests and CT scans for at least 5 years with your urologist. This is to ensure that any signs of the cancer returning are identified and treated in time. You need a camera check of your urethra / waterpipe (if it hasn’t been removed) once a year. In the long term, you will need get blood tests to check for nutritional deficiencies (Iron, Vit B12) yearly with your GP.