A cystectomy is a surgical procedure to remove the bladder.Appointment can be done in whole (radical) or in part. This procedure is often done to treat advanced bladder cancer.
The bladder is an organ that holds urine in the body before it is finally excreted. A cystectomy is generally performed if the cancer has grown to reach the muscle layer of the bladder. However, this procedure can also be done to treat other conditions that affect the bladder and urinary system.
Cystectomy or cystectomy consists of two types, namely:
Partial cystectomy
A partial cystectomy is performed by removing part of the bladder and repairing the other half. In this procedure, lymph nodes near the tumor will also be removed to check for cancer spread outside the bladder.
Radical cystectomy
A radical cystectomy is performed by removing the entire bladder and some of the surrounding lymph nodes. In men, this surgery also includes cutting the sperm-carrying ducts (vas deferens) and removing the prostate and seminal vesicles.
For women, the doctor will also remove the uterus, cervix, fallopian tubes, ovaries, and sometimes part of the vaginal wall.
Indications and contraindications for cystectomy
A cystectomy may be performed to treat the following conditions:
- Bladder cancer or cancer around the bladder that progresses to the bladder
- Birth defects that affect the urinary system
- Nerve disorders affecting the urinary system
- Bladder inflammation (cystitis) which causes severe damage to the bladder
The type of cystectomy performed depends on the underlying disease, the patient's medical condition, and the patient's preferences.
Partial cystectomy
Partial cystectomy may be performed in patients with the following conditions:
- Advanced cancer that is only located in one place
- Cancer is located far from important structures
- Cancer has not spread to the bladder neck or prostate
- Cancer has not spread (metastasized) to parts of the body far from the bladder
- Bladder function is still quite good after surgery
- Never had radiation therapy
Radical cystectomy
Radical cystectomy should be performed under the following conditions:
- The cancer experienced is a type of squamous cell carcinoma (SCC), sarcoma, or adenocarcinoma
- Cancer has grown to most of the muscle layer of the bladder, with or without spread to other parts of the body
- The cancer has spread to the prostate
- Cancer has metastasized
- Cancer cannot be treated with other procedures, such as chemotherapy or immunotherapy
- Cancer causes pain, blood in the urine (hematuria), or significant difficulty urinating
- Cancer comes back even though it has been done transurethral resection of bladder tumor (TURBT) or other treatment methods.
Please note, radical cystectomy is not intended for elderly patients. This procedure also can not be done if the spread of cancer is too severe and the risk of bleeding is very high.
Cystectomy Warning
A cystectomy can cause considerable changes to your daily routine, especially if a radical cystectomy is being performed. Therefore, it is important for patients to understand the benefits and risks of this surgery, as well as what changes need to be anticipated.
Patients who have undergone radical cystectomy cannot have children in the future. Therefore, the decision to undergo this surgery needs to be discussed with the doctor with your partner and family.
If a bladder cancer patient is still planning to have children, ask your doctor about options other than radical cystectomy that are still possible and safe to do.
Before Cystectomy
Before undergoing a cystectomy, patients need to do a consultation, regarding the conditions that may be experienced after undergoing this procedure. In addition, there are preparations that patients need to do before surgery, including:
- Tell the doctor about the drugs that are being taken, because the doctor may ask the patient to change or stop taking certain drugs
- Quit smoking, because smoking can increase the risk of side effects after cystectomy
- Undergo several supporting tests, such as blood tests or scans with X-rays or CT Scans, in preparation for surgery
- Prepare a companion who can help while in the hospital and take the patient home, because the patient will be prohibited from driving a vehicle after surgery
Cystectomy Procedure
A cystectomy generally lasts 4–6 hours. To start the cystectomy procedure, the nurse will attach an IV tube to the patient. The nurse will also give you medication to relieve pain and nausea, which may appear during and after the operation.
After that, the patient's body will be connected to the monitor screen. The patient will also be given blood-thinning medication to prevent blood clots, and antibiotics to prevent infection. Next, the nurse will give general anesthesia, so that the patient sleeps during the procedure.
The cystectomy procedure can be performed by two surgical methods. Here is the explanation:
Open cystectomy
An open cystectomy is performed by making one long incision in the abdomen. The doctor's hand will then go into the abdominal cavity to perform a bladder removal procedure.
Minimally invasive cystectomy
Minimally invasive cystectomy is performed with the help of a laparoscope or robot. The operation begins by making several small incisions in the abdomen. Through one of these incisions, the doctor will insert carbon dioxide to inflate the stomach. This aims to make it easier for doctors to see the condition in the stomach.
Through another incision, the doctor will insert a laparoscope tube equipped with a camera and some special surgical instruments. The surgical instrument can be controlled directly using the doctor's hand or connected to a surgical robot that can move more accurately.
After the cystectomy is complete, the doctor will recreate a new urinary tract, as a way out of urine from the body. The creation of a new urinary tract can be done in three ways, namely:
ileal channel
The ileal tract is created by cutting a portion of the small intestine. This piece will then be connected to the ureter, which is the tube that carries urine from the kidneys to the bladder. The other end of the piece of small intestine will then be attached to an opening in the skin (stoma), which is usually made on the right side of the abdomen near the belly button.
At the stoma, a bag will be attached to accommodate urine that comes out of the body. The collected urine can be discarded when the bag is full.
Urine container in the stomach
The doctor will make a new urine container using a piece of intestine with a larger size. The container will be connected to the ureter and placed in the abdomen, to collect urine.
After that, the other end of the container will be attached to the valve stoma on the skin of the abdomen. The valve will hold the urine in the container so it doesn't come out. However, this valve can be inserted a small tube (catheter), so that urine can be passed periodically.
New bladder reconstructionneobladder)
New bladder reconstructionneobladder) is done by making a new urine container in the body, using a piece of the small intestine that is quite long. The new container is created where the bladder was originally located.
One end of the piece of intestine will then be attached to the ureter, while the other end is attached to the urethra, the tube that carries urine from the bladder out of the body.
Patients who have undergone a new bladder reconstruction, will not feel the urge to urinate. Therefore, the schedule of urination must be determined.
Urine can be expelled from the container normally, namely by relaxing the pelvic muscles and tightening the abdominal muscles. Sometimes, however, patients need to use a catheter to drain urine.
Please note, some patients may also experience an inability to control the flow of urine (urinary incontinence) after undergoing this procedure.
After Cystectomy
After awakening and his condition has stabilized, the patient will be taken to the recovery room to rest for a few hours. After that, the patient will be taken to the inpatient room. The patient should stay in the hospital for 5–6 days, usually until the intestines can function normally to absorb fluids and nutrients.
The day after the procedure is complete, the patient will be advised to get up and walk frequently. This is useful for accelerating the healing process and restoring intestinal function, increasing blood circulation, and preventing muscle cramps and blood clots.
Pain may appear around the incision for several weeks. However, the pain will gradually subside as the healing process progresses.
Patients also need follow-up care in the first week after the cystectomy, and several months afterward. During this session, the doctor will conduct an examination to ensure that urine is draining out of the urinary tract properly, and that the patient does not have electrolyte disturbances.
If a cystectomy is performed to treat bladder cancer, the patient will also be advised to have regular check-ups with the doctor. This is to make sure the cancer doesn't come back.
In addition to the above, patients will also experience several changes after surgery, including:
Changes in urination
If the bladder is replaced with an ileal canal or a urine container in the abdomen, the patient will still experience discharge from the surgery for 6–8 weeks. The liquid will usually gradually change color from red, pink, brown, to yellow.
Meanwhile, in patients undergoing reconstruction of a new bladder, the urine that comes out can be mixed with blood. But in a few weeks, the color of urine will return to normal.
A bladder replacement procedure after a cystectomy will also cause urine to mix with mucus. This happens because the part of the intestine that is used instead of the bladder does normally produce mucus. Over time, mucus production will decrease, although it will still be present.
Changes in daily activities
For 6–8 weeks after surgery, patients may need to limit activities, such as lifting weights, driving, bathing, and going to school or work. The patient may also need to stop sexual activity for a while, so that the healing process can run well, until the patient's condition improves periodically.
Although a cystectomy can affect daily activities, patients are generally able to lead a normal life. Patients with ileal tract may have to get used to always carry a urine bag on their stomach at all times. However, most patients will quickly get used to this.
In patients who underwent neobladderIt is important to follow the doctor's advice regarding the urine disposal schedule, which is a maximum of every 4 hours. Therefore, the patient should make a schedule to urinate every day. This is to prevent neobladder become too large and difficult to empty.
Changes in sexual activity
Patients will also experience changes in sexual intercourse. In male patients, nerve damage that may occur during surgery can affect the ability to get an erection. But generally, the condition improves on its own over time.
Male patients will still be able to orgasm as usual. But keep in mind, patients who undergo radical cystectomy will lose the ability to ejaculate, secrete semen and produce sperm. In other words, the patient will no longer be able to have children after the operation.
For female patients, changes to the vagina after surgery can make sex less comfortable. Nerve damage can also affect arousal and the ability to reach orgasm. In patients undergoing radical cystectomy, the ovaries will also be removed, so the patient cannot have children.
For patients who use a stoma, sexual intercourse can still be done and will not cause pain in the stoma. To prevent leakage of the stoma, it is recommended to empty the stoma before having sex. The patient can also use protection, such as a pouch cover, to keep the stoma secure.
Cystectomy Side Effects
A cystectomy is a procedure that requires many changes to the internal organs in the abdomen, so it is quite complicated to perform. As a result, it is possible to have side effects, which include:
- Bleeding
- Blood clotting
- Heart attack
- Infection
- Pneumonia
The above side effects can be prevented, by doing thorough preparation before surgery.
Cystectomy also causes changes in the urinary bladder and small intestine, which can cause other side effects such as:
- Dehydration
- Electrolyte balance disorders
- Urinary tract infection
- A blockage that keeps food or fluids from passing through the intestines (bowel obstruction)
- Blockage of one of the urinary tracts from the kidney (blockage of the ureter)
