Cystectomy with Diversion
Types of bladder cancer surgery
Your healthcare provider will use the stage of your cancer to help decide the type of surgery you should have. There are several types of surgery for bladder cancer.
This surgery may be done if your cancer has a grade higher than II. Or it may be done if your cancer has spread to tissue beneath lining of the bladder, but is small and only in one place. In this case, only the part of the bladder with the cancer is removed.
This type of surgery is not often possible. But you may have it if a small tumor has invaded the muscle layer of your bladder, and the cancer is only in one place.
You’ll receive general anesthesia. This puts you to sleep and keeps you from feeling pain. A cut (incision) is made in the skin of your lower abdomen. Then your healthcare provider takes out the cancer and nearby bladder wall. Your lymph nodes may be removed, too. In some cases, this surgery is done through small cuts instead of one big one. A long, thin tube with camera (laparoscope) is put in one cut. Then your healthcare provider puts special tools in the other cuts to do the surgery. This is called laparoscopic surgery. After the cancer is removed, your healthcare provider will close the hole in your bladder wall with stitches. After healing, the bladder works like it did before surgery. But the bladder is smaller, so it may not hold as much urine. A concern with this surgery is that the cancer may come back in another part of your bladder.
This means all of your bladder is taken out during surgery. You may need this if your cancer has a grade higher than II or has spread to tissue beneath lining of the bladder, and is large or in more than one part of the bladder. When all the bladder is removed, you’ll need reconstructive surgeryto create a new path for urine to leave your body. You’ll only have one surgery at one time.
In men, the prostate gland and seminal vesicles are also removed. This is because the cancer can come back in these areas. In women, the uterus, fallopian tubes, ovaries, cervix, and the top of the vagina may need to be removed. Your healthcare provider will talk to you about which organs may need to be taken out. He or she will also talk to you about side effects.
You’ll stay in the hospital for about a week for this surgery. In the operating room, you’ll receive general anesthesia. This puts you to sleep and keeps you from feeling pain. A cut will be made in your lower abdomen. In some cases, the surgery may be done laparoscopically. Your surgeon must create a new way for urine to leave your body. So, right after radical cystectomy, you’ll have bladder reconstruction.
Reconstructive bladder surgery
There are many ways to rebuild a "bladder" after it’s been removed to treat cancer. Urine made by your kidneys will need to be stored and moved out of your body in a new way. This is called reconstructive surgery. Your surgeon does reconstructive surgery at the same time that you have your bladder removed. There are 2 main types of reconstructive surgery.
Incontinent urinary diversion
This is also called an urostomy. After this type of surgery, you no longer urinate the way you once did. You’ll wear a bag on the outside of your body to collect urine.
Continent urinary diversion
This surgery creates a new bladder for you. This way, you can control when the urine leaves your body and do not have to wear a bag. There are 2 main types of this surgery. One type is cutaneous continent diversion. This requires that urine be drained though a hole in your abdomen. This is called a stoma. This is done with a catheter, several times a day. The other type is orthotopic neobladder. This is the creation of a new bladder that’s emptied through your urethra the same way you did before surgery.
Incontinent urinary diversion or urostomy
This procedure is also called an ileal conduit. To do it, your healthcare provider makes a pouch out of a small piece of your intestine. Then, he or she connects it to your ureters. These are the tubes carrying urine out of your kidneys. The opening of the pouch is connected with your skin to direct urine through a stoma. Urine passes out of the opening into a plastic bag that’s attached to your skin. You then empty urine from the bag several times a day.
After the operation, urine will constantly flow through the ileal conduit into the external pouch. Right after surgery, a drainage tube from the ileal conduit will come out through stoma. This tube may be in place for 2 to 3 weeks after surgery. Your surgeon may take X-rays to check how well your bladder has healed. He or she will also make sure there isn't leakage before taking out the drainage tube.
Once the tube is removed, you'll use an adhesive patch to hold a plastic pouch to your skin over the stoma. When the pouch is full, you empty the urine through a valve at the bottom of it. You’ll need to change the pouch every 3 to 5 days. A special nurse (enterostomal nurse) will help watch your care when you've had a urostomy. The nurse will teach you how to keep the urine bag, catheter, or abdominal opening clean. The nurse will also give you advice on lifestyle issues, such as having sex or cleaning your urine bag at work.
Continent urinary diversion
During surgery, your healthcare provider takes a piece of your intestine and connects it to your ureters. This is done to make a new path for your urine to flow. The pouch made from the intestine is directed to a stoma. Your surgeon then creates a one-way valve that allows you to drain the pouch several times a day. You do this by inserting a catheter through the stoma. The catheter drains urine out of the pouch into a container. You can then dispose of the urine in the toilet. Many people prefer this approach because they don't need to wear a urine collection bag on the outside of their body.
After the operation, urine will flow through the ureters into the pouch inside your body. The pouch will hold about a pint of urine a few months after the operation, but will hold more urine as time goes by. You’ll learn to recognize the sensation when the pouch is getting full of urine. Then you’ll pass a catheter into the stoma to let the urine out. For a few weeks after the surgery, you'll likely need to drain the pouch every few hours. As the pouch stretches, you will probably empty it every 4 to 6 hours.
An enterostomal nurse will help teach you how to care for the stoma and use a catheter to get the urine out. The nurse will also give you advice on lifestyle issues, such as having sex or emptying your diversion at work.
This surgery may also be called orthotopic continent urinary reconstruction. You can only have it if your urethra was not removed during the surgery.
Your surgeon takes out a piece of your intestine and creates a pouch to hold urine. The pouch is called a neobladder or new bladder. It’s attached directly to your ureters and to your urethra. With this approach, you can pass urine through your urethra, just as you did before the surgery. Compared with other reconstructive surgeries, this type is most like your normal urinary system. Many people who have a neobladder say they feel the same urge to urinate as they did before surgery. It may take you awhile, though, to learn the sensations that mean you need to urinate. Right after surgery, you’ll have a catheter to drain out urine as your body heals. Urine control does not come right away after your catheter is taken out. You’ll learn the routine you should follow to help train your new bladder.
The ability to control urination during the day is better than 90% with a neobladder. Your ability to control urine flow at night may not be quite as good, especially in the first 6 to 9 months after surgery. You may be able to manage the problem by drinking less before bedtime. Men may also want to talk with their healthcare providers about a condom catheter. This attaches to the penis like a condom and connects to a tube that collects urine in a bag.
Recovering at home
Make sure you know how to take care of yourself after surgery and are able to manage the way you have to get urine out of your body. Also be sure you have supplies and know where to get more. It may help to have someone learn along with you, so you have a helper and support person at home.
When you get home, you may get back to light activity. But you should avoid strenuous activity for 6 weeks. Your healthcare team will tell you what kinds of activities are safe for you while you heal.
When to call your healthcare provider
Let your healthcare provider know right away if you have any of these problems after surgery:
- Redness, swelling, or fluid leaking from the incision site
- Irritation, redness, or swelling around the stoma
- Damage or injury to the stoma
- A blockage of urine flow
The physical and emotional changes from your cancer surgery may be significant. Ask your healthcare team for resources that will help you and your family manage the physical effects of cancer treatment, and also the mental and emotional changes.