The bladder is a muscular sac in the pelvis, about the size of a pear when empty with a capacity somewhere between 400 and 600ml when full. It receives urine from the kidneys and stores it for excretion.
Aside from cancer, a cystectomy may also be required to treat injuries to the bladder, neurological conditions affecting the urinary system and birth defects that affect the urinary system.
Partial cystectomy removes only the areas of the bladder where cancer is found. This allows for the remainder of the bladder to be preserved.
Radical cystectomy involves removal of the entire bladder, nearby lymph nodes, part of the urethra and any other nearby tissue that may contain cancer cells. This is the most common operation for muscle-invasive bladder cancer. In men, the prostate, urethra and seminal vesicles may also be removed. In women, the urethra, uterus, ovaries, fallopian tubes and a portion of the vagina may also be removed.
Cystectomy is performed with the patient under general anaesthesia. The procedure is executed either as open surgery, laparoscopically or robotically.
The procedure can be performed using open surgery where a single incision is made to access the bladder.
Laparoscopy uses three or four small abdominal incisions and fibre-optic technology to operate and is far less invasive than open surgery. As such, the recovery time is much quicker. The bladder is detached internally, then removed through one of the incisions.
Robotic surgery is also minimally invasive. Robotic-assisted instruments are inserted through the incisions and controlled by a surgeon. This allows for far more precise movement of the surgeon’s hands meaning it is an even less invasive procedure overall.
If the bladder is removed entirely, the urinary tract will need to be reconstructed in order for proper urinary function to return. This may involve a number of procedures:
Orthotopic continent urinary diversion – a piece of the intestine is used to create a tube that runs from the kidneys to a small reservoir which is connected to the urethra. This allows close to normal urinary function.
Urinary conduit (urostomy) – a piece of the intestine is used to create a tube that runs from the kidneys to the abdominal wall. A bag worn on the abdomen is used to collect the urine.
The reconstructive procedure used will depend on a few factors including the reason for surgery, your health, and your personal preferences.
Radical cystectomy can involve some complications. Short term problems may include bowel obstruction or kidney infection. Long term complications include kidney problems (such as renal failure), abdominal obstructions, issues with the reconstructed urinary tract, or scar tissue forming in the intestine.
Other side effects may include infertility (if a woman’s uterus or ovaries, or a man’s prostate gland is removed during the surgery), erectile dysfunction and premature menopause.
Following the procedure, patients are taken to recovery and monitored closely. Most patients will be required to stay in hospital for more than 5 days where they will be given pain medication, injections to reduce the risk of clots as well as intensive physiotherapy.
Once stable, patients can drink liquids. This will progress to a more advanced diet as their condition improves. Patients are encouraged to begin walking a soon as possible to help prevent complications.
Once home, patients are encouraged to stay active, although strenuous exercise, heavy lifting or excessive stair climbing is not recommended for at least 6 weeks. Driving is discouraged for 3-4 weeks after surgery.
Dr Arianayagam is an expert in robotic surgery and performs all radical cystectomies with the da Vinci robot. He performs the urinary diversion (conduit or neobladder) inside the body (intracorporeal).
Robotic cystectomy may hasten recovery and shorten hospital stay. It may also improve return of sexual function. Robotic cystectomy is associated with reduced blood loss as well. Patients may have their robotic cystectomy performed at either Nepean public hospital or Macquarie University Hospital.
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