Radical cystectomy

***What is involved in the* radical cystectomy *procedure?***

The urinary bladder is a hollow organ situated in the pelvic region that stores urine produced by the kidneys before its eventual expulsion from the body. Its elastic walls allow for expansion as urine accumulates, triggering the sensation of needing to urinate—the detrusor muscle, lining the bladder, contracts during voiding to expel urine through the urethra. Proper bladder function is crucial for maintaining urinary continence and overall renal health.
Radical cystectomy is the gold standard for treating muscle-invasive bladder cancers and certain superficial bladder cancers resistant to initial treatments like TURBT and intravesical therapies. This extensive surgery, ranging from 3 to 6 hours, requires a hospital stay of 1-2 weeks. The procedure involves the removal of the bladder, including the prostate in men and the uterus with a portion of the vagina in women. To reconstruct the urinary tract, a disconnected segment of the small bowel is employed to redirect urine either to the skin via a 'stoma' or back through the urethra. Different reconstruction methods are tailored to individual patient needs, considering factors such as cancer extent, overall health, and patient preferences.

Neoadjuvant chemotherapy, administered before surgery, has shown promising results in improving survival rates for certain patients undergoing radical cystectomy. Studies indicate a potential 8% enhancement in survival for those who receive this preoperative chemotherapy. This underscores the importance of a comprehensive approach to bladder cancer management, aiming to maximize therapeutic outcomes. Following radical cystectomy, regular postoperative monitoring becomes crucial for ongoing patient care and ensuring the best possible quality of life.

***Radical csytectomy***

***In men, this typically involves the removal of the bladder, prostate, and local lymph glands.***
***In women, it generally involves removing the uterus (womb), ovaries, upper vagina, and local lymph glands.***

Radical cystectomy main points

The objective of cystectomy is to achieve the removal of the bladder and the contained cancer and the surrounding lymph nodes.

In men, this typically involves the removal of the bladder, prostate, and local lymph glands to maximize cancer removal.
In women, generally involves removing the uterus (womb), ovaries, upper vagina, and local lymph glands to maximize cancer removal.
Following the removal of the bladder, urine diversion onto the abdominal wall is carried out using an isolated section of the bowel as a urostomy (ileal conduit).
In selected cases, a reservoir for urine is constructed from a section of the bowel connected to the urethra to form a "neobladder."
This procedure can be performed through an open or keyhole approach, often with robotic assistance.
Regardless of the approach, radical cystectomy is linked to notable morbidity, with the majority comprising minor complications; however, a small proportion of patients may encounter significant complications associated with the surgery.
Patients are often required to undergo 3-4 cycles of chemotherapy before their surgery (neoadjuvant chemotherapy).

surgery

What occurs on the day of the procedure?

A/Prof Homi Zargar will discuss the surgery once again to ensure your understanding and obtain your consent. An anaesthetist will meet with you to explore the options of a general or spinal anaesthetic and discuss post-procedure pain relief.

Details of the procedure:

General anaesthesia is utilized for the procedure.
An epidural or spinal anaesthetic may be employed by your anaesthetist to minimize post-operative pain.
Prior to the procedure, you typically receive an antibiotic injection after allergy checks.
The procedure is commonly performed through a lower abdominal incision or a laparoscopic (keyhole) approach, with robotic assistance.
In men removal involves the bladder, prostate, seminal vesicles, and, if necessary, the urethra.
Preservation of erection-controlling nerves may be attempted, but success varies and should be discussed with your urologist.
In women, the bladder, uterus, the upper part of the vagina, and maybe both ovaries will be removed.
Attempting to preserve nerves controlling sexual function may be possible, but success varies; discuss with your urologist beforehand.
The ureters are stitched to a section of small bowel, creating a urostomy (usually an ileal conduit).
Re-joining the ends of the small bowel is part of the procedure.
Closure of the wound is done with stitches or staples.
Drains are typically placed, and small splints in the ureters protrude from the urostomy.
A drainage bag is attached to the urostomy.
The procedure duration ranges from two to six hours, dependent on complexity and approach (open or keyhole).
Hospitalization typically lasts seven to 10 days.

After-Effects and Risks of the Procedure:

In men, inability to ejaculate (or father children) due to the removal of the sperm-carrying mechanism - Almost all patients
In men, there is an inability to get an erection (impotence) in almost all patients (unless nerves are preserved)
In women, discomfort or difficulty with sexual intercourse due to narrowing or shortening of your vagina - Almost all patients
In women, menopausal symptoms if your ovaries are removed - Almost all patients
The possibility that cancer may not be cured by the procedure (discussed before the operation) - Between 1 in 2 & 1 in 10 patients
The need for a blood transfusion - Between 1 in 2 & 1 in 10 patients
Paralytic ileus causing nausea, bloating, and vomiting, requiring an IV drip and a stomach drainage tube - Between 1 in 2 & 1 in 10 patients
Anaesthetic or cardiovascular problems possibly requiring intensive care - Between 1 in 10 & 1 in 50 patients (individual risk estimated by the anaesthetist)
Wound infection or an abscess in the abdominal cavity - Between 1 in 10 & 1 in 50 patients
Decrease in kidney function over time - Between 1 in 10 & 1 in 50 patients
The need to abandon a keyhole procedure and convert to open surgery due to operative difficulties - Between 1 in 10 & 1 in 50 patients
The risk of late stricturing (scarring) of the bowel or ureters requiring further surgery - Between 1 in 50 & 1 in 250 patients
Rectal injury at the time of surgery requiring a temporary colostomy (bowel opening on your abdomen) - Between 1 in 50 & 1 in 250 patients

Options for urinary diversion

Following cystectomy, patients have several options for urinary diversion, which involves rerouting urine after bladder removal. One common method is an ileal conduit, where a section of the small bowel is used to create a stoma on the abdominal wall for urine drainage. Another approach is the creation of a neobladder, constructing a reservoir from the small bowel connected to the urethra, allowing for a more natural voiding. A third, less common option is a continent cutaneous diversion involving the formation of a pouch from bowel segments, allowing intermittent catheterization for urine removal. It's important to note that experience with this option is limited compared to the other methods, and its use is not as widespread. The choice of diversion method depends on factors like patient preference, overall health, and the extent of cancer involvement. Comprehensive discussions with healthcare providers help determine the most suitable option for individual needs.

Neo-bladder creation follows cystectomy and encompasses the process of...

**Formation of neo-bladder**

Neo-bladder formation can be done in men and women

Stitching ureters to separated small bowel: In neo-bladder diversion, the ureters, responsible for draining urine from the kidneys to the bladder, are attached to a distinct section of the small bowel.

Creating a bladder substitute: The separated small bowel is shaped into a bladder substitute during the neo-bladder procedure.
Joining bladder substitute to the urethra: The bladder substitute is connected to the urethra, establishing a reconstructed urinary pathway (as shown in pictures).
Reconnecting small bowel ends: The ends of the small bowel used in forming the urostomy are reattached during the final steps of the neo-bladder urinary diversion.