Reviewed By : Dr. Aarti Joshi
Listed below is the step by step procedure of radical cystectomy:
- What is Radical Cystectomy?
- Why is Radical Cystectomy Required?
- Pre-operative Preparation
- Day Before Surgery
- Procedure Day
- Methods/Techniques of Radical Cystectomy Surgery
- Post Procedure
- Risks and Complications
What is Radical Cystectomy?
Also known as total cystectomy, this surgery is a medical solution for removal of urinary bladder in entirety. It is also a surgery that is used for treating bladder cancer patients and also people in whom the cancer has recurred. Surrounding organs may also be removed to prevent spread of cancerous cells to the remaining parts.
Why is Radical Cystectomy Required?
A radical cystectomy is recommended for:
- High risk bladder cancer: That means even though it is in an early stage, it has the possibility of being fatal.
- Invasive bladder cancer: Cancer that has spread from the origin to the whole of urethra and bladder.
- Locally advanced cancer: The scope of cancer is limited only to the organ that is the bladder, but nevertheless is still dangerous. It is also known as muscle invasive tumor.
- Recurrent cancer: Presence of high grade tumor that grows aggressively and whose scope is multifocal; meaning in multiple areas. Surgery is also required to treat cancer that has returned post chemotherapy cycles or related cancer treatment sessions.
- Blood tests: The doctor may ask you to undergo blood tests for knowing the status of various parameters like platelet count, hemoglobin etc.
- Urine analysis: Any abnormalities or infections in the urinary tract can be observed through the set of tests contained in urine analysis.
Along with the above mentioned tests, a CT scan
and chest X-ray
are also ordered. Results of these are taken into consideration before surgery is commenced.
Along with the above diagnostic tests, you also need to follow certain other precautions as mentioned below:
- Stop smoking in the weeks before surgery.
- Discuss whatever medication you currently are on with the doctor. He may ask you to discontinue blood thinners for the time being.
- Have a talk about your health history with the doctor, also for solving any surgical queries you may have.
- You need to tell the doctor if you have any artificial device implant such as pacemaker, coronary stent. Also, if you have undergone corneal transplant or knee joint replacement surgery, this needs to be intimated to the surgeon.
Day Before Surgery
- You will be asked to go off food and water at least 10 hours before the surgery day.
- You may be instructed to consume a high carbohydrate drink the night before and also the morning before. That is responsible for regulating intestinal function.
- On the day prior to surgery, you may also be given enema, that is an injectable drug for clearing the bowel well in advance of surgery.
- Firstly, the nurse makes a note of your breathing and pulse rate, blood pressure and body temperature.
- You have to change into a hospital gown.
- You are also asked to take off contact lenses, jewelry and accessories, make-up if you are wearing any.
- You will also have to sign a consent form suggesting that you know the surgery details and that your permission for undergoing it is given from your end.
- The skin that will be operated on is also shaved by a nurse prior to commencing surgery.
- A sedative is given to you an hour prior to surgery. Also, an intravenous line is attached to your body for giving fluids and preventing dehydration.
- Before shifting you into operation theater, a small tube is placed near your spine. This tube is used during and also after operation for passing on pain medication.
Methods/Techniques of Radical Cystectomy Surgery
A general anesthesia is administered to the patient before a radical cystectomy is performed. The ureters are cut through an incision that is made across the lower abdomen. In men, organs like prostate gland, seminal vesicles, vas deferens are also removed. Whereas in women the uterus, fallopian tubes, ovaries, and part of the vagina is removed.
In few cases, keyhole surgery is used for operating the patient. Specially designed instruments that can be inserted into the pelvis for inspecting it are used by surgeon. A keyhole surgery is known for the minimal discomfort and faster recovery for patient.
Reconstructive surgery for urinary passage is done post the above procedure. One method involves creating a passage way between intestine and ureter. The passage way facilitates urine to pass from kidneys and then out of the body. A small bag called a stoma bag is placed over the opening for collection of urine. The person cannot control the flow of urine when this method of reconstruction is used. Hence, it is known as incontinent diversion.
Alternatively, continent diversion is made use of when part or whole of the urethra is removed during your surgery. A pouch like structure made out of part of both small and large intestines is connected to the ureters. An opening is thus created on the abdominal wall. A catheter is then inserted into the opening for passage of urine.
A lot of care is exercised by operating team in order to not cause any damage to tissues and nerves that run around the prostate and bladder. The dissection is done very carefully during the radical cystectomy procedure. However, the nerves that run close to prostate are very much likely to get damaged during the surgery. Treatments for the same may be discussed with you before surgery. In women, the surgeon will perform vaginal reconstruction after total cystectomy by grafting the vaginal tube.
Post the surgery, you may be moved to the recovery area of the hospital. You may be moved to the intermediate dependency area if the doctors find any problems with surgery. Intravenous tubes are attached to your veins for administration of fluids and medicines.
Drinking and eating the normal way will happen in few days time. Vomiting can happen if consumption of food is done too early. Another drain is left in the body for draining out excess fluid from surgical site. In case of women, cotton gauze is left in the vagina to be taken out the day after surgery for preventing bleeding.
In the immediate 7-10 days in the hospital post surgery, you will be monitored carefully. In that period, you are either administered epidural injections or pain relief medication through a drip.
Dos and Don'ts after Radical Cystectomy Surgery
- Incision: Make sure to keep the incision area clean all the time. Do not rub it.
- Walking: Walking in the period post surgery is very important. Rest is also important, but getting walks throughout the day is important too. Make sure to increase the distance you cover every passing week.
- Be patient: Remember, the recovery is slow and eventual and not instant. The appetite and bowel movement return to normal with time.
- Heavy objects: You are advised not to lift any heavy objects in the first 6 weeks of recovery.
- Follow up: You will have to schedule follow up appointments that comprise usually of urinary examinations and CT scanning of pelvis and abdominal part. These appointments need to be planned every 3 months for next 2 years post surgery.
- External bag: An external bag is fitted under the patient's waist that connects to the stoma and collects the urine. It takes time for the patient to adjust carrying the bag and moving around. The stoma must be kept free of infections or getting blocked. Patients must be trained by nursing team to care for their stoma and keep it clean.
- Contact your surgeon if: Call the doctor soon if you notice high fever, swollen legs, chest pain, blooded urine, opened incisions, difficulty in breathing etc.
Risks And Complications
A radical cystectomy carries with itself few complications, as is the case with any other medical procedure. Few of them are mentioned below:
- Bowel function: The recovery of bowel function is slow and is not as fast as in any other procedure.
- Blood clots: Formation of blood clots in lungs or legs is a common occurrence.
- Infections: Infections or fluid coming out of incision made during surgery also happens post a cystectomy.
- Urinary incontinence: Involuntary leakage of stools or urine is a risk for patients undergoing radical cystectomy.
- Acidosis: Electrolytic imbalance because of intestine that was accessed for diverting urine from its original path is a short term complication that can be controlled through medication.
- Digestion problems: You may get diarrhea or constipation because of the strong medication used during surgery. However, the normal functioning of bowel returns in 6 weeks time.
Among other complications are bleeding, reactions to anesthesia, injuries to the rectum, bowel and joins that connect bowel and ureters.
- What are the benefits of radical cystectomy?
A. A radical cystectomy has several benefits like shorter hospital stay, smaller incisions and thus, very minimal scarring and blood loss. It also includes, a swifter recovery and resumption of routine activities of patient.
- What should the diet contain in recovery period post radical cystectomy?
A. Fluids are useful for keeping the urinary tract functioning properly. However, heavy and spicy foods should not be consumed in the initial few days. Eating a well-balanced diet in recovery period that has vitamins, proteins, fats etc. in correct proportions is very important for intestinal health.