Definition and Overview
A cystectomy is a bladder removal surgical procedure. It can also be performed to remove the gallbladder or a cyst that grows on or around the bladder. The procedure, which can be performed using either traditional open surgery or minimally invasive surgery, is most commonly used to treat several conditions affecting the bladder particularly bladder cancer. Although safe, the procedure is complex and is typically followed by a urinary diversion.
Who should undergo and expected results
Cystectomy is recommended for patients with any of the following conditions:
- Bladder cancer
- Cancer that grows near the bladder
- Urinary birth defects or abnormalities
- Injury to the bladder caused by trauma
- Neurological disorders affecting the urinary system
Depending on the need and the patient's condition, the surgeon may perform either:
- Partial cystectomy – This removes only the damaged part of the bladder. It is more commonly done when the damage is not close to the openings of the bladder where the urine pass through.
- Radical cystectomy – This is more appropriate if the bladder is severely damaged, if the damage has affected the muscle layer of the bladder, or if the affected part is near the opening of the bladder. In this procedure, the entire bladder is removed, as well as the lymph nodes near the bladder and some part of the urethra. For cancer cases, other nearby organs may also be affected if they are also found to have malignant cells. In some cases involving male patients, the vas deferens, prostate, and seminal vesicles are also removed. In cases involving female patients, the cervix, uterus, ovaries, and fallopian tubes may sometimes be affected.
The procedure is expected to remove the cancerous cells to treat cancer or to repair or reconstruct the bladder, in the case of congenital defects or traumatic injury.
In cancer cases, the patient may still need to undergo further treatment such as chemotherapy or radiation therapy. The cystectomy, however, helps keep cancer from spreading to other organs. Radical cystectomy can also completely prevent the recurrence of cancer and lengthen the life of patients who suffer or have been treated for bladder cancer.
How the procedure works
A cystectomy can be performed using different surgical techniques, namely:
- Traditional open surgery – A traditional open surgery is one wherein the patient's abdominal area is opened up using one long incision. This gives the surgeon direct open access to the bladder.
- Minimally invasive surgery – Modern surgical methods have enabled surgeons to perform surgery on internal organs without the need for a large incision. Generally known as minimally invasive surgery and laparoscopic surgery, this technique is performed by inserting special surgical tools such as a catheter into small incisions made at specific locations to gain access to the bladder.
- Robotic surgery – Considered as a specific type of minimally invasive surgery, robotic-assisted procedures are those in which the surgeon performs the surgery by controlling robotic tools remotely.
The choice as to which technique is used depends on the patient's preference and the surgeon's recommendation.
The removal of the bladder, either partially or completely, leaves major repercussions on important body functions. Thus, the procedure is always followed by a reconstruction surgery so the flow of the urine can be diverted. This surgery can be any one of the following:
- Urostomy – This is a procedure wherein the surgeon makes a urinary or ileal conduit using a piece of the patient's intestine. The conduit runs from the kidneys and is attached to the abdominal wall where the urine is collected in a bag.
- Orthotopic continent urinary diversion – Also called as a neobladder, this procedure works like a urostomy except that the conduit or tube runs from the kidneys to a small reservoir in the urethra, allowing the patient to urinate in a normal manner.
- Cutaneous continent urinary diversion – Also known as an Indiana pouch, this procedure allows urine to run through a tube from the kidneys to the abdominal wall where it exits through the belly button into a pouch that has to be emptied several times a day.
- Mainz 2 procedure – This refers to the creation of a pouch in the rectal area made from a piece of the bowel. Known as a recto-sigmoid pouch, it is attached to the ureter to collect the urine.
Due to the long-term effects of a cystectomy and the challenges that come with living with a urinary conduit, patients will require long-term care and continuous follow-up appointments.
Possible risks and complications
As a complex procedure, a cystectomy is linked to both short and long-term complications, including:
- Bowel obstruction
- Kidney infection
- Leakage of urine
- Acidosis, or electrolytes imbalance
- Kidney failure
- Intestinal obstruction
- Stoma, or problems of the new urinary opening
- Strictures, or when scar tissue forms in the intestines as a result of the procedure
Aside from the diversion of urine flow, a cystectomy has other long-term effects on the body that the patient will have to live with. These include:
- Infertility, especially if cystectomy also involved the removal of reproductive organs, such as the ovaries (among women) and the prostate gland (among men)
- Compromised or limited sexual function, if the cystectomy involved the removal of the seminal vesicles (among men) and a part of the vagina (among women)
Among women, a cystectomy will also change the way that the body responds to menopause.
- Wein AJ, ed., et al. Campbell-Walsh Urology. 10th ed. Philadelphia, Pa.: Saunders Elsevier; 2012. http://wwwclinicalkey.com.
- Shariat SF, et al. Urinary diversion and reconstruction following cystectomy. http://www.uptodate.com/home.
- Aron M, et al. Laparoscopic/robotic-assisted radical cystectomy. http://www.uptodate.com/home.