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A. The mainstay of treatment for muscle-invasive bladder cancer is surgical removal of the urinary bladder.
A. Your doctor has several reasons for recommending removal of the whole bladder:
A. Factors like your biological age (your body’s performance as it ages, measured as performance status or life expectancy) and other diseases that you have (diabetes, heart disease, high blood pressure) are also important. Patients older than 80 years of age have more problems recovering from such an operation. Physicians use special indexed scores to assess the risk of patients undergoing this stressful operation.
Prior abdominal surgery or radiotherapy makes surgery more difficult but is rarely a reason not to have surgery. Being overweight does not influence survival after surgery but does influence the risk of complications from wound healing.
A. Removal of the urinary bladder includes removal of the bladder, the endings of the ureters and the pelvic lymph nodes. Depending on factors like tumour location and type of urinary diversion part of the adjacent gender-specific organs (the prostate and seminal vesicles in men; the entire urethra, adjacent vagina, and uterus in women) are removed. Men should be aware that prostate cancer is sometimes found in removed prostates but generally does not affect long-term survival or treatment.
A. Removal of the urinary bladder is performed through an incision in the abdomen (open) with the patient under general anaesthesia (combination of intravenous drugs and inhaled gasses; you are ‘asleep’). The bladder, the ends of the ureters close to the bladder, the pelvic lymph nodes, and (part of) adjacent gender-specific organs are removed. Now another way to store and empty urine must be created (urinary diversion).
Ileal Conduit: The ureters (the tubes which drain urine from the kidneys to the bladder) are then sewn to a separated piece of small bowel which is positioned on the surface of the abdomen as an opening called a urostomy. The ends of the small bowel, from which the conduit is isolated, are then joined together again.
Neo-bladder: The ureters (the tubes which drain urine from the kidneys to the bladder) are then sewn to a separated piece of small bowel which is fashioned into a bladder substitute and joined to the water pipe (urethra).
The standard procedure at the moment is open surgery. However, sometimes it can be done as a laparoscopic or robotic-assisted procedure at centres that treat a lot of patients and have experienced and specialised surgeons
A. If you are a smoker, we advise you to stop smoking straight away.
If you are taking blood thinning medication on a regular basis, you must discuss this with your urologist because these drugs can cause increased bleeding after surgery. There may be a balance of risk where stopping them will reduce the chances of bleeding but this can result in increased clotting, which may also carry a risk to your health. This will, therefore, need careful discussion with regard to risks and benefits. Aspirin does not usually need to be stopped but will be the decision of your surgeon.
You will usually be admitted one day before your surgery. You will normally undergo pre assessment on the day of your clinic. After admission, you will be seen by members of the medical team which may include the consultant, junior urology doctors and nurse.
Part of your intestines will be used to create the urinary diversion. Your doctor will advise you in detail about how to prepare for the procedure.
You will be asked not to eat or drink for six hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.
Please be sure to inform your urologist in advance of your surgery if you have any of the following:
A. Most procedures have a potential for side effects. Radical Cystectomy is an extensive procedure with associated short term and long term complications:
Common (greater than one in 10)
The cancer may not be cured by the operation (this will be discussed with you before the operation)
Difficulty re-establishing normal bowel movements in the first few weeks after your operation. This can persist in the long-term in five to 10 % of patients
Temporary insertion of a stomach tube through the nose, a drain and ureteric stents
High risk of impotence (lack of erections)
Inability to ejaculate or father children because the structures which produce seminal fluid have been removed (occurs in 100% of patients)
One in three chance of unsuspected prostate cancer being found
Occasional (between one in 10 and one in 50)
Rare (less than one in 50)
A. There are several measures that can help you prevent complications such as:
A. The average hospital stay is usually 5 to 7 days. During hospitalisation, you will learn how to manage the urostomy or neobladder. Once you have learned how to use and empty the urostomy or internal urine pouch, a date for your discharge will be set
A. When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation.
Most patients feel tired and below par for a week or two because this is major surgery.
Ileal Conduit: You may experience problems with the stoma appliance in the early days, especially with leakage at night. As you become more familiar with your stoma and its fittings, this aspect will become less of a problem.
Neobladder: You will need to continue training your bladder substitute to increase its capacity once you get home. Initially, you will pass urine every two hours but this will gradually increase to four hourly by day and night. Bladder training may take up to 12 months to complete
The time taken to return to normal activity is between two and four months.
A. In the event of severe bleeding, passage of clots or sudden difficulty in passing urine, high grade fever, vomiting, inability to pass flatus or stool, you should contact your urologist immediately since it may be necessary for you to be re-admitted to hospital.
A. Your biopsy report will be available in 10 to 14 days. Depending on the biopsy results, further investigations (eg x-ray, CT scan), or a further admission may be arranged for you.
A. Most patients require a recovery period of three to four weeks at home before they feel ready for work. We recommend three to four weeks rest before resuming any job, especially if it is physically strenuous and you should avoid any heavy lifting during this time. Complete recovery may take upto four to six months.
A. Chemotherapy is administered before bladder removal to potentially shrink the tumour and kill cells that have already entered the blood or lymph nodes.
Adequate kidney function is necessary. Potential side-effects are usually monitored and managed by an oncologist.
A good response to chemotherapy improves survival but does not change the need for surgery.
Although neoadjuvant chemotherapy is currently advised, physicians are unable to identify who will definitely benefit from chemotherapy before removal of the bladder.
A. If a tumour is large (>3 cm), or could not be fully resected, or if cancer has spread to the lymph nodes (determined by the pathologist), chemotherapy after removal of the bladder is an option. Cancer that has spread to the lymph nodes indicates systemic disease and may need systemic treatment (with chemotherapy) in certain cases.
A. You should wait at least six weeks before sexual intercourse to allow proper healing to take place. Your sex life might be affected after having surgery for bladder cancer. This depends on the type of surgery you have.
Your body may look different after the surgery, which may take time to get used to. For men, the penis may appear slightly shorter than before the surgery. For both men and women, having a stoma can also affect the way you feel about yourself and how you feel about having sex.
Take your time to recover. You will feel when you are ready to start sexual intercourse again. In the meanwhile, spend time with your partner, share interest, enjoy cuddling and do not stop talking with each other.
Men: Bladder removal for men typically includes removing the prostate. This is done to prevent bladder cancer coming back in the prostate later. Without a prostate, you will not be able to produce semen fluid. You can still have an orgasm, but your orgasms will be dry (without semen). Sperm cells can still be produced in the testicles but you cannot make a partner pregnant by sexual intercourse. Talk with your doctor before surgery if you have questions about fertility.
Your ability to have an erection may be affected. Cystectomy can damage the nerves that control erection. If the nerves are not damaged, you might still need assistance to get an erection after surgery. Several options exist and can be used alone or together:
Women: Bladder removal for women typically includes removing the internal sexual organs, including the uterus, ovaries and the part of the vagina that is next to the bladder and urethra. This is not necessary in every case, but is typically done to make sure all the cancer is removed. The labia and clitoris are not removed, and most of the vagina will usually be left, so most women will still be able to have an orgasm and intercourse.
It may take time to get used to how this looks and feels. Sex may feel different than it did before surgery. You might have less sexual desire. You might need to use a gel to help with lubrication. Treatment is available if intercourse is painful (dyspareunia).