A radical cystectomy is a surgical operation used to treat localised bladder cancer (i.e. cancer that is not thought to have spread). The operation refers to removal of the bladder and surrounding tissue including pelvic lymph nodes as well as a diversion to collect and drain the urine from the ureters (tubes that drain the kidneys). This procedure is a major operation and is normally still done in with an open approach rather than keyhole surgery, although this may change in the future. Although the aim of most treatments for bladder cancer is to avoid the need to perform such a major operation, when needed, it can be a life-saving option.
WHAT DOES THE PROCEDURE INVOLVE?
The patient will need to undergo a general anaesthetic. Once asleep, the patient will be placed on the operating table and prepared in the standard fashion. An incision is made in the lower abdomen in the midline, normally from the bellybutton or just beside the bellybutton straight down to the top of the pubic bone. A special retractor is normally used to help open the tissue and allow the surgeon to isolate the bladder, carefully removing this organ completely intact. In males, the prostate is normally removed with the bladder as it is directly attached. In females, the uterus, if still present, is often removed as well as the front wall of the vagina. This may be altered depending on the stage of the tumour and the age of the patient and degree of normal sexual activity expected after the procedure.
As well as the bladder and possibly other pelvic organs, lymph nodes from the pelvis are also removed as this is a common area of spread from bladder cancers.
A very important part of the procedure is how to deal with the ureters once they have been detached from the bladder. All the urine from the kidneys runs down the ureters. In most cases, they are attached to a segment of bowel which is disconnected from the last part of the small-bowel (ileum). The tubes from the kidneys (ureters) are attached to one end of this segment and the other end is brought out through the skin in the abdomen to form a stoma. A bag is securely attached around it to collect the draining urine. This is called an “ileal conduit”. Another alternative is to use a large piece of bowel to create a new bladder (“neobladder”), and this may mean that the patient does not need to wear a bag. Only certain patients are suitable for this procedure. Your doctor will help you decide whether or not this is a suitable procedure to be offered. The final decision may depend on factors such as the type of cancer, the extent of the cancer, the position of the cancer, as well as the patient’s age and most importantly their wishes.
Once the operation has been completed, the wounds will be carefully closed using a combination of sutures and skin staples. There may be one or two drain tubes temporarily left in, often including a catheter, which is acting as a drain tube for the pelvis.
HOW DO I PREPARE BEFORE MY PROCEDURE?
- Appointment with clinical nurse specialist – you will have a 1-hour appointment with our practice nurse to discuss in detail your upcoming surgery, pre-operative investigations (blood and urine tests, ECG), admission instructions, what to expect following the operation as well as address any of your concerns.
- Appointment with a stomal therapist – you will be referred to a stomal therapist to discuss in detail how to manage a stoma. The discussion may vary depending on whether you will end up with an ileal conduit or a neobladder. Part of the assessment by the stomal therapist includes identifying and marking the ideal position for the stoma. This is used in surgery to try and create a stoma which will be the easiest for the patient to manage in the long-term.
- Referral to an anaesthetist or other medical specialist (e.g. cardiologist) – as mentioned previously, a radical cystectomy is a major operation with significant risks to the patients. In addition, the majority of patients undergoing this procedure are in the elderly age bracket and may often have other medical conditions, particularly as this cancer is strongly associated with smoking. Therefore, the patient may need to see an anaesthetist or other medical specialists to ensure all other health problems are optimised before surgery. Not every patient will require this, and this will be determined by your doctor.
- Blood thinners – these include aspirin, clopidogrel (Plavix), warfarin, rivaroxaban (Xarelto), apixaban (Eliquis), dabigatran (Pradaxa) and need to be stopped 2-10 days prior to your surgery. Your doctor will advise you further about this.
- Other regular medications – you can take all of these, up to and including the day of your surgery, unless otherwise instructed by your doctor.
- Fasting and admission – the hospital will call you the day prior to give you fasting instructions and when/where to come into hospital (please click here for contact details in the event you do not receive this call)
WHAT CAN I EXPECT IN HOSPITAL AFTER THE PROCEDURE?
- A surgical wound in the lower abdomen, normally closed with skin staples. It will normally be dressed so may not be visible under the dressing
- At least one drain tube in the pelvis. Despite the fact that the bladder has been removed, there will be a catheter in the urethra in a lot of cases as this can be used as a drain tube. In cases of a neobladder, the catheter will remain in the new bladder for a number of weeks. In some cases, the urethra will be completely removed as part of the procedure (in these cases there would be no catheter).
- In most cases, an ileal conduit is still the way that the bladder is connected so there will be a stoma, normally on the pre-marked spot on the abdominal wall, and there will be a bag which collects the urine around this stoma, to avoid leakage
- There will be some ureteric catheters (thin tubes) coming through the stoma. These are usually removed or fall out after 2-3 weeks
- Lower abdominal pain especially with moving/coughing. Pain relief after a cystectomy is often managed with an epidural for the first few days. This will give excellent pain relief in most cases. In some cases, this may not be so effective. Other very effective ways of managing pain are available including wound infusions with local anaesthetic, as well as PCA (patient-controlled analgesia). If the epidural is successful, these other methods are often not required until the epidural is stopped.
- You will be encouraged to move and cough as much as possible as this reduces the risk of lung infections and other potential problems such as clots in the legs. Whilst the epidural is in you will normally be confined to a bed or chair. Once the epidural is out, you will be helped with, and encouraged to walk as soon as possible.
- The reintroduction of diet will be done as soon as possible. Due to the fact that the bowel has been operated on, it can take a few days to start working again and for a normal diet to be able to be tolerated. The amount of time when patients are unable to eat does vary significantly. In addition, an ileus (where the bowel temporarily stops working) is quite common after a cystectomy. This normally resolved by itself but can last for over a week. This will be carefully monitored by your doctor.
- Nausea is common for the first 24 hours after anaesthetic and can be treated with anti-nausea medications. This can persist, particularly if the bowel is slow to start working again. The degree of nausea, distension of the abdomen due to gas and bowel activity will be carefully monitored to ensure there are no significant complications and to allow the reintroduction of eating and drinking at the appropriate time.
The aim before discharge is for you to be able to:
- Tolerate a normal diet without nausea
- Pass wind through the back passage and have had a bowel motion
- Pain be under control with tablets
- Be able to transfer in and out of bed and walk around
- Know how to look after your stoma, or in cases of a neobladder – a catheter, and any drain tube which may still be in situ at home. Occasionally, you may need to give yourself an injection of a blood thinner (clexane)
WHAT CAN I EXPECT AFTER I AM DISCHARGED?
- A follow-up appointment for you to see your doctor (in 2-3 weeks) or to have your catheter removed (if you were discharged with one)
- Pain should decrease day by day and need for pain killers should also reduce
- Bowels should start working as normal (see below about diet)
- Wound care – you will have waterproof (ie. shower as normal) dressings and steri-strips over your wounds. These can be removed and checked around 1 week after surgery. The sutures are all absorbable and do not need to be removed.
WHAT CAN I EXPECT AFTER I AM DISCHARGED?
- If there are any tubes still in your body, there will be a plan to monitor the output from 2 and to remove it at the appropriate time. This may include having nurses visit you at home.
- A follow-up appointment to see your doctor (in 2-3 weeks).
- Pain should decrease day by day and the need for painkillers should also reduce.
- Bowel should start working as normal (see below about diet).
- Wound care – you will have a waterproof (i.e. shower is normal) dressings and Steri-Strips over your wounds in most cases. These can be removed and checked about one week after being home although this may vary depending on how long you have been in hospital after the operation. You will be advised on this before leaving hospital and can always check if there are any concerns with our nurse specialist. If there are staples in the skin these may have been removed before your discharge or may be removed after you have gone home. This will also be arranged before your discharge from hospital.
- Stoma care - the majority of patients do have a stoma after this operation. Although this can be daunting, with appropriate advice and support from our specialist team, most patients quickly adapt and do not have long-term problems with its management.
WHAT ABOUT DIET?
- Drink plenty of fluids (8-10 glasses or 2-3 litres)
- Ensure adequate nutrition to improve healing. You may need to have 6 smaller meals rather than 3 larger ones.
- Eat a diet high in fibre or take a laxative (eg. coloxyl and lactulose) to prevent constipation and the need for straining when using your bowels
WHAT ABOUT EXERCISE/ACTIVITY?
- You can do gentle exercise such as walking less than 1.5km
- Avoid strenuous activity, heavy lifting (>3kg) or engage in sports (eg. golf) for 6 weeks to prevent wound complications such as hernias
- Avoid driving a car until you have no pain and not on any pain killers. This can vary from patient to patient but can take a number of weeks. Beware of fatigue as this may affect concentration and is very common after any operation. If in doubt it is safer to wait longer until commencing driving
- Returning to work depends on the physical demands of your duties. Although you may be able to return to work after a few weeks if there are low physical demands, be aware that fatigue is common after any major operation and can persist for up to 6 months. In most cases, up to 3 months may be required off work after this major open cancer operation. medical certificates can be supplied as required.
- Avoid overseas travel for 6 weeks as a minimum (inform your Doctor if you have a trip planned). Any non-essential travel should probably be put off for at least 3 months.
WHAT ABOUT MEDICATIONS?
- You can resume your usual medications
- If your blood thinning medication was stopped, your Doctor will let you know when to recommence
- You can take 1-2 paracetamol every 4-6 hours for pain and discomfort (no more than 8 in a day)
- Stronger pain medications may also have been prescribed and should be taken as directed. Their use should decrease every day, as taking them in the long term will often cause side effects such as constipation.
WHAT ARE THE POSSIBLE SIDE EFFECTS/COMPLICATIONS?
Expected/common
- Post-operative pain is common initially, particularly due to the larger open incision
- Difficulty with stoma management. This is expected initially as it is a fairly major change for patients. The stoma therapist will be of great assistance.
- Fatigue is very common, particularly after such a major operation.
- Ileus – slowing of bowels causing vomiting and constipation
- Bleeding – requiring transfusion is common during the operation due to the number of blood vessels in the pelvis surrounding the bladder. Ongoing blood loss after the operation is uncommon, but may require reoperation.
- Sexual dysfunction either related to damage to the nerves controlling blood flow to the penis, or in females altering the shape of the vagina is very common.
Occasional/uncommon
- Infection – of the wound, chest or urine.
- Leakage from the join between the ureter and the bowel (urine leak), or where the bowel has been re-joined (bowel anastamotic leakage). This will normally be picked up while still in hospital by careful attention to what is coming out of the drain tube.
- Decrease kidney function – at least partly due to the bowel re-absorbing some of the substances which had been filtered out in the urine. This is more common after a neobladder.
- Deep venous thrombosis/pulmonary embolus. These are potentially life-threatening complications. The use of stockings and similar devices during and after the operation, as well as the injections of blood thinners and encouragement of early movement after the operation will reduce but not eliminate the risk
- Recurrence of the cancer, e.g. lungs, liver or bones.
Rare
- Anaesthetic, cardiovascular or perioperative problems possibly requiring intensive care admission (including chest infection, stroke, heart attack and death)
- Hernia involving the wounds or around the stoma
- Long-term metabolic complications due to the stoma/neobladder absorption of urine
- Scarring of the joins between the ureters and the bowel causing blockage to the kidneys or at the level of the skin causing a blockage to the stoma. This may require further operations or procedures.
NOTIFY GM UROLOGY or your GP if you experience any of the following:
- Increased pain, redness or purulent discharge from any of the wounds
- Increased discomfort, severe abdominal/flank pain or bloating
- Vomiting
- Difficulty passing urine or worsening burning after catheter removed if you had a neobladder
- No urine coming from the stoma for more than a couple of hours
- Fever (temperature over 37.5 degrees), chills, shakes or feeling generally unwell
FOLLOW UP APPOINTMENT
You should have an appointment to see your doctor in 2-3 weeks. You may need an appointment earlier, particularly if there are catheters or drain tubes which need to be removed or checked. These appointment should be given to you on discharge.
If you have any queries please contact GM Urology on 03 5201 7000 during business hours OR leave a message on the After Hours Urology Paging Service 03 9387 1000