Robotic Cystectomy

Overview

After having your bladder removed, your surgeon also needs to create a urinary diversion — a new way to store urine and have it leave your body. There are multiple ways that urine can be stored and eliminated after bladder removal. Your doctor can help you decide which method is best for you.

Often, cystectomy is performed to treat invasive or recurrent non-invasive bladder cancer. Cystectomy may also be performed to treat other pelvic tumours — such as advanced colon, prostate or endometrial cancer — and some noncancerous (benign) conditions — such as interstitial cystitis or congenital abnormalities.

Why it’s done

Your doctor may recommend cystectomy to treat:

• Cancer that begins in the bladder or that begins nearby and grows to involve the bladder
• Birth defects that affect the urinary system
• Neurological or inflammatory disorders that affect the urinary system

What type of cystectomy and reconstruction you have depends on several factors, such as the reason for your surgery, your overall health and your preferences. Discuss your options with a surgeon to determine which procedures are right for you.

Risks

Cystectomy is a complex surgery, involving the manipulation of many internal organs in your abdomen. Because of this, cystectomy carries with it certain risks, including:

• Bleeding
• Blood clots
• Heart attack
• Infection
• Pneumonia
• Rarely, death can happen after surgery

Since cystectomy is a surgery not just to remove the bladder but also to create a urinary diversion, the surgery includes additional risks, such as:

• Dehydration
• Electrolyte abnormalities
• Urinary tract infection
• A blockage that keeps food or liquid from passing through your intestines (bowel obstruction)
• A blockage in one of the tubes that carries urine from the kidneys (ureter blockage)

Some complications may be life-threatening. You may need to go back to the operating room for surgery to fix the complication, or you may need to be readmitted to the hospital. Ask your surgeon what additional risks there may be for your particular surgery.

How you prepare

Before cystectomy, talk with your doctor about the medicines you take and your use of caffeine, alcohol or other drugs. You may need to make changes to your medications or avoid certain substances to help with healing and recovery after surgery.

If you smoke, the best thing you can do for your health is to quit before surgery. Not only is smoking a risk factor for developing bladder cancer, smoking also increases the risk of developing problems after surgery.

When you schedule your surgery, you’ll receive specific instructions on how to prepare for the procedure. If you have questions about the instructions, follow up with your surgeon or other member of your health care team.

What you can expect

During cystectomy, your surgeon removes the bladder and part of the urethra, along with nearby lymph nodes. In men, removing the entire bladder (radical cystectomy) typically includes removal of the prostate and seminal vesicles. In women, radical cystectomy also involves removal of the uterus, ovaries and part of the vagina. Your surgeon also creates a new route for urine to leave your body.

Your surgeon may recommend one of these approaches for your surgery:

• Open surgery. This approach requires a single incision on your abdomen to access the pelvis and bladder.
• Minimally invasive surgery. Your surgeon makes several small incisions on your abdomen where special surgical tools are inserted to access the abdominal cavity.
• Robotic surgery. During this type of minimally invasive surgery, your surgeon sits at a console and remotely operates the surgical tools.

During the procedure

You’re given a medicine (general anaesthesia) that keeps you asleep during surgery. Once you’re asleep, your surgeon cuts into your abdomen — one larger incision for open surgery or several smaller incisions for minimally invasive or robotic surgery.

Your surgeon next removes your bladder along with nearby lymph nodes. Your surgeon may also need to remove other organs near the bladder such as the urethra, prostate and seminal vesicles in men and the urethra, uterus, ovaries and part of the vagina in women.

After your bladder is removed, your surgeon works to reconstruct the urinary tract in order to allow urine to leave your body. Several options exist:

• Ileal conduit. During this procedure, your surgeon uses a piece of your small intestine to create a tube that attaches to the ureters and connects your kidneys to an opening in your abdominal wall (stoma). Urine flows from the opening continuously. A bag you wear on your abdomen sticks to your skin and collects urine until you drain it.
• Neobladder reconstruction. During creation of a neobladder, your surgeon uses a slightly larger piece of your small intestine than the one used for an ileal conduit to create a sphere-shaped pouch that becomes your new bladder. Your surgeon places the neobladder in the same location inside your body as your original bladder and attaches the neobladder to the ureters so that urine can drain from your kidneys. The other end of the neobladder is attached to your urethra, allowing you to urinate in a relatively normal fashion.A neobladder isn’t a completely new, normal bladder. If you have this surgery, you might need to use a catheter to help better empty the neobladder. Also, some people experience urinary incontinence after surgery.
• Continent urinary reservoir. During this procedure, your surgeon uses a piece of your intestine to create a small reservoir inside your abdominal wall. As you make urine, the reservoir fills and you use a catheter to drain the reservoir several times a day.With this type of urinary diversion, you avoid the need to wear a urine collection bag on the outside of your body. But you’ll need to use a long, thin tube (catheter) several times a day to drain the internal reservoir. Leakage from the catheter site may cause some problems or the need to return to the operating room for revision surgery.

The goal of urinary diversion is to facilitate the safe storage and timely elimination of urine after your bladder has been removed, while preserving your quality of life.

Talk with your doctor to understand what’s involved with each of these urinary diversion options so that you can choose the one that’s best for you.

After the procedure

You may need to stay in the hospital for up to five or six days after surgery. This time is required so that your body can recover from the surgery. The intestines tend to be the last part to wake up after surgery, so you may need to be in the hospital until your intestines are ready once again to absorb fluids and nutrients.

After general anaesthesia, you may experience side effects such as sort throat, shivering, sleepiness, dry mouth, nausea and vomiting. These may last for a few days but should get better.

Starting the morning after surgery, your health care team may have you get up and walk often. Walking promotes healing and the return of bowel function, improves your circulation, and helps prevent joint stiffness and blood clots.

You may have some pain or discomfort around your incision or incisions for a few weeks after surgery. As you recover, your pain should gradually get better. Before you leave the hospital, talk with your doctor about medicine and other ways to improve your comfort.

Urinary changes

If you have ileal conduit surgery, you may have drainage of fluid from your urethra for six to eight weeks after surgery. Usually, the drainage slowly changes in colour from bright red to pink, brown and then yellow.

With neobladder reconstruction, you may have bloody urine after surgery. In a few weeks, your urine should return to a yellowish colour.

With either procedure, you can expect to see mucus in your urine, because the piece of intestine used in the procedure will still make mucus like your intestines normally do. Over time, you should have less mucus in your urine, but it will never go away completely. If you have a neobladder, you may need to flush your catheter if you have significant mucus to prevent plugging.

Follow-up appointments

You may return to the clinic for follow-up care in the first few weeks after cystectomy and again after a few months. At these appointments, your doctor will check to make sure that your upper urinary tract drains adequately and that you’re not experiencing electrolyte imbalances.

If cystectomy is performed to treat bladder cancer, your doctor will recommend regular follow-up visits to check for cancer recurrence.

Return to activities

During the first six to eight weeks after surgery, you may need to restrict activities such as lifting, driving, bathing, and going back to work or school. You’ll gradually regain your strength, and your energy level should increase.

Ask your doctor when it’s safe to resume sexual activities. You should wait about six weeks before sexual intercourse to allow proper healing to take place.

Results

Cystectomy has the potential for a big impact on quality of life, but even so, you can still lead a pretty normal life after cystectomy surgery.

You may have concerns about having a stoma, if you have that type of surgery. Work with your medical care team to understand what to expect with a stoma and how to address some of your concerns. With time, you can feel more at ease with caring for your stoma. As you gain confidence, you can enjoy the people and social activities you always enjoyed.

With neobladder reconstruction, your new bladder starts out small and slowly gets bigger over the first few months. At first, you may need to urinate every few hours during the day, or as often as your doctor recommends. As time goes on, you may be able to increase the time between urination to every four hours. It’s important to follow the schedule your doctor recommends so that the new bladder doesn’t stretch to become too big, as this may make it difficult to empty your bladder completely.

Sexual changes

After cystectomy, you may experience sexual changes. Share your concerns with your partner and be patient as you both learn to live with a new normal.

For men, nerve damage during surgery could impact ability to have erections. This can improve over time, but you may want to discuss this possibility with your doctor and ask whether your doctor can use nerve-sparing techniques during surgery. But even with nerve-sparing techniques, it might take some time for erectile function to return. Many options exist to help with erectile function after cystectomy. Be patient and work with your doctor if this is an important part of your recovery.

For women, changes to the vagina could make sex less comfortable after surgery. Nerve damage also can impact arousal and ability to have an orgasm. Ask your doctor whether nerve-sparing surgery might be an option for you. If you do experience sexual difficulties after surgery, take your time, be patient and discuss your concerns with your doctor if this is an important part of your recovery.

Intimacy with a stoma pouch is still possible. Know that intimacy won’t hurt your stoma, and reassure your partner that sex is OK. To minimize possible leaks, empty the pouch before sex. A pouch cover, sash or snug-fitting top can secure the pouch and keep it out of your way. You may need to experiment with different positions during intercourse until you find what’s comfortable for you.