Cystectomy (removing the bladder)
A cystectomy is an operation to remove the whole bladder.
This operation is one of the main treatments for muscle-invasive or locally advanced bladder cancer. You may also be offered this treatment if you have very high-risk non-muscle-invasive bladder cancer or bladder cancer that comes back after BCG treatment.
Some people with rarer types of bladder cancer may be able to have only part of their bladder removed. This is called a partial cystectomy.
Your operation will usually involve removing some areas close to the bladder, as well as the whole bladder.
Before surgery, your surgeon or specialist nurse will explain the operation and the effects this may have on your life. This includes possible effects on your sex life and fertility.
In men, the surgeon removes the bladder, prostate gland, seminal vesicles (where semen is stored) and sometimes part, or all, of the urethra. They also remove the lymph nodes (glands) close to the bladder.
After a cystectomy, you may have difficulties getting or keeping an erection. This is called erectile dysfunction or ED. This is because the prostate gland is removed and surrounding nerves may be damaged. Your doctor can tell you about treatments that may help improve ED.
After the operation, you will not be able to produce semen. This means you will not be able to make someone pregnant. If you are worried about this, talk to your doctor or specialist nurse before treatment starts. You may be able to store sperm to help preserve your fertility.
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In women, the surgeon removes the bladder, nearby lymph nodes and the urethra. They usually also remove the womb, ovaries, cervix and part of the vagina. If you have not been through the menopause, your doctor may talk to you about leaving your ovaries in place.
After surgery, women may find their sexual sensation is very different. Removing part of the vagina makes it shorter, which may make it uncomfortable or more difficult to have penetrative sex. You may be advised to use a vaginal dilator to try to help with this. Your specialist nurse can give you more advice.
Having your womb and ovaries removed will cause infertility if you have not been through the menopause. It can be difficult to hear that you may become infertile due to cancer treatment. Before treatment starts, talk to your doctor or nurse if you are worried about the effect of treatment on your fertility. You may be able to freeze embryos or eggs. Your doctor or nurse can refer you to a fertility clinic for advice about this.
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When your whole bladder is removed, the surgeon will make a new way for you to pass urine (pee). This is called a urinary diversion. It is done at the same time as the operation to remove your bladder. There are different types of urinary diversion:
Your surgeon and nurse can advise you on which type is most suitable for you.
After a urinary diversion you will not pass urine (pee) in the same way as before. Your specialist nurse will give you lots of support before and after your operation. They will show you how to care for and manage the type of urinary diversion you have.
The thought of this may seem overwhelming. Asking questions before your operation can help. Your nurse may be able to arrange for you to meet someone who already has a urinary diversion. With time and practice, living with your urinary diversion will get easier.
A cystectomy and urinary diversion may be done as open surgery or as laparoscopic (keyhole) surgery. Your surgeon will talk to you about which type of surgery is likely to be best in your situation.
Open surgery means the surgeon makes one large cut (incision) in your tummy (abdomen).
In laparoscopic (keyhole) surgery, the surgeon makes several small cuts in the tummy rather than one big cut. They pass a thin tube with a light and camera on the end (a laparoscope) into your tummy through one of the cuts. They pass specially-designed surgical tools through the other cuts to remove the cancer.
Keyhole surgery may have less complications than open surgery, and your wounds may heal faster. Keyhole surgery is not suitable for everyone. It is not available in all hospitals. You may need to be referred to another hospital to have it done.
Sometimes the surgeon uses a machine (robot) during keyhole surgery. This is called robotically-assisted surgery. The surgeon controls a robotic tool (console) that holds the instruments. Your surgeon can explain more about the benefits and disadvantages of this type of surgery.
Removing the bladder is a specialised operation and is not available in all hospitals. You may have to travel to a hospital further away from your local hospital to have it.
Before your operation, you will go to a pre-assessment clinic for tests to check you are well enough to cope with the operation. These can include:
- blood tests
- a blood pressure check
- a recording of your heart (ECG).
Some people will have further tests.
You will meet a member of the surgical team to discuss the operation. This is a good time to ask questions or talk about any concerns you may have about the operation. If you need help when you go home, tell them as soon as possible. They can help you with this.
Some hospitals follow an enhanced recovery programme. This aims to reduce the time you spend in hospital and speed up your recovery. It also involves you more in your own care. For example, you will be given information about diet and exercise before surgery. You may be given supplement drinks to take too.
Before the operation, you may have:
You may have antibiotics to prevent infection. You may have them as an injection or as tablets.
Because part of your bowel is used for a urinary diversion, you may need an empty bowel for the surgery. You may have fluid given into the back passage (rectum) to help empty the bowel. This is called an enema. It is usually given the evening before the operation.
You usually go to the hospital on the morning of the operation. You will be given elastic stockings (TED stockings) to wear during the operation and for some time afterwards. This is to prevent blood clots in your legs.
Planning your urinary diversion
A specialist nurse will talk to you about managing your urinary diversion. They will also arrange to visit you after your surgery.
For a urostomy, the nurse or doctor will carefully plan the position of the stoma. They make a mark on your tummy, so the surgeon knows the best place for the stoma. They do this even if you are planning to have a bladder reconstruction. This is in case they need to make a urostomy.
A stoma is often placed on the right side of your belly button (navel). But if you are left-handed, it can be positioned on your left side. It is usually placed to suit your needs.
If you are having a continent urinary diversion, the stoma is placed where you can see it and put a catheter into it.
After the operation, you will be looked after in a high-dependency or intensive care unit for 1or 2 days.
The nurses will encourage you to start moving about as soon as possible after your operation. This helps to prevent problems such as chest infections or blood clots. They will encourage you to do regular leg movements and deep breathing exercises. A physiotherapist or nurse can explain these to you.
You may have loose bowel movements after your surgery. This is because part of the bowel is used to make a urinary diversion. It usually gets better over time. Tell your doctor or specialist nurse if it continues.
Drips and drains
At first, a nurse gives you fluids through a drip (infusion) into a vein in your hand or arm. You may be given painkillers through your drip. Once you are eating and drinking again, it is removed.
Some people may have a tube that goes up the nose and down into the stomach (nasogastric tube). It is used to remove fluid from the stomach, so you do not feel sick. This is usually removed 1 or 2 days after surgery.
You may have a tube close to the operation wound to drain fluid away. A nurse will take this out after a few days, when fluid stops draining.
You will have tubes to help drain urine from your body. The tubes you have depend on the type of urinary diversion you have. Your doctor and nurse will explain more about this to you.
After your operation, you will need painkilling drugs for a few days.
To begin with, you may be given painkillers into a vein using an electronic pump. You control the pump using a hand control that you can press when you need more of the painkiller. This is called patient-controlled analgesia (PCA). It is fine to press the hand control whenever you have pain. The nurse sets the pump so you cannot have too much painkiller.
Some people are given painkillers into their back. This is called an epidural. The drugs numb the nerves in the area where you had the operation to control your pain. You usually have them through a drip (infusion) attached to an electronic pump.
Sometimes during the operation, the surgeon puts small tubes into the area around the wound. After the operation, your doctor or nurse uses these tubes to give you painkillers. This helps to numb the nerves in the same way as an epidural.
If you are in pain, tell your nurse or doctor straight away. You will be given painkillers to take before you go home.
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How long you are in hospital for will depend on the operation you have had and how quickly you recover. It can be from 4 to 14 days.
Your doctor will tell you how soon you can get back to doing things such as work, driving, shopping, gardening or playing sport. This will depend on the operation you had and your recovery.
Before you leave hospital, you will be given an outpatient appointment for a follow-up a few weeks after your surgery. It is a good time to discuss any concerns you may have after your operation. Your doctor will tell you if you need any further treatment.