Cystectomy

Last updated
Cystectomy
Diagram showing the layers of the bladder CRUK 304.svg
Bladder layers and anatomy
ICD-9-CM 57.6-57.7
MeSH D015653
OPS-301 code 5-576

Cystectomy is a medical term for surgical removal of all or part of the urinary bladder. It may also be rarely used to refer to the removal of a cyst. [1] The most common condition warranting removal of the urinary bladder is bladder cancer. [2]

Contents

Two main types of cystectomies can be performed. A partial cystectomy (also known as a segmental cystectomy) involves removal of only a portion of the bladder. [3] A radical cystectomy involves removal of the entire bladder along with surrounding lymph nodes and other nearby organs that contain cancer. [4]

Evaluation of the tissue removed during cystectomy and lymph node dissection aids in determining pathological cancer staging. This type of cancer staging can be used to determine further work-up, treatment, and follow-up needed along with potential prognosis. [5]

After the bladder has been removed, a urinary diversion is necessary to allow elimination of urine. [6]

Medical uses

Malignancy

Radical cystectomy is the recommended treatment for bladder cancer that has invaded the muscle of the bladder. Cystectomy may also be recommended for individuals with a high risk of cancer progression or failure of the cancer to respond to less invasive treatments. [6] [7] [8]

Types

When determining the type of cystectomy to be performed many factors are taken into consideration. Some of these factors include: age, overall health, baseline bladder function, type of cancer, location and size of the cancer, and stage of the cancer. [9]

Partial cystectomy

A partial cystectomy involves removal of only a portion of the bladder and is performed for some benign and malignant tumors localized to the bladder. [9] Individuals that may be candidates for partial cystectomy include those with single tumors located near the dome, or top, of the bladder, tumors that do not invade the muscle of the bladder, tumors located within bladder diverticulum, or cancer that is not carcinoma in situ (CIS). [7] A partial cystectomy may also be performed for removal of tumors which have originated and spread from neighboring organs such as the colon. [4]

Radical cystectomy

A radical cystectomy is most commonly performed for cancer that has invaded into the muscle of the bladder. In a radical cystectomy the bladder is removed along with surrounding lymph nodes (lymph node dissection) and other organs that contain cancer. In men, this could include the prostate and seminal vesicles. In women, this could include a portion of the vagina, uterus, Fallopian tubes, and ovaries. [4]

Technique

Open

In an open radical cystectomy a large incision is made in the middle of the abdomen from just above or next to the umbilicus to the pubic symphysis. The following information provides general steps to the procedure and may occur in varying order depending on the surgeon. The ureters are located and cut free from the bladder. The bladder is separated from surrounding structures and removed. The urethra, which drains urine from the bladder, may also be removed depending on tumor involvement. In men, the prostate may or may not be removed during this procedure. Pelvic lymph node dissection (PLND) is performed. A urinary diversion is then created and the free ends of the ureters are reconnected to the diversion. [9] [10]

Minimally invasive

A minimally invasive radical cystectomy more commonly known as a robot-assisted laparoscopic radical cystectomy (RARC) may be an option for individuals depending on several factors including but not limited to: their overall health (with special attention to their lung health), body mass index (BMI), number and types of previous surgeries, along with the location and size of the bladder cancer. In a RARC several small incisions are made across the abdomen to allow placement of surgical instruments. These instruments are then connected to a surgical robot that is controlled by the surgeon. A head down (Trendelenburg) position is used and the abdomen is inflated with gas (insufflation) to allow better operating space and visualization. The remainder of the procedure is carried out in a fashion similar to the open procedure. [6] [11] Compared to open surgery, minimally invasive radical cystectomy probably requires fewer blood transfusions and may shorten hospital stay slightly. [12]

For rates of major or minor complications, quality of life, time to recurrence and rates of cancerous cells left behind after surgery, there may be little to no difference between robotic and open surgery as treatment for bladder cancer in adults. [12]

Contraindications

Generally, there are no specific contraindications to having a cystectomy. However, cystectomy should not be performed in individuals who are not healthy enough to undergo a major surgical procedure. This includes individuals who cannot tolerate general anesthesia or those with severe or inadequately managed co-morbidities such as diabetes, heart, lung, kidney, or liver disease. This also includes individuals who are severely malnourished, have problems with blood clotting, or severe laboratory abnormalities. Also, individuals with an active illness or infection should delay surgery until recovery. [13] [14] [15]

Robotic-assisted or laparoscopic surgery is contraindicated for individuals with severe heart and lung disease. During this method of surgery the positioning and abdominal insufflation places extra strain on the chest wall impairing lung function and the ability to oxygenate the blood. [6] [16]

A partial cystectomy is contraindicated in a form of bladder cancer called carcinoma in situ (CIS). Other contraindications for partial cystectomy include severely diminished bladder capacity or cancer in very close proximity to the bladder trigone, where the urethra and ureters connect to the bladder. [9]

Risks and complications

Radical cystectomy with the creation of a urinary diversion can be associated with several risks and complications due to the extent and complexity of the surgery. As with most major surgeries there is risk from anesthesia, also, risk of bleeding, blood clots, heart attack, stroke, and pneumonia or other respiratory problems. There is also a risk of infection involving the urinary tract, abdomen, and gastrointestinal tract. After the surgical incisions are closed there is a risk of infection at these sites. [17] [13] Complications are similar between open and minimally invasive cystectomy techniques [18] and include the following:

Gastrointestinal tract

An ileus, where movement within the intestines slows down is the most common complication following cystectomy. This is due to a variety of factors including manipulation of the intestines due to their proximity of the bladder, the actual operation on the intestines to create a urinary diversion, or even certain medications such as narcotics. In addition to slowing of the small intestine, the small intestine can also become obstructed. After creation of a urinary diversion, intestinal contents can leak at the site where the intestine are reconnected. [19] [20]

Urinary tract

With creation of a urinary diversion it is possible for the ureters to become obstructed preventing the drainage of urine from the kidneys. If this occurs, another procedure to insert a percutaneous nephrostomy tube may be need to allow drainage of urine from the body. Obstruction of the ureter most commonly occurs at the site where the ureters are reconnected to the urinary diversion created. A small, hollow, flexible tube called a stent may be placed inside the ureter at the time of surgery to possibly help the reconnection site to heal. This reconnection site is also at risk for leaking urine within the abdomen. [19] [11]

If a partial cystectomy is performed, damage to the ureter may occur depending on the location of the tumor removed. This may require an additional procedure to repair. [9]

Nerve injury

Due to the location of the operation, damage to nerves in the pelvis can occur during removal of the bladder or lymph nodes. Nerves in this area are responsible for movement and sensation of the legs and include the obturator nerve, the genitofemoral nerve, and the femoral nerve. [19]

Any of these complications may require another operation or re-admission to the hospital.

Recovery

Diet before and after surgery

Immediately after surgery no food or drink is allowed due to involvement of the gastrointestinal tract in the surgery. The diet will then be slowly advanced to liquids and then solid foods as tolerated. If gastrointestinal complications such as nausea, vomiting, or abdominal bloating occur the diet may be stopped or advancement of the diet slowed down depending on the severity. [11]

For people who have difficulties eating before or after a radical cystectomy, additional nutrition may be beneficial when compared with waiting until ordinary food can be tolerated. [21] Immuno-enhancing nutrition with high levels of nutrients may decrease complications within 90 days of surgery. When compared with a multivitamin and mineral supplement, perioperative oral supplements may slightly decrease postoperative complications. It is uncertain if giving an individual undergoing a radical cystectomy amino acids, branch chain acids or preoperative oral supplements improve complications after surgery. [21] Feeding into a vein and early postoperative feeding may increase postoperative complications. These diet interventions do not appear to affect the length of hospital stay. [21]

Pain control

Intravenous pain medication such as narcotics are typically used immediately after surgery. Pain medications can be switched to an oral form once a diet is tolerated. [11]

Activity

Early activity is encouraged after surgery. Individuals may be able to walk and sit in a chair as early as the same day of surgery. Usually individuals are able to walk around their room or hospital ward within a day or two after surgery. Some individuals may require additional assistance or physical therapy in the hospital or once discharged home. [11]

Venous thromboembolism prevention

Approaches to prevent venous thromboembolism (VTE) are performed both before and after surgery. Compression devices placed around the legs or medications such as Heparin or low molecular weight heparin (LMWH) are commonly used. [11] VTE prophylaxis with LMWH may even be continued after hospital discharge if needed. [9]

Surgery follow-up

If an open cystectomy was performed, the staples closing the incision are usually removed 5 to 10 days after surgery. Further follow-up with the surgeon is typically scheduled 4 to 6 weeks after surgery and may involve laboratory or imaging studies to assess recovery along with further care and follow-up. [9]

Related Research Articles

<span class="mw-page-title-main">Urology</span> Medical specialty

Urology, also known as genitourinary surgery, is the branch of medicine that focuses on surgical and medical diseases of the urinary-tract system and the reproductive organs. Organs under the domain of urology include the kidneys, adrenal glands, ureters, urinary bladder, urethra, and the male reproductive organs.

<span class="mw-page-title-main">Ureter</span> Tubes used in the urinary system in most animals

The ureters are tubes made of smooth muscle that propel urine from the kidneys to the urinary bladder. In a human adult, the ureters are usually 20–30 cm (8–12 in) long and around 3–4 mm (0.12–0.16 in) in diameter. The ureter is lined by urothelial cells, a type of transitional epithelium, and has an additional smooth muscle layer that assists with peristalsis in its lowest third.

<span class="mw-page-title-main">Bladder cancer</span> Urinary system cancer that begins in the urinary bladder

Bladder cancer is any of several types of cancer arising from the tissues of the urinary bladder. Symptoms include blood in the urine, pain with urination, and low back pain. It is caused when epithelial cells that line the bladder become malignant.

<span class="mw-page-title-main">Urinary retention</span> Inability to completely empty the bladder

Urinary retention is an inability to completely empty the bladder. Onset can be sudden or gradual. When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. When of gradual onset, symptoms may include loss of bladder control, mild lower abdominal pain, and a weak urine stream. Those with long-term problems are at risk of urinary tract infections.

<span class="mw-page-title-main">Nephrectomy</span> Surgical removal of a kidney

A nephrectomy is the surgical removal of a kidney, performed to treat a number of kidney diseases including kidney cancer. It is also done to remove a normal healthy kidney from a living or deceased donor, which is part of a kidney transplant procedure.

<span class="mw-page-title-main">Urostomy</span>

A urostomy is a surgical procedure that creates a stoma for the urinary system. A urostomy is made to avail for urinary diversion in cases where drainage of urine through the bladder and urethra is not possible, e.g. after extensive surgery or in case of obstruction.

<span class="mw-page-title-main">Prostatectomy</span> Surgical removal of all or part of the prostate gland

Prostatectomy is the surgical removal of all or part of the prostate gland. This operation is done for benign conditions that cause urinary retention, as well as for prostate cancer and for other cancers of the pelvis.

<span class="mw-page-title-main">Sentinel lymph node</span> First lymph node to receive drainage from a primary tumor

The sentinel lymph node is the hypothetical first lymph node or group of nodes draining a cancer. In case of established cancerous dissemination it is postulated that the sentinel lymph nodes are the target organs primarily reached by metastasizing cancer cells from the tumor.

<span class="mw-page-title-main">Pelvic exenteration</span> Surgical removal of all pelvic organs

Pelvic exenteration is a radical surgical treatment that removes all organs from a person's pelvic cavity. It is used to treat certain advanced or recurrent cancers. The urinary bladder, urethra, rectum, and anus are removed. In women, the vagina, cervix, uterus, Fallopian tubes, ovaries and, in some cases, the vulva are removed. In men, the prostate is removed. The procedure leaves the person with a permanent colostomy and urinary diversion.

<span class="mw-page-title-main">Mitrofanoff procedure</span>

The Mitrofanoff procedure, also known as the Mitrofanoff appendicovesicostomy, is a surgical procedure in which the appendix is used to create a conduit, or channel, between the skin surface and the urinary bladder. The small opening on the skin surface, or the stoma, is typically located either in the navel or nearby the navel on the right lower side of the abdomen. Originally developed by Professor Paul Mitrofanoff in 1980, the procedure represents an alternative to urethral catheterization and is sometimes used by people with urethral damage or by those with severe autonomic dysreflexia. An intermittent catheter, or a catheter that is inserted and then removed after use, is typically passed through the channel every 3–4 hours and the urine is drained into a toilet or a bottle. As the bladder fills, rising pressure compresses the channel against the bladder wall, creating a one-way valve that prevents leakage of urine between catheterizations.

<span class="mw-page-title-main">Radical retropubic prostatectomy</span>

Radical retropubic prostatectomy is a surgical procedure in which the prostate gland is removed through an incision in the abdomen. It is most often used to treat individuals who have early prostate cancer. Radical retropubic prostatectomy can be performed under general, spinal, or epidural anesthesia and requires blood transfusion less than one-fifth of the time. Radical retropubic prostatectomy is associated with complications such as urinary incontinence and impotence, but these outcomes are related to a combination of individual patient anatomy, surgical technique, and the experience and skill of the surgeon.

<span class="mw-page-title-main">Ileal conduit urinary diversion</span> Surgical technique for urinary diversion

An ileal conduit urinary diversion is one of various surgical techniques for urinary diversion. It has sometimes been referred to as the Bricker ileal conduit after its inventor, Eugene M. Bricker. It is a form of incontinent urostomy, and was developed during the 1940s and is still one of the most used techniques for the diversion of urine after a patient has had their bladder removed, due to its low complication rate and high patient satisfaction level. It is usually used in conjunction with radical cystectomy in order to control invasive bladder cancer.

An Indiana pouch is a surgically-created urinary diversion used to create a way for the body to store and eliminate urine for patients who have had their urinary bladders removed as a result of bladder cancer, pelvic exenteration, bladder exstrophy or who are not continent due to a congenital, neurogenic bladder. This particular urinary diversion results in a continent reservoir that the patient must catheterize to empty urine. This concept and technique was developed by Drs. Mike Mitchell, Randall Rowland, and Richard Bihrle at Indiana University.

<span class="mw-page-title-main">Vaginectomy</span> Surgical removal of the vagina

Vaginectomy is a surgery to remove all or part of the vagina. It is one form of treatment for individuals with vaginal cancer or rectal cancer that is used to remove tissue with cancerous cells. It can also be used in gender-affirming surgery. Some people born with a vagina who identify as trans men or as nonbinary may choose vaginectomy in conjunction with other surgeries to make the clitoris more penis-like (metoidioplasty), construct of a full-size penis (phalloplasty), or create a relatively smooth, featureless genital area.

<span class="mw-page-title-main">Vesicoureteral reflux</span> Medical condition

Vesicoureteral reflux (VUR), also known as vesicoureteric reflux, is a condition in which urine flows retrograde, or backward, from the bladder into one or both ureters and then to the renal calyx or kidneys. Urine normally travels in one direction from the kidneys to the bladder via the ureters, with a one-way valve at the vesicoureteral (ureteral-bladder) junction preventing backflow. The valve is formed by oblique tunneling of the distal ureter through the wall of the bladder, creating a short length of ureter (1–2 cm) that can be compressed as the bladder fills. Reflux occurs if the ureter enters the bladder without sufficient tunneling, i.e., too "end-on".

<span class="mw-page-title-main">Ureteral stent</span>

A ureteral stent, or ureteric stent, is a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney. The length of the stents used in adult patients varies between 24 and 30 cm. Additionally, stents come in differing diameters or gauges, to fit different size ureters. The stent is usually inserted with the aid of a cystoscope. One or both ends of the stent may be coiled to prevent it from moving out of place; this is called a JJ stent, double J stent or pig-tail stent.

<span class="mw-page-title-main">Ureterostomy</span>

A ureterostomy is the creation of a stoma for a ureter or kidney.

<span class="mw-page-title-main">Mani Menon</span>

Mani Menon, born 9 July 1948 in Trichur, India, is an American surgeon whose work has helped to lay the foundation for modern Robotic Cancer Surgery. He is the founding director and the Raj and Padma Vattikuti Distinguished Chair of the Vattikuti Urology Institute at the Henry Ford Hospital in Detroit, MI, where he established the first cancer-oriented robotics program in the world. Menon is widely regarded for his role in the development of robotic surgery techniques for the treatment of patients with prostate, kidney, and bladder cancers, as well as for the development of robotic kidney transplantation.
Menon is the recipient of the Gold Cystoscope award, Hugh Hampton Young award, the Keyes Medal, the prestigious B.C. Roy award.

<span class="mw-page-title-main">Ureteral cancer</span> Medical condition

Ureteral cancer is cancer of the ureters, muscular tubes that propel urine from the kidneys to the urinary bladder. It is also known as ureter cancer, renal pelvic cancer, and rarely ureteric cancer or uretal cancer. Cancer in this location is rare. Ureteral cancer becomes more likely in older adults, usually ages 70–80, who have previously been diagnosed with bladder cancer.

<span class="mw-page-title-main">Michael Stifelman</span> American physician and urologist

Michael D. Stifelman Michael D. Stifelman, M.D., is Chair of Urology at Hackensack University Medical Center, Director of Robotic Surgery at Hackensack Meridian Health, and Professor and Inaugural Chair of Urology at Hackensack Meridian School of Medicine.

References

  1. ↑ "NCI Dictionary of Cancer Terms". National Cancer Institute. 2011-02-02. Retrieved 2018-01-15.
  2. ↑ Clark PE, Stein JP, Groshen SG, Cai J, Miranda G, Lieskovsky G, Skinner DG (July 2005). "Radical cystectomy in the elderly: comparison of clinical outcomes between younger and older patients". Cancer. 104 (1): 36–43. doi: 10.1002/cncr.21126 . PMID   15912515.
  3. ↑ "Segmental cystectomy" . Retrieved 2018-01-15.
  4. 1 2 3 Wieder JA (2014). Pocket Guide to Urology. US. pp. 54–57. ISBN   978-0-9672845-6-9.{{cite book}}: CS1 maint: location missing publisher (link)
  5. ↑ "NCCN Clinical Practice Guidelines in Oncology". www.nccn.org. 2018. Retrieved 2018-01-12.
  6. 1 2 3 4 Hanno PM, Guzzo TJ, Malkowicz SB, Wein AJ (2014). Penn clinical manual of urology (2nd ed.). Philadelphia, PA. ISBN   9781455753598. OCLC   871067936.{{cite book}}: CS1 maint: location missing publisher (link)
  7. 1 2 Wein AJ, Kavoussi LR, Partin AW, Peters C, Campbell MF, Walsh PC (2016). Campbell-Walsh urology (11th ed.). Philadelphia, PA. ISBN   9781455775675. OCLC   931870910.{{cite book}}: CS1 maint: location missing publisher (link)
  8. ↑ McAninch JW, Lue TF, Smith DR (2013). Smith and Tanagho's general urology (18th ed.). New York: McGraw-Hill Professional. ISBN   9780071624978. OCLC   778040102.
  9. 1 2 3 4 5 6 7 Smith Jr JA, Howards SS, Preminger GM, Dmochowski RR (2017-02-24). Hinman's atlas of urologic surgery (4th ed.). Philadelphia, PA. ISBN   9780128016480. OCLC   968341438.{{cite book}}: CS1 maint: location missing publisher (link)
  10. ↑ Traver MA, Vaughan ED, Porter CR (December 2009). "Radical retropubic cystectomy". BJU International. 104 (11): 1800–21. doi:10.1111/j.1464-410x.2009.09043.x. PMID   20053198. S2CID   32376371.
  11. 1 2 3 4 5 6 Bishoff JT, Kavoussi LR (December 2016). Atlas of laparoscopic and robotic urologic surgery (3rd ed.). Philadelphia, PA. ISBN   9780323393263. OCLC   960041110.{{cite book}}: CS1 maint: location missing publisher (link)
  12. 1 2 Rai BP, Bondad J, Vasdev N, Adshead J, Lane T, Ahmed K, et al. (Cochrane Urology Group) (April 2019). "Robotic versus open radical cystectomy for bladder cancer in adults". The Cochrane Database of Systematic Reviews. 2019 (4): CD011903. doi:10.1002/14651858.CD011903.pub2. PMC   6479207 . PMID   31016718.
  13. 1 2 Garden OJ (2012). Principles and practice of surgery (6th ed.). Edinburgh: Churchill Livingstone Elsevier. ISBN   9780702043161. OCLC   797815510.
  14. ↑ Paterson-Brown S (2014). Core topics in general and emergency surgery (5th ed.). Edinburgh. ISBN   9780702049644. OCLC   829099224.{{cite book}}: CS1 maint: location missing publisher (link)
  15. ↑ Lawrence PF (2013). Essentials of general surgery (5th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN   9780781784955. OCLC   768469762.
  16. ↑ Falcone T, Goldberg JM (2010). Basic, advanced, and robotic laparoscopic surgery. Philadelphia, PA. ISBN   9781416062646. OCLC   912279810.{{cite book}}: CS1 maint: location missing publisher (link)
  17. ↑ "Postoperative complications". Standford Health Care. 2017. Archived from the original on 2020-10-28. Retrieved 2018-01-17.
  18. ↑ Lauridsen SV, Tønnesen H, Jensen BT, Neuner B, Thind P, Thomsen T (August 2017). "Complications and health-related quality of life after robot-assisted versus open radical cystectomy: a systematic review and meta-analysis of four RCTs". Systematic Reviews. 6 (1): 150. doi: 10.1186/s13643-017-0547-y . PMC   5541663 . PMID   28768530.
  19. 1 2 3 Taneja SS, Shah O (2017-11-07). Taneja's complications of urologic surgery : diagnosis, prevention, and management (5th ed.). Edinburgh. ISBN   9780323392426. OCLC   1004569839.{{cite book}}: CS1 maint: location missing publisher (link)
  20. ↑ Cookson MS (2018). Contemporary Approaches to Urinary Diversion and Reconstruction. Elsevier - Health Science. ISBN   9780323570060. OCLC   1004252333.
  21. 1 2 3 Burden S, Billson HA, Lal S, Owen KA, Muneer A, et al. (Cochrane Urology Group) (May 2019). "Perioperative nutrition for the treatment of bladder cancer by radical cystectomy". The Cochrane Database of Systematic Reviews. 2019 (5): CD010127. doi:10.1002/14651858.CD010127.pub2. PMC   6527181 . PMID   31107970.
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