Cystectomy : Indications & More

A cystectomy is a surgery to remove the urinary bladder. In most cases, it's used to treat bladder cancer. It can be done differently, from saving part of the bladder to taking it all out, along with surrounding structures and tissues.

Cystectomy refers to the process of surgically removing all or part of the bladder; it is most often performed to treat bladder cancer. This involves the removal of the entire bladder, nearby lymph nodes, and, in men, the prostate. In women, the uterus, fallopian tubes, ovaries, and part of the vagina may also be removed. After the surgery, the surgeon will have to make a new way for urine to exit your body, this is known as urine diversion. There are different types of urinary diversions, including ileal conduit, continent cutaneous pouch (such as an Indiana pouch or a neobladder), and orthotopic neobladder. Read on to understand when a cystectomy is recommended.

Cystectomy is most commonly indicated in the following scenarios:

• Bladder Cancer: The most common reason for cystectomy is bladder cancer, especially when the cancer is invasive or has not responded to other treatments such as chemotherapy or radiation. 
• Muscle invasive bladder cancer: If the cancer has spread into the muscle layer of the bladder wall.
• Non-muscle invasive bladder cancer: Here, the cancer is confined to the inner layer of the bladder and has not invaded the muscle layer.
• Congenital Abnormalities: In rare cases, individuals born with congenital abnormalities affecting the bladder may require cystectomy.
• Severe interstitial cystitis: Also known as painful bladder syndrome this is a condition characterized by inflammation of the bladder wall. The procedure may be recommended as a last resort when pain and urinary symptoms are unrelenting and life-altering.
• Trauma or damage: In cases of significant bladder damage or dysfunction not amenable to other treatments.

Every case is evaluated separately, and the choice to continue with a cystectomy considers the patient's preferences, general health, and possible advantages, risks, and alternatives.

To secure a favorable outcome and reduce the risks before a cystectomy, It is essential to go through several steps while preparing for the surgery. Although a guide will vary from person to person, here is an overall outline of the things to be done:

• Consultation: Make an appointment with your surgeon to understand the procedure well. Your surgeon will explain the steps of the procedure, the risks, and what to expect afterward.
• Preoperative Evaluation: The surgeon will assess your overall health and make sure that you are fit to undergo the procedure. This may include blood tests, imaging tests, and others.
• Nutritional Optimization: You will be given specific instructions for choosing your diet while preparing for the surgery. Sticking to a healthy diet that is rich in fiber would help  maintain a healthy gut and improve your overall health. 
• Stop certain medications and supplements: Make sure you know which medicines and supplements you are allowed to continue taking and which you should stop before your surgery.
• Arrange for support at home: Arrange for a friend or a family member to drop you home after the procedure. Also, plan to have help at home during your recovery. 

Preparation for cystectomy is a complex process that requires physical, and emotional, planning. Make sure that you are clear about the advantages and risks of the procedure. Have open communication with your healthcare team to clear all your queries.

A cystectomy involves the following steps:

• Anesthesia: The patient is administered with general anesthesia, which will render them unconscious and pain-free during the procedure.
• Incision: The surgeon cuts through the skin and tissue below the skin in the middle of the lower abdomen.

1. For open surgery, this is usually a larger single incision.
2. For laparoscopic or robotic-assisted surgery, several small incisions are made for the insertion of the laparoscope and surgical instruments. 

• Removal of the bladder:

1. Only the affected part of the bladder is taken out during a partial cystectomy.
2. A radical cystectomy involves the removal of the entire bladder. In men, a radical cystectomy usually includes the removal of the prostate and seminal vesicles. In women, a radical cystectomy usually includes removal of the uterus, ovaries, and part of the vagina if necessary.

• Lymph Nodes: Lymph nodes near the tumor are often removed to see if they are cancer-free as part of the procedure. 
• Urinary Diversion: Since the bladder is removed, the surgeon creates a new way for urine to exit the body. This can be done in various ways, including,

1. Creating an ileal conduit (urine drains into a bag outside the body).
2. Making a continent urinary reservoir (urine is stored in a pouch fashioned from the ileal pouch and drained periodically).
3. Constructing a neobladder (a new bladder is constructed from intestinal tissue and connected to the urethra).

• Closure: The incisions are sutured, stapled, or sealed with surgical tape.
• Recovery: The patient is taken to a recovery area for close attention as they wake up from anesthesia.

The length of the surgery varies, depending on the complexity of the procedure and whether additional organs (like the prostate in men) need to be removed or reconstructed. After surgery, patients stay in the hospital to recuperate and learn how to manage their new urinary diversion. Read on to understand recovery and aftercare post-cystectomy.

Recovery and aftercare following a cystectomy generally involve these steps:

• Hospital Recovery: You will spend a few days in the hospital before your discharge. During this time you will be monitored to ensure that you are healing well and the team will make sure that there are no risks of complications.
• Pain Management: Some amount of pain and discomfort is common after any procedure. This can be managed with the help of prescribed pain medications. Make sure to communicate with your healthcare team in case of intense pain.
• Wound and Stoma Care: You will learn how to care for your surgical site and, to manage the urine diversion method. (either for an ileal conduit or continent reservoir). This will include cleaning it and, if applicable, learning how to change the bag or do catheterization techniques.
• Monitoring: You will have regular follow-up appointments to check on the progress of healing and to check for any complications.
• Lifestyle Adjustments: Most patients are on a restricted diet and are told to avoid heavy lifting and any strenuous activity for several weeks. 

The length of each person’s recovery differs based on factors such as the complexity of the surgery is and whether further treatment, that is, chemotherapy or radiation, will be needed. It is vital to follow the healthcare provider’s instructions very carefully for a smooth recovery.

The complications associated with cystectomy surgery can be either immediate (short term) and/or longer term. They can range from those complications that could occur with any surgery to more specific problems with the urinary diversion. Some of the potential complications are listed here:

• Infection: There is a risk of infections of the urinary tract and the abdominal cavity after surgery. 
• Bleeding: Though rare, there is a risk of significant blood loss during the procedure, which can require a blood transfusion or even developing a collection of blood under your skin after the surgery, called a postoperative hematoma.
• Urinary problems: Depending on the type of diversion you have, you may develop incontinence (leak urine) or a blocked urine flow.
• Sexual problems: Men may have trouble getting an erection (having sex), or women may have trouble with changes in the vagina or problems having sex.
• Complications of the stoma: If a stoma is created in your surgery, you may have problems with the opening becoming too small (usually called a stenosis), or it may become longer or a different shape from the original (usually called a prolapse). 

Patients should have open and thorough discussions with their surgical team about the procedure's risks and how to recognize complications early. Patients should continue with close follow-up care after the procedure to monitor and manage potential issues.

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