Bladder Cancer

Removal and reconstruction

If you have muscle-invasive bladder cancer, superficial cancer involving a large area of the bladder, or your cancer recurred after having intravesical therapy, your care team may recommend surgical removal of the bladder (cystectomy). In most cases, the entire bladder is removed (radical cystectomy), along with nearby lymph nodes and reproductive organs.

A radical cystectomy may be performed through one incision in your belly or done with a laparoscope or robotic equipment through several smaller incisions.

Reconstructive surgery

After the bladder has been removed, the surgeon will perform reconstructive surgery to provide a new way to store and eliminate urine (a urinary diversion). The type of diversion depends on your medical condition and personal preferences. Options include the following:

  • Ileal conduit – the surgeon removes a section of the intestine and then reconnects the rest of the intestine. One end of the removed section is connected to the ureters, which carry urine from the kidneys. The other end is attached to a surgically made opening in the belly (a stoma). Urine flows continuously through this ileal conduit to the outside, collecting in a small bag attached to the stoma (an ostomy bag) that is emptied periodically. The pouch will lie flat against the body and can be covered with your clothes. This surgery is known as an incontinent diversion because the patient no longer controls the flow of urine from the body.
  • Continent cutaneous pouch – the surgeon uses a section of intestine to create a urine storage pouch within the body. This pouch, also referred to as an Indiana pouch, is connected to the ureters on one end and to a stoma on the other. The patient drains the pouch by inserting a catheter (small thin tube) through the stoma. This surgery is known as a continent diversion because the patient controls the flow of urine.
  • Orthotopic bladder (neobladder) – The surgeon uses a section of intestine to create a replacement for the bladder. One end of the intestine is connected to the ureters, and the other end is connected to the urethra, the tube that normally drains urine from the body. The urge to urinate is lost with this procedure.

With an ileal conduit, stents (small mesh tubes) may be inserted through the stoma to the ureters to help drain urine while the patient heals. For a continent cutaneous pouch or neobladder, catheters and/or stents may be placed to help with drainage.

The typical stay in the hospital after surgery is about a week. During this time, you will learn how to care for your urinary diversion and for any catheters or stents that may still be in place when you go home. One of the most important things to remember is to always wash your hands with soap and water before and after caring for your urinary diversion.


Living with urinary diversion

Once at home, you will continue caring for your urinary diversion as you were taught in the hospital.

  • Ileal conduit – the stoma and skin around it must be washed, rinsed, and dried completely each day. The plastic pouch attached to the stoma needs to be rinsed and cleaned daily and changed every five to seven days. A cover can be used over the pouch to absorb sweat and make you feel more comfortable. A valve at the bottom of the pouch is used to empty urine into the toilet. At night, a tube can be attached to the valve to carry urine to a bigger pouch while you sleep.
  • Continent cutaneous pouch – after any stents and catheters are removed, urine can be emptied by inserting a catheter through the stoma and draining the urine into the toilet. The stoma and surrounding skin must be washed and dried before and after each catheterization. Initially, the pouch will need to be drained every two to three hours, but over time, you should be able to drain the pouch every four to six hours.
  • Neobladder – after the catheters are removed, an incontinent pad (such as Depends) and an absorbent pad on the bed at night will be necessary until your urinary control improves. Your doctor will give you a urination schedule, which usually begins with urinating every two hours. Bearing down (the Valsalva maneuver), as if having a bowel movement will cause urination. You may be asked to insert a catheter twice a day after urinating to see if the bladder is emptying completely. The catheter must be irrigated during one of the catheterizations to remove mucus produced by the piece of intestine used to make the neobladder.

In subsequent weeks, the length of time between urinating will increase, and you will be able to catheterize and irrigate fewer times a day. Most patients have satisfactory urinary control during the day within three months, although there occasionally may be a little leakage, such as when you cough. Nighttime leakage may continue for a year or be permanent. Performing Kegel exercises will help to strengthen the sphincter muscle that holds urine in.

You probably will be able to resume normal activity four to six weeks after surgery, although recovery time varies by individual.

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