Urinary Bladder Removal (Cystectomy)

Cystectomy (synonyms: urinary bladder removal; complete removal of the bladder) is the surgical removal of the complete urinary bladder. The following forms of cystectomy are distinguished:

  • Simple cystectomy – only the urinary bladder is removed.
    • Indication: benign (benign) disease.
    • Advantages: Preservation of continence (ability to withhold urination for a period of time or to voluntarily trigger the process of excretion) and potency in men; in men, seminal vesicles (glandula vesiculosa, vesicula seminalis) and prostate (cystoprostatectomy) are preserved; in women, uterus (uterine; hysterectomy) and adnexa (fallopian tubes and ovary; ovariectomy) are preserved
  • Radical cystectomy – removal of the urinary bladder and pelvic lymph nodes (pelvic lymphadenectomy).
    • Indication: malignant (malignant) diseases.
    • Lymph node dissection (removal of lymph nodes) extends to the lymph nodes in the obturator fossa (area in the small pelvis of the body) and the vasa iliaca externa to the junction of the internal iliac artery. Optionally, the procedure can be extended to the level of the aortic bifurcation.
    • Additionally removed are:
      • In men, seminal vesicles (glandula vesiculosa, vesicula seminalis) and prostate (cystoprostatectomy).
      • In women, taking into account the age, uterus (uterus; hysterectomy) and adnexa (fallopian tubes and ovary; ovarectomy) and, if necessary, the anterior vaginal wall.

Indications (areas of application)

  • Benign (benign) diseases:
    • Dysfunction of the bladder such as shrinkage bladder (nephrocirrhosis).
    • Interstitial cystitis (IC; chronic abacterial cystitis/bladder inflammation).
  • Malignant (malignant) diseases:
    • Urinary bladder carcinoma (bladder cancer) – deeper infiltrating tumors (T2-T4, NXM0), without distant metastases (daughter tumor not located near the primary tumor and regional lymph node system).
    • Recurrent (recurrent) superficial carcinoma of the urinary bladder.

Contraindications

  • Blood clotting disorders

Before surgery

  • Before surgery, the patient must be informed or educated in detail about the procedure and any risks or side effects, and must give written consent.
  • Discontinuation of anticoagulants (anticoagulants) – Discontinuation of anticoagulants such as acetylsalicylic acid (ASA) or Marcumar should be done in consultation with the attending physician. Discontinuing medication for a short period of time significantly minimizes the risk of rebleeding without a significant increase in risk to the patient. If there are diseases that can affect the blood clotting system and are known to the patient, this must be communicated to the attending physician.
  • A urinary tract infection must be excluded.
  • If necessary, stoma consultation (due tourinary diversion).
  • If the cystectomy is performed in the context of a tumor disease, it may be that neighboring organs are already infiltrated. In this case, the affected part or the whole organ will be removed with during the cystectomy. The patient should be informed in advance about this possibility and give his consent to the resection (surgical removal).

The surgical procedures

Cystectomy can be performed by open surgery (the entire abdomen is opened; gold standard) or by laparoscopy (minimally invasive). In laparoscopy, surgical instruments are inserted into the abdomen through small incisions. By removing the urinary bladder, a new urinary diversion must be created. The following methods are available to preserve continence:

  • Continent urinary diversion – urinary diversion via a reservoir; voluntary urination is preserved.
    • Complications: Absorption disorders (impaired absorption of macro- and micronutrients) due to impaired intestinal function → chronic diarrhea (diarrhea), osteoporosis (bone loss), acid-base imbalances
      • Neobladder
        • Prerequisite: urethra (urethra) and urethral sphincter remain intact
        • Bladder replacement made from a piece of small intestine placed in the same place of the original bladder and sewn to the urethra.
        • Advantage: The patient can let water naturally (higher quality of life).
        • Complications: Urinary incontinence, nocturnal urinary incontinence.
      • Pouch bladder
        • The urethra (urethra) must also be removed.
        • A piece of small or large intestine is used to form the reservoir. This is discharged through the skin (in most cases in the area of the navel). 4-6 times a day, the catheter must be emptied by the patient.
        • Complications: difficult emptying of the reservoir due to constrictions at the opening.
      • Ureterosigmoideostomy (uretero-intestinal impaction/HDI).
        • The reservoir is located in the rectum (rectal). The ureters are sutured into the sigmoid (connection between the colon and rectum). Urine is retained by the sphincter ani (anal sphincter). Stool and urine are emptied together.
        • Complications: Decrease in continence due to an age-related decrease in the strength of the anal sphincter; increased risk of malignant changes in the area where the ureters (ureters) have been implanted.
        • Method rarely used anymore.

Which method is chosen depends on the individual situation of the patient – gender, age, physical condition. Likewise, the psychological condition must also be taken into account.If a continent urinary diversion is not possible, the following methods are available:

  • Incontinent urinary diversion – urine is drained via special collection systems; there is no replacement bladder
    • Conduit
      • The ureter and skin are connected by a piece of intestine (small or large bowel) (stoma/artificial outlet). Urine is passed directly into an adhesive bag attached to the skin (usually right lower abdomen).
      • Advantage: Especially suitable for elderly patients (simplest form of urinary diversion).
      • Complications: Stenosis (narrowing) in the area of the connection of ureter (ureter) and skin; necrosis (death of tissue) in the area of the conduit; impairments of the adhesive bag supply by e.g. skin changes.
    • Renal fistula
      • Connection of the kidney with a catheter attached to the skin.
    • Ureterodermal fistula (ureterocutaneous fistula; synonym: ureterocutaneostomy).
      • Suturing of one or both ureters (ureters) directly into the skin (derma).
      • Very rarely used method.

Further notes

  • Perioperative mortality (death rate during surgery) and morbidity (incidence of disease) are <5%.
  • Laparoscopic (“by laparoscopy“) radical cystectomy is equivalent to open surgery in terms of recurrence-free survival, cancer-specific survival, and overall survival.
  • Alternatives to cystectomy for muscle-invasive bladder cancer:
    • “Radical” transurethral resection ± chemotherapy; methotrexate and cisplatin allow bladder-preserving approach in 60% of patients.
    • Partial bladder resection, radiotherapy ± chemotherapy [close follow-up required! ]If recurrence occurs, the indication for salvage cystectomy should be generous
  • Patients with superficial high-risk tumors (pTa, pTis, pT1, each with indication for cystectomy) and T2 tumors underwent transurethral resection (TUR; tumor is removed via the urethra)) with the goal of R0 TUR) and radiotherapy (radiation therapy); in case of residual or recurrent tumor (recurrence of the tumor), salvage cystectomy (cystectomy as a palliative measure after previous failed, curatively intended radiotherapy) was subsequently performed. Results: 83% of patients (290 of 369) experienced complete tumor remission at control TUR 6 weeks after radiotherapy. The CR (complete response) rate was 68% after radiotherapy alone, 86% after radiochemotherapy, and 87% after radiochemotherapy plus hyperthermia (heat therapy).

Cystectomy is performed under general anesthesia.

Possible complications

  • Bleeding
  • Damage to neighboring organs
  • Nerve or vascular damage
  • Skin and tissue damage
  • Wound healing disorders and wound infections
  • Suture insufficiency
  • Incisional hernia (scar hernia)
  • Hematomas (bruises)
  • If there is injury to the intestine during surgery: peritonitis (inflammation of the peritoneum), intestinal fistula, ileus (intestinal paralysis/obstruction).
  • If lymphatic vessels were removed during cystectomy: Accumulation of lymphatic fluid
  • Thrombosis (formation of blood clots), pulmonary embolism (occlusion of a pulmonary artery by a thrombus (blood clot)).
  • Storage damage
  • Women:
    • Dyspareunia (pain during sexual intercourse).
    • Sterility (infertility)
    • Climacterium praecox (premature menopause; premature menopause).
  • Men:
    • Erectile dysfunction (common)
    • Sterility (infertility) after radical cystectomy; if childbearing is desired, a sperm depot (cryopreservation of sperm) should be created prior to the procedure
  • Complications of urinary diversions
    • Stenosis (narrowing) and stricture (scarring constriction), especially where the ureter (ureter) and urethra (urethral) are connected to the skin or portions of the bowel; increased risk of urinary retention