Removal of the bladder, called radical cystectomy, is the preferred treatment for patients with muscle-invasive bladder cancer (MIBC) as well as for some with non-muscle-invasive bladder cancer (NMIBC), such as those whose cancer persists despite therapy with intravesical treatments (reviewed in previous articles in this series).
In men undergoing radical cystectomy, the prostate and seminal vesicles may also be removed, depending on how far the cancer has spread. In women, the surgery can include removal of the uterus, ovaries, and fallopian tubes. Nearby lymph nodes are also removed during radical cystectomy.
Radical cystectomy may be performed as an open procedure or via minimally invasive surgery called laparoscopy. Tiny holes are cut into the abdomen, through which the surgical instruments are passed. In some instances, a robotic system including a camera and mechanical arms may be used to help the surgeon control the laparoscopic instruments with a computer console near the operating table.
You will require a new way to pass urine once your bladder is removed. This is called urinary diversion, which can take the form of an ileal conduit (a removable bag placed outside the body to collect urine), a continent urinary diversion (creation of an internal pouch to hold urine and a new opening through your stomach through which urine passes), or a neobladder (creation of a new bladder using a portion of your intestines).
Radical cystectomy is major surgery, and as such will usually involve a 1- to 2-week stay in the hospital for observation and recovery. During this time, you will have several catheters (tubes) placed to drain fluids from your surgical wounds, to pass urine, and to administer painkillers. Your wounds will be dressed and cleaned during your stay.
Possible Complications
As can be expected, surgery has potential risks, which will be reviewed in detail by your treating urologist. Some of these may result from the type of urinary diversion performed. A leak where the surgeon re-attaches your bowel following the urinary diversion is one such risk. It may result in infection and needs to be addressed as soon as possible. You will have follow-up imaging scans to check for such problems. Other operative risks may be specific to your case depending on your underlying medical conditions such as history of heart disease, lung disease, etc., and these will be reviewed in detail by your surgery and anesthesia team. Problems with bowel and kidney function, bleeding, infection, and kidney problems are other possible risks from the surgery and the diversion.
A stricture (narrowing) of the ureters (the tubes that drain urine from the kidneys) may also occur as a result of scarring from the surgery. This may be treated by dilating the ureter and inserting a stent (hollow tube) to keep the ureter open and help drain the urine. You may need more than one dilation if strictures recur.
Men may not be able to ejaculate following radical cystectomy, because the prostate is also normally removed. Women may have reduced sensation with sex from a narrowing of the vagina following surgery.
Lymph Node Surgery
About one fourth of patients with MIBC have spread of their disease to the lymph nodes, known as lymph node metastases. For such patients, in addition to radical cystectomy, removal of the pelvic lymph nodes that are positive for cancer has been the gold standard for management.
In patients with MIBC, pelvic lymph node dissection (LND) can identify locally advanced cancer, with the potential to improve further spread of the cancer. National and international guidelines for the management of MIBC support the role of lymph node removal during radical cystectomy.
Survival outcomes are superior when pelvic LND is performed compared with no LND, but early studies of the comparison were performed before the era of neoadjuvant chemotherapy -- that is, given before the time of surgery.
The optimal number of nodes to be removed during radical cystectomy/LND for the treatment of MIBC has been controversial, but recent research offers some clarity about the appropriate extent of the removal. The traditional thinking has been that an extended lymph node dissection is better than a limited one. While removing many lymph nodes can potentially eradicate cancer that is too small to be detected by a scan -- "micrometastatic disease" -- and improve staging of bladder cancer, an extended dissection that involves removal of additional nodes has not been proven to improve outcomes, including survival.
Lymph Node Removal in Non-Muscle-Invasive Disease
Some patients with NMIBC that has returned may also be candidates for radical cystectomy and lymph node removal, although the benefits of removing lymph nodes in NMIBC are less clear. The role of LND during radical cystectomy for NMIBC was examined by researchers from Mayo Clinic, Cleveland Clinic, and the University of Texas MD Anderson Cancer Center.
In a study that included more than 1,600 patients with NMIBC undergoing radical cystectomy, investigators found that this group does benefit from LND in the form of a lower rate of disease recurrence and increased cancer-free survival and overall survival, and that LND should not be omitted simply because patients do not have MIBC.
However, as with LND in MIBC, studies have found no advantage to extended LND on survival outcomes in patients with NMIBC.
Follow-up After Surgery
Caring for your surgical wounds is important after you are discharged from the hospital. Sutures normally will dissolve, but any clips placed to close wounds will have to be removed by a nurse at home or will require a return to the hospital.
Leaking after bladder reconstruction is a possibility. Pelvic floor exercises may help to reduce leaking. With removal of lymph nodes, edema (swelling) in your legs may occur as drainage of lymph fluid may be affected.
Detailed discussion of operative risks, approaches to urinary diversion, and close follow-up with your surgical team after discharge are all important aspects of your path to recovery.
Read previous installments in this series:
For Your Patients: Urothelial Cancer 101
For Your Patients: Staging Urothelial Cancer
For Your Patients: Weighing the Treatment Possibilities for Non-Muscle-Invasive Bladder Cancer
For Your Patients: Immunotherapy Increasingly Important for Muscle-Invasive Bladder Cancer
"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.
