Radical cystectomy with urinary diversion

Definition:

• Simple cystectomy: bladder removal.
• Total cystectomy: removal of bladder, prostate, seminal vesicles in man; removal of the bladder, uterus and the anterior part of the vagina in woman.
• Radical cystectomy: as the total, plus the removal of regional lymph nodes.
• The ureters, once detached from the bladder, must be connected or to an intestinal loop, which acts as a link with the outside (continent neobladder, catheterizable neobladder, intestinal canal) or directly to the skin.

Indications:
Bladder neoplasms
Small contracted vesicles
Radiation cystitis
Interstitial cystitis
Bladder tuberculosis
Uncontrollable bleeding of bladder origin
Complex bladder fistulas

The operation is performed as an ordinary hospitalization and implies a hospitalization that varies between 8 and 15 days and has the purpose of removing the bladder and simultaneously building a urinary derivation. When possible, the urinary derivation may be a continent orthotopic neobladder, that is a new bladder built with the intestine, positioned in the same pelvic bladder, which allows urination through the urethra and which is continent. As an alternative to the neobladder it is possible to pack a urinary derivation by isolating a section of intestine and connecting the ureters (ducts that carry the urine from the kidneys) on one side while the other end of the intestinal tract is sutured to the skin of the abdomen, generally below and to the right of the navel. Through this intestinal duct the urine flows continuously outside and must be collected in a watertight bag.

Preparation:
the patient must be shaved in the incision sites. It is necessary that the intestine be as clean as possible from the fecal residues through repeated and sometimes medicated purges to begin two days before the intervention. Oral prophylaxis with antibiotics non-absorbable from the gastrointestinal tract to sterilize the intestine as much as possible is also useful. During the operation it is necessary to place a small tube through the nose that reaches the stomach to drain the gastric juices. It will remain in place until the intestine has started functioning again.

Description of the technique:
BLADDER REMOVAL
If performed for a tumor disease the intervention usually involves a preliminary time of removal of the lymphatic glands that drain the lymph coming from the bladder (iliac and obturator loco-regional lymphadenectomy).
In summary, after having cut the abdominal wall it is necessary to access the peritoneum (sack that wraps the abdominal viscera), open it and separate the bladder from the peritoneal membrane; the deferent ducts are dissected (canalicles that transport the sperm) and the ureters are isolated, which are detached from the bladder where they penetrate it.
The bladder is then detached from the rectal wall at the back until the bladder is removed, the urethra is dissected and the excision (exeresis) is concluded. In the case of a male subject, the operative time involves the excision of the bladder, prostate and seminal vesicles in a single block. This also involves the removal of the erigentes nerves, which run in close contact with the prostate and the urethra, resulting in the loss of the ability to have a spontaneous erection. In the case of a female subject it may be necessary to remove, in addition to the bladder, the uterus and the appendages and the anterior part of the vagina.
If necessary, the intervention ends with the removal of the urethra which may require in men an additional incision in the perineum (between the scrotum and the anus).
As mentioned, in selected cases and in general for non-tumor pathologies, the removal can be limited to the bladder alone without removing the prostate, the seminal vesicles and the urethra in the man (superpullary cystectomy) or uterus and annexed in the woman. In these cases sexual activity is generally preserved.

URINARY DERIVATION
After bladder removal (cystectomy) the gastrointestinal tract most suitable for urinary derivation will be identified and isolated.
If it is decided for a neobladder, whatever the tract of an isolated intestine (ileum or colon), this will be modified, in order to obtain a spherical tank, at low pressure (that is, do not stretch before at least 200-300 cc of urine are deposited inside it) and as much as possible without peristalsis (that continuous movement that allows the intestinal material to progress towards the anus), otherwise the appearance of incontinence. There are many types of bladder reconstructions.
If possible the “new bladder” will be connected through a suture to the urethra and therefore the continence will be delegated to the normal sphincter mechanisms; if the urethra can not be used, a particular type of neobladder will be connected to the skin, which should ensure good continence; in this case the evacuation of the urine must necessarily take place at regular intervals through a catheter that from the skin reaches into the neobladder (self-catheterization). In the case of non-continent derivation (Ileale duct), the elimination of the urine, which are collected in an bag, will take place due to continuous spillage.
The ureters can be reconnected (re-implanted) to the new bladder with more or less complex techniques; In general, there is a tendency to create an anti-reflux mechanism between the ureter and the neobladder in order to avoid damage from kidney infections but it is not actually demonstrated that these effects are actually obtained; it is also proven that the more complex the techniques are, the greater the risk of complications is. Generally a ureteral tube (tutor) is placed for 10-12 days in order to facilitate the healing of the suture between the ureter and the intestine.
The intervention ends with the positioning of one or more drains (suction tubes) and the reconstruction of the incised planes.

Duration of the intervention:
depending on the complexity of the derivation, the times can be variable from two hours to a time greater than four hours.
Complications: the frequency of complications in patients undergoing radical cystectomy is about 25%; they are distinguished in intraoperative or postoperative. The frequency of reoperation after cystectomy varies between 10% and 20%. Mortality is around 1%.

The intraoperative complications are represented by:

• bleeding that can be abundant especially if the disease involves the large blood vessels and may require blood transfusions;
• accidental injuries of the obturator nerve during lymphadenectomy;
• accidental lesions of the intestine during bladder removal or preparation of the intestinal tract that will be used later.

Postoperative complications can be immediate (within 30 days) and late (after 30 days).

Among the immediate ones related directly to the creation of the derivation it is recalled:

• anastomotic dehiscence (failing) of the suture between neobladder and ureter or of the walls of the remodeled intestine with escaping of urinary liquid. It involves abdominal pain and prolonged intestinal blockage (paralytic ileus); if it continues over time (a non-absolute time limit is 30 days), it may require re-operation but normally it heals itself (conservative or waiting treatment) thanks to the drainage tube that carries this extravasation of urine outside;
• infections;
• difficult intermittent catheterization of the neobladder (when it is not directly connected to the urethra) which is normally resolved by leaving a catheter in place for 2 or 3 weeks; rarely requires a re-operation;
• ureteral obstruction (usually modeling tutors are left in place to protect the suture between neobladder and ureter just to avoid this complication). If it occurs after their removal or in their absence it may require a re-operation, most often endoscopic, at least in the first instance.
• ureteral reflux: it is a frequent complication that must be followed over time and corrected only if it causes kidney damage.

Among the immediate ones not directly related to the creation of the derivation it is recalled:

• infections: if collected (abscess) can require a surgical drainage; they are normally treated conservatively; especially in debilitated patients it can be life threatening;
• anastomotic dehiscence (failing) of enteric suture with leakage of intestinal fluid. It involves abdominal pain and prolonged intestinal blockage (paralytic ileus). Almost always requires a reoperation to close the gap created; the mechanical ileus (intestinal block) from the impossibility of transit of the feces through reconstituted intestinal continuity (angulation of a loop, adherent bridle, internal hernia, devascularization of a loop). Requires a re-operation;
• wound complications: the wound may be the site of superficial or deep infection, which may require “curettage” surgery (surgical cleaning) usually under local anesthesia, or post-intervention hernias; they are complications common to any abdominal surgery;
• prolonged lymphorrhea (loss of lymphatic fluid) through the drainage tube: it is a self-limiting complication and does not require re-intervention except when responsible for a saccharged accumulation of lymph (lymphocele).

Among the late complications related to the creation of the neobladder it is recalled:

• rupture of the neobladder or its fixation: it may require intervention or simple percutaneous drainage or repair of the neobladder with open surgery;
• formation of stones: they can form on the metal point used in the construction of a neobladder or be secondary to infections, collections of mucus or foreign bodies. They require a reoperation that is most often done endoscopically through the section that makes it communicate with the outside (urethra or intestinal duct or appendix). Rarely may require open surgical intervention;
• Ureteral obstruction: it is probably the most frequent complication and it sees as its main cause the poor blood supply (ischemia) of the terminal tract of the ureter. It is responsible for kidney failure if it affects both the kidneys at the same time. It often requires an initial drainage of the urine through a thin catheter placed, most of the time, under local anesthesia through the lumbar skin. Once the urinary drainage is obtained, the procedure aimed at solving the obstruction can be planned: it can be done either by endoscopic, retrograde or anterograde techniques, or by open surgery. The anterograde technique, which follows the urine flow from top to bottom, expands the connection created between skin and excretory way of the kidney to bring down from the kidney, along the ureter, a flexible instrument (ureteroscope) that reaches at the site of the obstruction and through which one can then obtain an incision of the narrowing. It is also possible to use particular catheters that can dilate and / or affect the site of the narrowing on radiological guidance. The retrograde technique, which is performed in the opposite direction to the urinary flow, from the bottom upwards, requires the passage of endoscopic instruments through the urine drainage pathway to reach and incise or dilate the ureteral narrowing. Increasingly these techniques are used simultaneously. The traditional surgical route requires an open reoperation with isolation of the ureters, incision of the narrow section and new suture with the neobladder;
• ureteral reflux: it is the passage of urine that comes from the neobladder towards the kidneys. It may require re-intervention only if responsible for deterioration of the kidney function;
• urinary incontinence: it is a common occurrence if it happens sporadically, especially at night or following sudden increases in abdominal pressure and in such cases it does not require treatment unless a prescription of subsidies to contain it. If frequent or persistent it can be caused either by insufficiency of the sphincter mechanisms or by a reduced capacity of the neobladder (it keeps little urine and when it is filled it overflows). In the first case you can try to solve it either with gymnastics to strengthen the pelvic muscles, or injecting into the urethra a substance that by expanding under the mucosa obstructs the channel (internal diameter) or with an open surgery aimed at restricting the width of the channel. In the second case it is only a question of patience: within 6-12 months the neobladder will become more capacious.
• hyper continence: it is a possible event especially in the continent urinary derivations in women and it is characterized by the impossibility of completely emptying the bladder. It is usually treated with intermittent clean self-catheterizations;
  problems of the ostomy: they go from the narrowing of the cutaneous stoma (new-formed orifice through which the neobladder is attached to the skin) usually resolvable with progressive and continuous dilations, to the parastomal hernia. The latter must be corrected surgically if particularly annoying or voluminous. Approximately 25% of patients are affected overall;
• deterioration of kidney function and anemia: it is necessary to monitor throughout life the kidney function. Even in the absence of the aforementioned complications, it is possible to have an insidious and slow progression towards kidney failure, often aggravated by the reabsorption of substances present in the urine by the gastrointestinal tract used to construct the neobladder. These disorders over time tend to shrink and are related to the previous function of the intestinal tract used. To counteract this modification of electrolytes in the blood (hyperchloremic acidosis) it is usual to give bicarbonate. Hemoglobin and red blood cell counters should also be controlled throughout life because the use of an intestinal tract can reduce the absorption of vitamins such as e.g. vitamin B12 responsible for anemia. Vitamin B12 can be administered by injection;
• phlebothrombosis and / or pulmonary embolism, cardiopulmonary complications, gastric ulcers can complicate any type of operation.

Post-operative hospitalization:
the postoperative hospital stay is always variable, we can only say that if the course is regular, drainage in the pelvic excavation takes place on the 4th or 8th day (in any case it is subordinated to the presence of lymphorrhea). The average hospital stay is around 12-15 days. In the first postoperative period (first 4-6 days) it may be necessary to use a central vein (subclavian) to feed; feeding by mouth will resume in 4th – 5th day once the bowel has started moving again. We can roughly say that if the course is regular, the catheter that enters the neobladder must remain in place for 10-15 days on average.

Convalescence:
intestinal anastomosis normally takes some time to settle. The discharge will necessarily be scheduled only after the patient has resumed normal intestinal function. Generally it can be said that after one month the patient can resume his normal activities.

How to behave in case of complications arising after discharge:
it is necessary that for the whole life the patient remains in contact with a urological center and that it communicate to it every related and pertinent problem of the intervention, as difficult emptying of the neobladder (sense of tension or abdominal filling), fever that does not recede with traditional antibiotic therapy, marked asthenia, anemia, abdominal pains of uncertain nature, alteration of the blood parameters of kidney function, lumbar pains or colic pains etc.