Cystectomy is a medical term for

surgical Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...

removal of all or part of the

urinary bladder The urinary bladder, or simply bladder, is a hollow organ in humans and other vertebrates that stores urine from the kidneys before disposal by urination. In humans the bladder is a distensible organ that sits on the pelvic floor. Urine enters ...

. It may also be rarely used to refer to the removal of a

cyst A cyst is a closed sac, having a distinct envelope and cell division, division compared with the nearby Biological tissue, tissue. Hence, it is a cluster of Cell (biology), cells that have grouped together to form a sac (like the manner in which ...

. The most common condition warranting removal of the

bladder cancer Bladder cancer is any of several types of cancer arising from the tissues of the urinary bladder. Symptoms include blood in the urine, pain with urination, and low back pain. It is caused when epithelial cells that line the bladder become mali ...

. Two main types of cystectomies can be performed. A partial cystectomy (also known as a segmental cystectomy) involves removal of only a portion of the bladder. A radical cystectomy involves removal of the entire bladder along with surrounding lymph nodes and other nearby organs that contain cancer. Evaluation of the tissue removed during cystectomy and lymph node dissection aids in determining pathological

cancer staging Cancer staging is the process of determining the extent to which a cancer has developed by growing and spreading. Contemporary practice is to assign a number from I to IV to a cancer, with I being an isolated cancer and IV being a cancer that ha ...

. This type of cancer staging can be used to determine further work-up, treatment, and follow-up needed along with potential prognosis. After the bladder has been removed, a

urinary diversion Urinary diversion is any one of several surgical procedures to reroute urine flow from its normal pathway. It may be necessary for diseased or defective ureters, bladder or urethra, either temporarily or permanently. Some diversions result in a ...

is necessary to allow elimination of urine.

Medical uses

Malignancy

Radical cystectomy is the recommended treatment for

that has invaded the muscle of the bladder. Cystectomy may also be recommended for individuals with a high risk of cancer progression or failure of the cancer to respond to less invasive treatments.

Types

When determining the type of cystectomy to be performed many factors are taken into consideration. Some of these factors include: age, overall health, baseline bladder function, type of cancer, location and size of the cancer, and

stage Stage or stages may refer to: Acting * Stage (theatre), a space for the performance of theatrical productions * Theatre, a branch of the performing arts, often referred to as "the stage" * ''The Stage'', a weekly British theatre newspaper * Sta ...

of the cancer.

Partial cystectomy

A partial cystectomy involves removal of only a portion of the bladder and is performed for some benign and malignant tumors localized to the bladder. Individuals that may be candidates for partial cystectomy include those with single tumors located near the dome, or top, of the bladder, tumors that do not invade the muscle of the bladder, tumors located within bladder

diverticulum In medicine or biology, a diverticulum is an outpouching of a hollow (or a fluid-filled) structure in the body. Depending upon which layers of the structure are involved, diverticula are described as being either true or false. In medicine, t ...

, or cancer that is not

carcinoma in situ Carcinoma ''in situ'' (CIS) is a group of abnormal cells. While they are a form of neoplasm, there is disagreement over whether CIS should be classified as cancer. This controversy also depends on the exact CIS in question (i.e. cervical, skin, bre ...

(CIS). A partial cystectomy may also be performed for removal of tumors which have originated and spread from neighboring organs such as the colon.

Radical cystectomy

A radical cystectomy is most commonly performed for cancer that has invaded into the muscle of the bladder. In a radical cystectomy the bladder is removed along with surrounding lymph nodes (

lymph node dissection Lymphadenectomy or lymph node dissection is the surgical removal of one or more groups of lymph nodes. It is almost always performed as part of the surgical management of cancer. In a regional lymph node dissection, some of the lymph nodes in th ...

) and other organs that contain cancer. In men, this could include the prostate and seminal vesicles. In women, this could include a portion of the vagina, uterus, Fallopian tubes, and ovaries.

Technique

Open

In an open radical cystectomy a large incision is made in the middle of the abdomen from just above or next to the umbilicus to the

pubic symphysis The pubic symphysis is a secondary cartilaginous joint between the left and right superior rami of the pubis of the hip bones. It is in front of and below the urinary bladder. In males, the suspensory ligament of the penis attaches to the pubic ...

. The following information provides general steps to the procedure and may occur in varying order depending on the surgeon. The

ureter The ureters are tubes made of smooth muscle that propel urine from the kidneys to the urinary bladder. In a human adult, the ureters are usually long and around in diameter. The ureter is lined by urothelial cells, a type of transitional epit ...

s are located and cut free from the bladder. The bladder is separated from surrounding structures and removed. The

urethra The urethra (from Greek οὐρήθρα – ''ourḗthrā'') is a tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body of both females and males. In human females and other primates, the urethra con ...

, which drains urine from the bladder, may also be removed depending on tumor involvement. In men, the prostate may or may not be removed during this procedure. Pelvic lymph node dissection (PLND) is performed. A urinary diversion is then created and the free ends of the ureters are reconnected to the diversion.

Minimally invasive

A minimally invasive radical cystectomy more commonly known as a robot-assisted laparoscopic radical cystectomy (RARC) may be an option for individuals depending on several factors including but not limited to: their overall health (with special attention to their lung health),

body mass index Body mass index (BMI) is a value derived from the mass (weight) and height of a person. The BMI is defined as the body mass divided by the square of the body height, and is expressed in units of kg/m2, resulting from mass in kilograms and he ...

(BMI), number and types of previous surgeries, along with the location and size of the bladder cancer. In a RARC several small incisions are made across the abdomen to allow placement of surgical instruments. These instruments are then connected to a

surgical robot Robotic surgery are types of surgical procedures that are done using robotic systems. Robotically assisted surgery was developed to try to overcome the limitations of pre-existing minimally-invasive surgical procedures and to enhance the capabil ...

that is controlled by the surgeon. A head down ( Trendelenburg) position is used and the abdomen is inflated with gas (

insufflation In religious and magical practice, insufflation and exsufflation are ritual acts of blowing, breathing, hissing, or puffing that signify variously expulsion or renunciation of evil or of the devil (the Evil One), or infilling or blessing with goo ...

) to allow better operating space and visualization. The remainder of the procedure is carried out in a fashion similar to the open procedure. Compared to open surgery, minimally invasive radical cystectomy probably requires fewer blood transfusions and may shorten hospital stay slightly. For rates of major or minor complications, quality of life, time to recurrence and rates of cancerous cells left behind after surgery, there may be little to no difference between robotic and open surgery as treatment for bladder cancer in adults.

Contraindications

Generally, there are no specific contraindications to having a cystectomy. However, cystectomy should not be performed in individuals who are not healthy enough to undergo a major surgical procedure. This includes individuals who cannot tolerate general anesthesia or those with severe or inadequately managed co-morbidities such as diabetes, heart, lung, kidney, or liver disease. This also includes individuals who are severely malnourished, have problems with blood clotting, or severe laboratory abnormalities. Also, individuals with an active illness or infection should delay surgery until recovery. Robotic-assisted or laparoscopic surgery is contraindicated for individuals with severe heart and lung disease. During this method of surgery the positioning and abdominal insufflation places extra strain on the chest wall impairing lung function and the ability to oxygenate the blood. A partial cystectomy is contraindicated in a form of bladder cancer called

(CIS). Other contraindications for partial cystectomy include severely diminished bladder capacity or cancer in very close proximity to the bladder trigone, where the urethra and ureters connect to the bladder.

Risks and complications

Radical cystectomy with the creation of a urinary diversion can be associated with several risks and complications due to the extent and complexity of the surgery. As with most major surgeries there is risk from anesthesia, also, risk of bleeding, blood clots, heart attack, stroke, and pneumonia or other respiratory problems. There is also a risk of infection involving the urinary tract, abdomen, and gastrointestinal tract. After the surgical incisions are closed there is a risk of infection at these sites.Complications are similar between open and minimally invasive cystectomy techniques and include the following:

Gastrointestinal tract

ileus Ileus is a disruption of the normal propulsive ability of the intestine. It can be caused by lack of peristalsis or by mechanical obstruction. The word 'ileus' is from Ancient Greek ''eileós'' (, "intestinal obstruction"). The term 'subileus' re ...

, where movement within the intestines slows down is the most common complication following cystectomy. This is due to a variety of factors including manipulation of the intestines due to their proximity of the bladder, the actual operation on the intestines to create a urinary diversion, or even certain medications such as

narcotic The term narcotic (, from ancient Greek ναρκῶ ''narkō'', "to make numb") originally referred medically to any psychoactive compound with numbing or paralyzing properties. In the United States, it has since become associated with opiates ...

s. In addition to slowing of the small intestine, the small intestine can also become obstructed. After creation of a urinary diversion, intestinal contents can leak at the site where the intestine are reconnected.

Urinary tract

With creation of a urinary diversion it is possible for the ureters to become obstructed preventing the drainage of urine from the kidneys. If this occurs, another procedure to insert a percuntaneous nephrostomy tube may be need to allow drainage of urine from the body. Obstruction of the ureter most commonly occurs at the site where the ureters are reconnected to the urinary diversion created. A small, hollow, flexible tube called a stent may be placed inside the ureter at the time of surgery to possibly help the reconnection site to heal. This reconnection site is also at risk for leaking urine within the abdomen. If a partial cystectomy is performed, damage to the ureter may occur depending on the location of the tumor removed. This may require an additional procedure to repair.

Nerve injury

Due to the location of the operation, damage to nerves in the pelvis can occur during removal of the bladder or lymph nodes. Nerves in this area are responsible for movement and sensation of the legs and include the

obturator nerve The obturator nerve in human anatomy arises from the ventral divisions of the second, third, and fourth lumbar nerves in the lumbar plexus; the branch from the third is the largest, while that from the second is often very small. Structure The o ...

, the

genitofemoral nerve The genitofemoral nerve refers to a nerve that is found in the abdomen. Its branches, the genital branch and femoral branch supply sensation to the upper anterior thigh, as well as the skin of the anterior scrotum in males and mons pubis in femal ...

, and the

femoral nerve The femoral nerve is a nerve in the thigh that supplies skin on the upper thigh and inner leg, and the muscles that extend the knee. Structure The femoral nerve is the major nerve supplying the anterior compartment of the thigh. It is the largest ...

. Any of these complications may require another operation or re-admission to the hospital.

Recovery

Diet before and after surgery

Immediately after surgery no food or drink is allowed due to involvement of the gastrointestinal tract in the surgery. The diet will then be slowly advanced to liquids and then solid foods as tolerated. If gastrointestinal complications such as nausea, vomiting, or abdominal bloating occur the diet may be stopped or advancement of the diet slowed down depending on the severity. For people who have difficulties eating before or after a radical cystectomy, additional nutrition may be beneficial when compared with waiting until ordinary food can be tolerated. Immuno-enhancing nutrition with high levels of nutrients may decrease complications within 90 days of surgery. When compared with a multivitamin and mineral supplement, perioperative oral supplements may slightly decrease postoperative complications. It is uncertain if giving an individual undergoing a radical cystectomy amino acids, branch chain acids or preoperative oral supplements improve complications after surgery. Feeding into a vein and early postoperative feeding may increase postoperative complications. These diet interventions do not appear to affect the length of hospital stay.

Pain control

Intravenous Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...

pain medication such as narcotics are typically used immediately after surgery. Pain medications can be switched to an oral form once a diet is tolerated.

Activity

Early activity is encouraged after surgery. Individuals may be able to walk and sit in a chair as early as the same day of surgery. Usually individuals are able to walk around their room or hospital ward within a day or two after surgery. Some individuals may require additional assistance or physical therapy in the hospital or once discharged home.

Venous thromboembolism prevention

Approaches to prevent

venous thromboembolism Venous thrombosis is blockage of a vein caused by a thrombus (blood clot). A common form of venous thrombosis is deep vein thrombosis (DVT), when a blood clot forms in the deep veins. If a thrombus breaks off (embolizes) and flows to the lungs to ...

(VTE) are performed both before and after surgery. Compression devices placed around the legs or medications such as

Heparin Heparin, also known as unfractionated heparin (UFH), is a medication and naturally occurring glycosaminoglycan. Since heparins depend on the activity of antithrombin, they are considered anticoagulants. Specifically it is also used in the treatm ...

low molecular weight heparin Low-molecular-weight heparin (LMWH) is a class of anticoagulant medications. They are used in the prevention of blood clots and treatment of venous thromboembolism (deep vein thrombosis and pulmonary embolism) and in the treatment of myocardial in ...

(LMWH) are commonly used. VTE prophylaxis with LMWH may even be continued after hospital discharge in needed.

Surgery follow-up

If an open cystectomy was performed, the staples closing the incision are usually removed 5 to 10 days after surgery. Further follow-up with the surgeon is typically scheduled 4 to 6 weeks after surgery and may involve laboratory or imaging studies to assess recovery along with further care and follow-up.

References

{{Urologic surgical and other procedures Urologic surgery Surgical removal procedures