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Urinary Cystectomy
Removal of the urinary bladder

Over 50,000 cases of urinary bladder cancer are diagnosed every year and is the 5th most common cancer detected in the United States. These cancers occur three times more commonly in men than in women.

Anatomy and Physiology

  • The bladder is located in the pelvis. It is held in place by ligaments and can be felt in the lower abdomen when full
  • The urinary bladder is a hollow muscular organ that serves as a reservoir of urine. Normally the bladder can hold 350 - 450 cc (12 - 15 ounces) of urine
  • Urine is produced in the kidneys and travels down through the ureters to enter the bladder
  • The urethra is located at the base (lowest part) of the bladder and drains the urine out of the bladder. In women the outlet of the urethra can be seen just in front of the vagina. In men the urethra lies within the penis
  • Sphincters (small circular muscles that contract to hold the urine within the bladder) control the passage of urine through the urethra. Fullness of the bladder sends signals to the brain, and voluntary control determines whether the sphincter remains contracted or allows relaxation for urination
  • In males, the bladder has the prostate gland below (through which the urethra passes), and the seminal vesicles (which store sperm) and vas deferentia (which transport sperm) behind. The rectum is also located behind the bladder (Figure 1) (See Prostatectomy)
Figure 1 - Male anatomy. See description in the text. © A. Bhandary
  • In females, the uterus and the vagina lie between the bladder and the rectum. (Figure 2)
Figure 2 - Female anatomy. See description in the text. © A. Bhandary
  • The inner layer of the bladder is called the mucosa and is lined by a layer of cells called transitional cells. Between the muscle layer of the bladder and the mucosa lies the submucosa (Figure 3)

Pathology

  • The most frequent tumors come from the transitional cells
  • There is an association between these tumors and cigarette smoking, coffee and tea consumption, heavy use of pain medications, and exposure to chemicals used in the dye, rubber and oil refinery industries. The bladder may be exposed to breakdown products from such materials while excreted in the urine. Chronic (long term) irritation of the epithelium may predispose to cancerous changes
  • Tumors are usually staged (Figure 3) by the depth of the tumor, lymph node spread or evidence of metastases (tumor cells going to another organ)
Figure 3 - The layers of the bladder wall are illustrated as well as examples of the various stages of tumor growth. © A. Bhandary
Tumor (T)
Tis - Tumor in situ (limited to the epithelial layer)
T1 - Tumor that invades into the submucosa
T2 - Tumors that invade into the muscular layer
T3 - Invasion into the fat layer that covers the bladder
T4 - Invasion into the surrounding organs
Nodes (N)
N0 - No involvement of lymph nodes
N1-3 - Involvement of the pelvic lymph nodes
N4 - Involvement of lymph nodes in abdomen around aorta (the major artery of the body)
Metastasis (M)
M0 - No distant metastases
M1 - Distant metastases
  • About 80% of patients usually present with superficial disease (Tis or T1)
  • Advanced cancer may metastasize to the liver, lungs or bones

History and Examination

  • Examination may include a detailed history of possible exposure to carcinogens (cancer producing chemicals)
  • Hematuria (blood in the urine) is the commonest symptom
  • Hematuria is usually painless but patients may have symptoms of irritation of the bladder such as frequent urination, urgency and pain while urinating
  • If the ureters from the kidney to the bladder are obstructed by the tumor it may give rise to dilation of the kidney (hydronephrosis) and back or flank pain
  • A rectal exam and a pelvic exam in a woman is performed to feel the bladder and possible involvement of surrounding structures. Examination of the flank may be performed to evaluate for a dilated kidney
  • Advanced disease may present with weight and appetite loss or bone pain
  • Similar symptoms may be seen with urinary tract infections or interstitial cystitis (an inflammatory condition of the bladder wall)
  • Hematuria and flank pain may also be seen in kidney stone disease or even kidney tumors

Testing

  • Cystoscopy (visualization of the interior of the bladder via a fiberoptic lens system) is the most important test to be performed. Visible tumors are usually resected (removed) through the cystoscope if thought to be early (Transurethral Resection of Bladder Tumor - TURBT). This resection includes part of the muscle wall to identify depth of invasion.
  • Intravenous pyelogram (IVP) is a test, in which an iodine containing dye is injected into a vein, collects in the kidneys and is passed in the urine. The dye thus outlines the kidneys, ureters and bladder on X-ray film
  • A urine sample for blood and malignant cells
  • Radiographic imaging may include a CT scan of the abdomen and/or pelvis to look at the bladder and evaluate the kidneys for possible spread of the tumor
  • Advanced cancer requires further investigation with chest X-ray, liver function tests and a bone scan to look for metastases

Indications for Surgery

  • Patients who have superficial tumors (Tis or T1) completely resected via TURBT need no additional therapy
  • Patients with superficial tumors with some risk factors, such as a high grade tumor, more than one tumor mass in the bladder or residual (not resected) tumor at the time of TURBT benefit from intravesical (placed in the bladder) chemotherapy or immunotherapy (antibody therapy). These may also be treated with a partial cystectomy (removal of only a portion of the bladder)
  • Patients with invasion of the muscle found on TURBT (T2 and above) are considered for a full radical cystectomy. These tumors have a higher chance of spreading and a workup for metastatic disease (chest X-ray, liver function tests, bone scan and CT scan) should be performed first
  • Presence of distant metastases (M1) indicates very poor outcome and the patient may not benefit from a major procedure like a radical cystectomy. They are usually treated with chemotherapy/radiation or palliative procedures like urinary diversion (see below)
  • Cystectomies are also performed as part of radical procedures done for advanced cancers of the rectum or ovaries.

Intravesical chemotherapy/immunotherapy

  • This may be used for patients with risk factors for recurrence of cancer after a TURBT
  • Immuno or chemotherapeutic agents are instilled directly into the bladder by catheter for a period of 1 - 2 hours
  • This method of instillation avoids most systemic complications of chemotherapy and helps to reduce recurrence of tumors

Radical Cystectomy (Figures for both man and woman)

  • This procedure is performed for locally advanced tumors without distant metastases. It involves removal of some pelvic organs and lymph nodes. In men, this includes the bladder, prostate and seminal vesicles. In women, this includes the bladder, cervix, uterus, anterior (front) vaginal wall, ovaries and urethra (Figure 4)
Figure 4a - The thin layer of peritoneum over the bladder and rectum is divided in order to expose the bladder and rectum in the male. © A. BhandaryFigure 4b - The bladder is exposed as well as the rectum. © A. BhandaryFigure 4c - The bladder is removed to expose the prostrate gland and urethra. © A. Bhandary
  • Urinary diversion, where the ureters are separated from the bladder and placed into a specially constructed loop of bowel (ileostomy) to drain to the outside, is also usually required. The skin is marked before surgery to determine the best site for placement of the ileostomy opening
  • The bowel is prepared the day before surgery for the ileostomy procedure. This usually consists of laxatives and oral antibiotics to clean the bowel of stool
  • The procedure is done under general anesthesia with the patient lying flat with a slight arch of the back
  • A low midline incision is made and the bladder, rectum and, in women, the uterus identified. The ascending and descending colons (see Colectomy) are freed from their attachments and rolled medially (to the center). The ureters usually lie under these segments of the colon and these are freed from the surrounding tissues. The ureters are then divided near the bladder. Specimens of these ureters are sent to pathology to confirm that there is no spread of the cancer to the ureters
  • The lymph nodes in the pelvis are removed for examination pathologic staging. This involves removal of lymphatic vessels and nodes along the surface of the aorta and vena cava (major draining vein) and their branches (internal iliac arteries and veins) down in the pelvis
  • The lateral ligaments (bands of strong fibrous tissue) holding the bladder to the pelvis wall are then divided. This included the main blood supply to the bladder comes from the internal iliac arteries, which run through the lateral ligaments. In women, the lateral ligaments attaching the uterus are also divided
  • In men, the space between the bladder and prostate anteriorly (in front) and the rectum posteriorly (in back) is opened. The area around the prostate is dissected free. Traction on the prostate upwards helps to identify the urethra, which is then divided
  • In women, the space between the uterus and the rectum is opened, the vagina opened and the anterior wall of the vagina along with the cervix is removed. Most of the urethra is removed. The remainder of the vagina is sutured closed
  • The margins at the end of the urethra are examined for spread of tumor and if positive, more urethra is resected

Urinary diversion - With the bladder resected, it is necessary to divert the urine out of the body. There are several methods that include:

    1. Nephrostomy tubes - these are tubes placed into the kidneys that drain urine through the skin. This procedure, although easier, has a higher rate of patient discomfort and infection
    2. Ureterosigmoidostomy - The ureters are attached to the sigmoid portion of the colon (see Colectomy). This requires no external device for urinary collection, however it has been associated with electrolyte (salt in the blood) imbalances (due to urine absorption in the colon) and infection
    3. Bowel conduit - this is currently the most common procedure performed for urinary diversion. (Figure 5) A small segment of small bowel (see Surgery of the Jejunum and Ileum) of about 15 - 20 cm (6 - 8 inches) in length is freed from the rest of the bowel along with its blood supply. The ureters are attached to one end and the other end of the bowel is brought out through the skin as an ileostomy. This procedure has the best long term results. A plastic bag is placed over the ileostomy opening and sealed to the skin to collect the urine
    4. Reconstruction of the bladder - there are several centers, which are reconstructing a bladder using bowel wall. This is then attached to the remainder of the urethra so the patient may urinate normally without an external collecting device. Problems with leaking urine are still a problem
    Figure 5a - A section of ileum is formed into a pouch, the ileal conduit or ileostomy. The blood supply to the ileum is preserved. © A. BhandaryFigure 5b - One end of the conduit is closed and the ureters attached to the conduit. The open end is passed through the abdominal wall. A plastic bag over the opening collects the urine. © A. Bhandary

Complications

  • Specific complications associated with cystectomies include:
  • Infection or bleeding in the pelvis
  • Rectal injury that may require repair or colostomy
  • Recurrence of cancer or distant spread implies a poor prognosis
  • Deep venous thrombosis (clotting of blood vessels of the thigh or pelvis)
  • Electrolyte imbalances due to absorption of urine from a bowel conduit
  • Ischemia (loss of blood supply) of the bowel conduit. This may require resection and creation of a new conduit
  • Urinary tract infections and kidney stones
  • Stricture (narrowing) of the ureters that may require dilating
  • Lower extremity edema with increased chance of skin infections due to removal of the pelvic lymph nodes
  • Kidney failure

Postoperative care

  • Patients may have a tube through in the nose that goes into the stomach to drain the stomach for a few days. The tube is removed after the bowel regains function and the patient started on a diet
  • The skin around the ileostomy is carefully protected, as urine leakage can be an irritant to the skin
  • Male patients may have a catheter through their penis over the first few postoperative days to drain any fluid collections in the pelvis
  • Drains in the pelvis may be removed after 2-3 days based on the amount of drainage
  • Pelvic surgery is associated with higher rates of clotting in the veins of the thighs. Blood thinners or calf compression devices are used to prevent clot forming until the patient is walking
  • Approximately 5 - 7 days are spent in the hospital. After discharge, the patient may need a visiting nurse to help with management of the ileostomy

Other Therapy

  • Patients who undergo radical cystectomy may be given 3 -4 cycles of chemotherapy to prevent recurrence and prolong survival
  • Radiation therapy is sometimes offered to patients who may be poor surgical candidates because of advanced age or other medical problems
  • Cancer with distant metastases is usually treated with chemotherapy alone. Long term response is seen in only 10% of patients