Radical cystectomy with orthotopic and heterotopic urinary derivations
When is this procedure indicated?
Radical cystectomy is the standard treatment of infiltrating bladder cancer or recurrent superficial cancer at high risk for progression.
How is it performed?
Radical cystectomy surgery is performed under general anesthesia. Surgery can be performed open or by robotic-assisted technique. In men, bladder, prostate, seminal vesicles, vas deferens and obturator and iliac lymph nodes are removed; in women, bladder, uterus, adnexa, anterior wall of the vagina and loco-regional lymph nodes are removed. Next, the urine must be drawn out, and the choice of drawing out method depends on several factors:
- Uretero-ileo-cutaneostomy: in patients with moderate surgical risk but with locally advanced tumor disease, represents the most performed urinary shunt in the world. A 15-20 cm segment of intestine is used, which is connected on one side to the ureters and on the other side to the abdominal skin. Urine is collected in a bag applied at the skin ostomy.
- Orthotopic neobladder: the bladder is replaced by a reservoir made from an approximately 40-60 cm segment of ileal intestine or colon-sigma, properly configured to look like a spherical container, which is placed in the pelvic cavity and anastomosed to the urethra. With this shunt, the patient does not have to use any external prostheses.
In case of ureteroileocutaneostomy, the presence of the pouch on the skin makes it necessary to modify one's life habits: the patient and the relatives will have to be instructed in the emptying and periodical substitution of the pouches, for which initially the assistance of a specialized stoma nurse will be fundamental.
In case of neovesis, the urinary urge is no longer felt and the patient usually reports feeling full or vague suprapubic pain. The patient will urinate through the urethra after releasing perineal plane muscles and increasing abdominal pressure (sitting position with trunk flexed forward and hand compression of lower abdomen). Occasionally, incomplete reservoir emptying (such that periodic catheterizations are required to empty the neobladder) and/or partial daytime or nighttime urinary incontinence may occur. In addition, the patient will be referred for pelvic floor rehabilitation treatment in order to accelerate the recovery of urinary continence post-operatively.
In addition, during follow-up, it will be necessary to monitor the acid-base balance and supplement the patient's diet with bicarbonate tablets to counteract the acidosis that is associated with reabsorption of the section of bowel used for the neobladder
In this type of surgery, complications are very frequent, up to 70% of patients can incur them. The most common complication is postoperative fever, in 50% of cases, which is treated with intravenous antibiotic therapy, followed by delayed intestinal canalization that may require enemas and prokinetics to restart. Mild urinary bleeding may also occur due to decubitus ureteral catheters, irritation of the skin around the stoma.
After several weeks, hernias may form at the surgical incision site of the abdominal wall (laparocele) or at the level of the ostomy (stomal hernia). A stenosis of the anastomosis between the ureter and bowel may also appear, which can result in renal failure. In this case, it may be necessary to place a percutaneous nephrostomy in order to place a ureteral catheter to safeguard renal function. In the long term, it should be remembered that several metabolic imbalances of different nature may occur. The literature notes vitamin deficits, metabolic acidosis and, in some cases, worsening of renal function and, in some cases, occurrence of renal failure.