Radical cystectomy with ureterocutaneostomy

What is it?

Technical difficulty:
very high
Average duration of the intervention:
4-6 hours
Average duration of hospitalization:
13 days

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 in the operating room under general anesthesia. It includes the first phase, when the bladder is removed, followed by the reconstructive phase that involves creation of a urinary shunt. Surgery can be performed either by open or robotic-assisted technique, depending on the characteristics of the bladder disease and the patient's health status. 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 regional lymph nodes are removed.

Once the total removal of the bladder has been performed, it is necessary to proceed to draw out the urine that can no longer be eliminated through the bladder. The choice of type of urinary shunt depends on numerous clinical variables, disease, physical conformation of the patient, and intraoperative findings. When possible, orthotopic and heterotopic urinary bowel shunts are performed.

In selected patients in whom intestinal shunts cannot be performed, the ureters are attached directly to the skin by making two ureterocutaneostomies at the lower quadrants of the abdomen. In this case, it is necessary to apply two external collecting bags in correspondence of each of the two ostomies. A variant of the ureterocutaneostomy provides that one of the two ureters (if sufficiently long) may join the lateral counter, forming a single skin ostomy. Ostomies are not sphincter structures capable of controlling and scheduling micturition, as they lack suitable muscle structures and the necessary nervous control. In addition, it should be remembered that the ureters, by virtue of their small size, may undergo sclerotization as a result of the scarring reaction that forms with the skin to which they are anastomosed.

Therefore, in this type of derivation, it is essential to place two small "catheters" (ureteral braces) in the ureters to facilitate the passage of urine from the kidneys to the collection bag. These ureteral braces are replaced periodically (every 3 to 6 months) even in day hospital. 

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After discharge, the patient is advised to abstain from intense physical exertion for approximately one month. The presence of bags on the skin makes it necessary to change one's lifestyle habits. The patient and family members will need to be instructed in the periodic emptying and replacement of bags, so assistance from a trained ostomy nurse will be essential initially. In all other respects, the patient will be able to go about his or her daily life without any particular limitations.

Short-term complications

In this type of surgery, complications are very frequent, up to 70% of patients can incur them. The most frequent complication is post-operative fever, in 50% of cases, which is treated with intravenous antibiotic therapy. Mild urinary bleeding may also occur due to decubitus ureteral catheters, irritation of the skin around the stoma. A very common complication encountered at home is the deposition of catheters, requiring rapid access to the emergency department for repositioning.

Long-term complications

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).

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