Dr. Sean Elliott, MD
Reconstructive Urologist
Cystectomy and Urinary Diversion Overview
What is a cystectomy?
A cystectomy is a surgical procedure in which all or nearly all of the bladder is removed through an incision on the lower abdomen. After the bladder has been removed, we then need to create a new pathway for the urine to exit the body (described below).
Why would someone need a cystectomy?
Although the most common reason to do this surgery is to treat bladder cancer, Dr. Elliott is focused on non-cancer surgery. The most common reasons he performs this surgery is to remove a bladder damaged by radiation or neurologic diseases like spinal cord injury or spina bifida. Cystectomy is usually the last resort, after other treatments have failed.
Why would someone with radiation cystitis need a cystectomy?
Radiation cystitis can result in frequent bladder bleeding, pain, urinary leakage, and kidney damage. When these problems have failed to improve with medications or less invasive surgeries, cystectomy can provide ultimate relief and can help someone get their quality of life back.
Why would someone with neurogenic bladder need a cystectomy?
Neurogenic bladder can usually be managed with catheter and medications. But in some cases, complications of neurogenic bladder such as bladder infections, bladder stones, urinary incontinence or kidney damage fail to improve with typical treatments. In these cases, cystectomy can provide ultimate relief and can help someone get their quality of life back.
How is the bladder removed?
The bladder is removed by a lower abdominal incision and then dividing the connections between the bladder and the surrounding tissue. The ureters are the 2 tubes that carry urine from the kidneys to the bladder. The urethra exits from the bottom of the bladder. In men, the urethra is part of the prostate where it exits the bottom of the bladder. Depending on the situation, the prostate may or may not need to be removed with the bladder. In women, the vagina is behind the bladder. In men, the rectum is behind the bladder. The bladder must be separated from the vagina or rectum; this is straight-forward in most people, but after radiation it can be difficult and requires expertise.
After the bladder is removed, how does the urine exit the body?
The urine will drain from the kidneys to the ureters. The ureters are delicate tubes about the size of a cell phone charging cord. We use intestine in place of the bladder to carry the urine from the ureters out of the body. We call this a urinary diversion because we are diverting the urine from where it used to go (the bladder). There are 2 main ways this can be done. The simplest is to create a conduit, or straight tube, of intestine that carries the urine from the ureters in the back of the abdomen to a stoma on the front abdominal wall. The more complicated option is to reconfigure the tube of intestine so that it creates a pouch, or neobladder, to hold the urine inside the body like a bladder. This pouch then needs to be emptied every few hours by passing a catheter through a small stoma, usually located in the belly button, into the pouch.
Can you make a neobladder that allows me to pee out of my urethra like a normal bladder or do I have to catheterize a stoma to empty the pouch?
When the bladder is removed for bladder cancer, it is common to make a neobladder (literally, “new bladder”) out of intestine; this is built in the same space where the bladder used to be and it is connected to the urethra. This is possible in the bladder cancer situation because the surrounding structures are normal – only the bladder is affected by the cancer. In contrast, when we remove a bladder for non-cancerous reasons, the surrounding structures are always abnormal too, not just the bladder; so it is not possible to connect the neobladder to the urethra and pee normally. When we remove the bladder for radiation complications, the radiation has damaged the sphincter muscle and the urethra too, making it impossible to have normal urination through the urethra. When we remove the bladder in people with spinal cord injury, or other neurologic diseases, there are usually similar bad processes affecting the urethra or sphincter muscle. So, in non-cancerous cystectomy, urinary diversion is always done by a conduit or a pouch. When a neobladder is connected to the belly button for catherization rather than the urethra for urination, we call it a pouch instead of a neobladder.
Is it better to do this surgery robotically or through an open incision?
When the bladder is removed for bladder cancer, some surgeons remove it robotically. After the bladder is removed, some of these same surgeons then open the abdomen to do the urinary diversion whereas others continue the rest of the surgery robotically. Research has not shown that patients go home any sooner or recover any better with robotic compared to open bladder removal. When we remove the bladder for non-cancerous reasons there is usually more damage to surrounding structures (like after radiation), so we feel it is safer and more efficient to remove the bladder through an open incision.
How do we decide to do a conduit vs. a pouch?
This is a balance of the patient’s preferences, their ability to care for the different urinary diversion options, and their overall health.