Cystectomy is a medical term for surgical removal of all or part of the urinary bladder. It may also be rarely used to refer to the removal of a cyst. The most common condition warranting removal of the urinary bladder is bladder cancer.
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. 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 is necessary to allow excretion of urine.
Medical uses
Malignancy
Radical cystectomy is the recommended treatment for bladder cancer 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 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.
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 (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 that is controlled by the surgeon. A head down (Trendelenburg) position is used and the abdomen is inflated with gas (insufflation) to allow better operating space and visualization. The remainder of the procedure is carried out in a fashion similar to the open procedure.
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.
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 carcinoma in situ (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. and include the following:
Gastrointestinal tract
An ileus, 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 narcotics. 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 percutaneous nephrostomy tube may be needed 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. 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.