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Total Cystectomy Surgery

What is Total Cystectomy?

Cystectomy is surgical removal of all or part of the urinary bladder. Total Cystectomy, also known as Radical Cystectomy is surgical is the removal of the entire bladder, nearby lymph nodes (lymphadenectomy), part of the urethra, and nearby organs that may have been invaded by the cancer cells. In men, the nearby organs that are removed are the prostate, the seminal vesicles, and part of the vas deferens. In women, the cervix, the uterus, the ovaries, the fallopian tubes, and part of the vagina are also removed. The ureters are disconnected from the bladder and urinary diversion is created.

What is Partial or Segmental Cystectomy?

Partial Cystectomy or Segmental Cystectomy is removal of part or segment of the bladder and is usually performed for the resection of stage I and II bladder cancer.

Who is an ideal candidate for Total Cystectomy?

If you have bladder cancer that has invaded the muscle layer and is locally invasive or if your cancer has come back after the initial treatment, then you are an ideal candidate for Total Cystectomy.

Purpose of Total Cystectomy

Cystectomy is most commonly performed to treat cancer of the bladder. Once a patient has been diagnosed with bladder cancer, a staging system is used to indicate how far the cancer has spread and determine appropriate treatments. Superficial tumors isolated to the inner lining of the bladder (stage 0 or I) may be treated with non-surgical therapies such as chemotherapy or radiation, or with partial or simple cystectomy. Radical cystectomy is the standard treatment for cancer that has invaded the bladder muscle (Stage II, III, or IV). Muscle-invasive cancer accounts for 90% of all bladder cancers.

Other conditions that may require cystectomy include interstitial cystitis (chronic inflammation of the bladder), endometriosis that has spread to the bladder, severe urinary dysfunction, damage to the bladder from radiation or other treatments, or excessive bleeding from the bladder.

How do I prepare for Total Cystectomy?

Your surgical team will provide you with instructions about the care of the urostomy opening and the bag. Routine blood and urine analysis, CT of abdomen and chest x-ray will be requested by your physician on your pre-operative consult. Inform your physician about your other health conditions and medications (including all the prescription, non-prescription medications, nutritional supplements i.e. vitamins, minerals and herbal products). Refrain from taking aspirin or Ibuprofen at least 2 weeks before Total Cystectomy.Stop smoking a few weeks before Total Cystectomyto prevent healing problems during recovery period. Do not eat or drink anything for at least 10 hours before the Total Cystectomy surgery. You will be instructed to be hospitalized the night before the surgery. You may be given an enema the night
before to cleanse your bowel.

Description of Total Cystectomy surgery:

Partial cystectomy

During partial or segmental cystectomy, only the area of the bladder where the cancer is found is removed. This allows for most of the bladder to be preserved. Because the cancer must not have spread to the bladder muscle and must be isolated to one area, partial cystectomy is only used infrequently for the patients who meet these select criteria.

The patient is first placed under general anesthesia. After an incision is made into the lower abdomen, the bladder is identified and isolated. The surgeon may choose to perform the operation with the bladder remaining inside the abdominal cavity (transperitoneal approach) or with the bladder lifted outside of the abdominal cavity (extraperitoneal approach). The cancerous area is excised (cut out) with a 0.8 in (2 cm) margin to ensure that all abnormal cells are removed. The bladder is then closed with stitches. The pelvic lymph nodes may also be removed during the procedure. After the cancerous tissue is removed, it is examined by a pathologist to determine if the margins of the tissue are clear of abnormal cells.

Simple or radical cystectomy

While partial cystectomy is considered a bladder-conserving surgery, simple and radical cystectomy involves the removal of the entire bladder. In the case of radical cystectomy, other pelvic organs and structures are also removed because of the tendency of bladder cancer to spread to nearby tissues. After the patient is placed under general anesthesia, an incision is made into the lower abdomen. Blood vessels leading to and from the bladder are ligated (tied off), and the bladder is divided from the urethra, ureters, and other tissues holding it in place. The bladder may then be removed.

The surgical procedure for radical cystectomy differs between male and female patients. In men, the prostate, seminal vesicles, and pelvic lymph nodes are removed with the bladder. In women, the uterus, fallopian tubes, ovaries, anterior (front) part of the vagina, and pelvic lymph nodes are removed with the bladder. If the surgery is being performed as a treatment for cancer, the removed tissues may be examined for the presence of abnormal cells.

Aftercare of Total Cystectomy surgery:

After the operation, the patient is given fluid-based nutrition until the intestines begin to function normally again. Antibiotics are given to prevent infection. The nature of cystectomy means that there will be major lifestyle changes for the person undergoing the operation. Men may become impotent if nerves controlling penile erection are cut during removal of the bladder. Infertility is a consequence for women undergoing radical cystectomy because the ovaries and uterus are removed. Most women who undergo cystectomy, however, are postmenopausal and past their childbearing years.

Patients are fitted with an external bag that connects to the stoma and collects the urine. The bag is generally worn around the waist under the clothing. It takes a period of adjustment to get used to wearing the bag. Because there is no bladder, urine is excreted as it is produced. The stoma must be treated properly to ensure that it does not become infected or blocked. Patients must be trained to care for their stoma. Often, there is a period of psychological adjustment to the major change in lifestyle created by the stoma and bag. Patients should be prepared for this by their physician.

What is the recovery period like following Total Cystectomy?

Total Cystectomyentails surgery to the bladder as well as the bowel. You will spend the next couple of days in the Intensive Care Unit (ICU) under observation following Total Cystectomy. Your vital signs, circulation and respiration will be closely monitored. You will also be closely monitored for any immediate post-operative complications like excessive bleeding. There may be a stoma bag collecting urine that will need to be cared for. You will notice thin tubes coming out of the urostomy. These are called stents. They will be removed 7-10 days after your Total Cystectomy operation. There will also be a small plastic drain tube from your abdomen that will stay in place for about 5-7 days. You will experience some pain and discomfort which can be alleviated by the use of pain medication. Keep the operation area clean; avoid heavy lifting and sexual activity for 3 - 4 weeks. You will be able to get back to your normal activities in 2 months time following Total Cystectomy. You will probably be hospitalized for 8 - 10 days after Total Cystectomy procedure. Before going home you will be provided with a follow up regimen that will comprise of Cystoscopy and urinary exams every 3 months for at least 2 years, with regular CT scans of the pelvis and abdomen.

What is the outcome of Total Cystectomy?

The 5 year survival rate for people who have bladder cancer is 75%. Adjuvant therapy may be needed following a Total Cystectomy which may include radiation therapy, chemotherapy or biological therapy (immunotherapy).
Benefits of Total Cystectomy:

• The 5 year survival rate after Total Cystectomy, for people who have bladder cancer is 75%.

Risks involved in Total Cystectomy surgrey:

As with any major surgery, there is a risk of infection; in this case, infection of the intestine is especially dangerous as it can lead to peritonitis (inflammation of the membrane lining the abdomen). In the case of partial cystectomy, there is a risk of urine leakage from the bladder incision site. Other risks include injury to nearby organs, complications associated with general anesthesia (such as respiratory distress), excessive blood loss, sexual dysfunction, or urinary incontinence (inadvertent leakage of urine).

Normal results of Total Cystectomy surgery:

During a successful partial cystectomy, the cancerous or damaged area of the bladder is removed and the patient retains urinary control. A successful simple or radical cystectomy results in the removal of the bladder and the creation of a urinary diversion, with little or no effect on sexual function. Intestinal function returns to normal and the patient learns proper care of the stoma and bag. He or she adjusts to lifestyle changes and returns to a normal routine of work and recreation.

Morbidity and mortality rates of Total Cystectomy surgery:

The overall rate of complications associated with radical cystectomy may be as high as 25–35%; major complications occur at a rate of 5%. The rate of radical cystectomy-related deaths is 1–3%. Partial cystectomy has a complication rate of 11–29%. Some studies have placed the rate of cancer reoccurrence after partial cystectomy at 40–80%.

Alternatives for Total Cystectomy:

Transurethral resection (TUR) is one method that may be used to treat superficial bladder tumors. A cystoscope (a thin, tubular instrument used to visualize the interior of the bladder) is inserted into the bladder through the urethra and used to remove any cancerous tissue. Non-surgical options include chemotherapy and radiation.

Medical specialists and facilities available in India?

Training and experience of Indian doctors is widely acknowledged particularly in the US and UK where they have made significant contributions to the delivery of healthcare in the host countries. Many of these doctors after having specialized and practiced in the West have returned home to set up impressive state of the art facilities with the latest in equipment, technology and service levels particularly in Delhi, Mumbai and Bangalore and to a lesser extent in Ahmedabad, Pune, Hyderabad and Chennai. Modern dental and eye care is, however, far more widely available at large sized towns and cities throughout the country.

Medical facilities in India vary from world class in metros to the mediocre elsewhere but medical skills of specialist doctors rate far higher. Out of a population of 20,000 hospitals surveyed in India by us, we propose restricting usage for Medical Tourism to just 59 hospitals as centers of excellence both for infrastructure and equipment as also the skill sets that reside in their highly experienced specialists. These include 14 hospitals in Delhi, 12 in Mumbai, and 9 in Bangalore, 6 each in Chennai and Hyderabad and 4 each in Ahmedabad, Pune and Kolkata. The conditions for which these hospitals are recognized include Cardio Thoracic Surgery, Cancer, Renal Transplant/Dialysis, Lithotripsy, Kidney/Urethral Stone, Prostate Surgery, Total Hip/Knee Joint Replacement, Lab Sciences and Radiology, Cosmetic Surgery and Ophthalmology. Outstanding professional skills and facilities are therefore a norm for medical tourism given the huge prestige gains that are at stake for hospitals.

Indian doctors are enthusiastic invitees at medical seminars all over the world and constantly upgrade their skills to remain abreast of cutting edge developments, technology and procedures. In early July 2005 Indian Hospitals announced a tie up with Histosystem of the US for establishing treatment centers for cord blood stem therapy and for preserving the umbilical cord of new-bornss for later use. Mutual Funds are actively tracking the Healthcare Sector in India owing to the unique value proposition and rapid growth it offers.