A radical cystectomy is a type of surgical operation carried out in people who have advanced bladder cancer, which has invaded the muscle of the bladder wall. The operation involves removing the entire bladder, together with lymph nodes situated nearby. In women, the womb and ovaries may also be removed, together with part of the vagina and the tube that carries urine from the bladder, known as the urethra. For men, a radical cystectomy generally includes removal of the prostate, and sometimes the urethra as well. Laparascopic radical cystectomy, where keyhole surgery is used to remove the bladder through small incisions, can be an option, and the instruments can sometimes be controlled robotically, with a greater chance of avoiding damage to the nerves controlling sexual functions.
Radical cystectomy surgery is normally performed in cases of bladder cancer where the tumor has spread into the muscle layer of the bladder wall. It may also be carried out in cases where a cancer has not grown so deeply, but for some reason the tumor is difficult to remove using keyhole surgery. For patients in whom bladder cancer has already spread to other parts of the body, chemotherapy is usually the first treatment, with surgery being reserved for the relief of symptoms. A partial cystectomy, where only part of the organ is removed, creating a smaller bladder, is occasionally used for specific types of bladder cancer.
When the whole bladder is removed during a radical cystectomy, it is necessary to provide a way for urine to leave the body, and there are different methods used for this. One method involves the construction of what is called a urinary diversion, where a portion of gut is removed and used to connect the tubes, or ureters, which carry urine from the kidneys, to an opening in the skin of the abdomen. A special pouch, known as a urostomy bag, is joined on to this opening to collect the urine.
An alternative procedure, which avoids the need for a urostomy bag, is where a piece of bowel is formed into a urine-collecting pouch inside the body, with an opening in the skin below the navel. The patient empties the pouch by inserting a small tube into the opening, but it is important to keep the area very clean to avoid infection. Sometimes pieces of bowel can be used to reconstruct the bladder if the urethra has been saved, although there is the problem that there are no nerves to tell the brain when the bladder is full, and it is necessary to learn how to empty the bladder by pushing down with the abdominal muscles.
A recto-sigmoid pouch is another option associated with a radical cystectomy, and its creation involves adding a piece of gut to the rectum to form a pouch. The ureters are then joined to the pouch, so urine can be eliminated from the body together with feces. This procedure requires that patients have good muscle control, and there is a risk of infection spreading up the urinary tract.