636 CHAPTER 16 Urological surgery and equipment

Radical cystectomy

Indications

•Muscle-invasive bladder cancer

•Adenocarcinoma of bladder (radioresistant)

•Squamous carcinoma of bladder (relatively radioresistant)

•Non-muscle-invasive TCC bladder that has failed to respond to intravesical chemotherapy or immunotherapy

•Recurrent TCC bladder post-radiotherapy

Combined with urethrectomy if

•There are multiple bladder tumors

•There is involvement of the bladder neck or prostatic urethra

Anesthesia

General anesthesia is used.

Postoperative care and common post-operative complications and their management

Monitor cardiovascular status, urine output, and respiratory status carefully in the first 48 hours. Routine chest physiotherapy is started early in the postoperative period to reduce the chance of chest infection. Mobilize the patient as early as possible to minimize the risk of DVT and PE.

Drains are removed when they stop draining. Some surgeons prefer to leave them for a week or so, so that late leaks (urine, intestinal contents) will drain via the drain track and not cause peritonitis.

Try to remove the nasogastric tube, if used, as soon as possible to assist respiration and reduce the risks of chest infection. The patient usually starts to resume their diet within a week or so. If the ileus is prolonged, start parenteral nutrition.

Hemorrhage

Persistent bleeding that fails to respond to transfusion should be managed by re-exploration.

Wound dehiscence requires resuturing under general anesthetic.

Ileus is common. It usually resolves spontaneously within a few days.

Small bowel obstruction

This occurs from herniation of small bowel through the mesenteric defect created at the junction between the two bowel ends. Continue nasogastric aspiration. The obstruction will usually resolve spontaneously.

Reoperation is occasionally required when the obstruction persists or when there are signs of bowel ischemia.

Leakage from the intestinal anastomosis

This can lead to the following:

•Peritonitis—requiring reoperation and repair or refashioning of the anastomosis

•An enterocutaneous fistula—bowel contents leak from the intestine and through a fistulous track onto the skin. A low-volume leak (<500

RADICAL CYSTECTOMY 637

mL/24 hr) will usually heal spontaneously. Normal (enteral) nutrition may be maintained until the fistula closes (which usually occurs within a matter of days or a few weeks). If the leak is high volume, spontaneous closure is less likely and reoperation to close the fistula may be required.

Pelvic abscess

Formal surgical (open) exploration of the pelvis is indicated with drainage of the abscess and careful inspection to see if the underlying cause is a rectal injury, in which case a defunctioning colostomy should be performed.

Partial cystectomy

Indications

This is done to remove primary, solitary bladder tumors at a site that allows 2 cm of normal tissue around it in a bladder that will have adequate capacity and compliance after operation.

There should be the following:

•No prior history of bladder cancer

•No carcinoma in situ

•A solitary muscle-invasive tumor located well away from the ureteral orifices which includes 2 cm of normal surrounding bladder

High-grade tumors should not be excluded if these criteria are met. The lesions most commonly amenable to partial cystectomy are G2 or G3 TCCs or adenocarcinomas located on the posterior wall or dome.

Contraindications

These include associated carcinoma in situ, deeply invasive tumors, and tumors at the bladder base (i.e., near the ureteric orifices).

Procedure-specific consent form—recommended discussion of adverse events

Serious or frequently occurring complications of radical cystectomy

See also consent for ileal conduit if this is the planned form of urinary diversion.

Common

•Temporary insertion of a nasal tube, drain, and stent

•High chance of impotence (lack of erections) due to unavoidable nerve damage

•No semen is produced during orgasm (dry orgasm), causing infertility.

•Blood loss requiring transfusion or repeat surgery

•In women, pain or difficulty with sexual intercourse from narrowing or shortening of vagina and need for removal of uterus and ovaries (causing premature menopause in those not at menopause)

Occasional

•Cancer may not be cured with surgery alone.

•Need to remove penile urinary pipe as part of procedure

Rare

• Infection or hernia of incision, requiring further treatment

638CHAPTER 16 Urological surgery and equipment

•Anesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack)

•Decreased renal function with time

Very rarely

•Rectal injury, very rarely needing temporary colostomy

•Diarrhea due to shortened bowel, vitamin deficiency requiring treatment

•Bowel and urine leak, requiring reoperation

•Scarring of bowel or ureters, requiring operation in the future

•Scarring, narrowing, or hernia formation around stomal opening, requiring revision

Alternative treatment includes radiotherapy, neobladder formation rather than ileal conduit urinary diversion.

Formation of neobladder with bowel

Common

•Need to perform intermittent self-catheterization if bladder fails to empty.

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