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Cystectomy & Urinary Diversions:

 

The Operation:

 

Cystectomy is surgery to remove the bladder. Some of the tissues around the bladder, such as the lymph nodes(Lymph Glands), will also be taken out. The tube that takes the urine from the bladder to the outside of the body (urethra) may be taken out. For women who have been through the menopause, the womb and ovaries will be removed if they have not already been removed at a previous operation (hysterectomy). For men, the prostate gland is taken out.

Cystectomy is carried out under general anaesthetic in a major hospital. The bladder is removed through an incision in the abdomen. The cut usually goes from just above the belly button to the pubic bone. In some hospitals, the bladder can be removed by keyhole surgery (Laparoscopic or robotic surgery) where the operation is done with telescopic surgery via a few small cuts in the abdomen instead of one large one.

 

The Diversions:

 

People who have had their bladder removed need to get used to another way of drainage of urine from their body. The choices are (a) Urinary Stoma- A bag on the abdomen into which the urine drains - (a piece of bowel is used to connect the kidneys to the stoma to allow urine to flow into the bag) (b) A bladder substitute or Neo-Bladder (A large length of bowel is used to make a replacement for your bladder by forming a pouch. The tubes that allow urine to pass from the kidneys to the bladder are attached to this new reservoir) (c) Cutaneous catheterisable reservoir (a urine pouch sometimes called a 'Mitrofanoff') is made inside the abdomen and attached to the abdominal wall, often at the navel. There is a valve mechanism that prevents continual leakage of urine. The pouch is emptied by passing a catheter into the pouch via the navel.

 

Pros and Cons:

 

It will take time to adjust to the way urine drainage works. Older patients often find having a stoma and an external bag easier to use, whereas younger patients often prefer a neo-bladder as they like the concept of no change in their outward appearance. Either of the internal pouches require time to get used to how they work and to use them effectively. Some people find it hard to come to terms with a stoma, as this can affect relationships with partners, family friends and work colleagues.

 

People who have had their bladders removed may suffer some urinary incontinence, depending on what type of surgery they have. A stoma with an external bag can leak if the bag does not fit the skin correctly (Specialist Stoma Nurses are available to help and advise with these problems) People who have a Bladder substitute may find it difficult to control their urinary flow at first. However, about 90% achieve urinary continence during the day and about 80% achieve continence at night.

 

Surgery to remove the bladder will usually have some effect on people's sex life for both men and women.  Almost all men will get erection problems after surgery because the nerves that control erection can be damaged during surgery. This means that almost all men having this surgery will either not get any erections or will not get erections firm enough for sex. Men, almost always have their prostate gland taken out which means that they cannot ejaculate after surgery. In women surgery can make the vagina shorter and narrower. This may make having sex more difficult and painful. Removal of the womb and ovaries will also mean they can  no longer have children.

 

As the above shows, there are both advantages and disadvantages of all of the types of diversion used in a cystectomy operation, and the decision as to which is best is a decision that needs to be taken by the patient and surgeon together. Medical needs may determine which diversion is the most suitable. Younger people may prefer an internal pouch so as to not affect their figure. Older people may prefer an external pouch as it is easier to get used to and gives them greater confidence and control of their urinary continence. But, at the end of the day, every patient's needs are different and every decision is personal to that patient.

 

Research has shown, however, that several months after surgery nearly all patients are happy with their diversion and are convinced that they made the right decision.