The urinary bladder temporarily stores urine produced by the kidneys and controls its release from the body. This hollow, muscular organ can hold up to 500 milliliters of urine in a healthy adult before signaling the brain to prompt urination. While this natural system is efficient, medical advancements allow people to live a full life without a bladder. When the bladder must be removed due to disease, surgeons create a new pathway or reservoir for urine, allowing the body to continue waste removal.
Medical Necessity for Bladder Removal
The need to remove the bladder, known as a radical cystectomy, is most frequently driven by invasive bladder cancer. This surgery becomes necessary when cancer has spread into the muscle wall or when high-risk tumors persist despite treatments like immunotherapy. Removing the entire bladder, surrounding lymph nodes, and potentially nearby organs is often the most effective step to prevent cancer spread.
Less common, non-cancerous conditions can also necessitate this major surgery. These include severe, chronic inflammatory conditions like radiation cystitis, where previous radiation therapy severely damaged the bladder. Intractable neurogenic bladder dysfunction, where nerve damage prevents proper function, may also lead to a cystectomy. In all cases, bladder removal requires creating a new way for urine to exit the body, called a urinary diversion.
External Urinary Diversion Methods
The most common type of urinary diversion is an external method, which allows urine to drain continuously into an external collection device. The Ileal Conduit, sometimes called Bricker’s operation, is often favored for its simplicity and lower risk of complications. This procedure involves isolating a short segment of the small intestine, typically 15 to 20 centimeters of the ileum.
The ureters, which carry urine from the kidneys, are surgically connected to one end of this intestinal segment. The other end is brought out through the abdominal wall to create a stoma, a small, spout-like opening.
Since this intestinal segment is a simple channel and not a storage reservoir, urine flows through it continuously. Because the flow is uncontrolled, a specialized external appliance, known as an ostomy bag or urostomy pouch, is required to collect the urine. This lightweight, adhesive pouch sticks to the skin around the stoma and must be emptied several times daily. Patients learn stoma care from specialized nurses and quickly manage the appliance, allowing them to return to most normal activities.
Internal Urinary Diversion Methods
Internal methods, known as continent urinary diversions, create a reservoir inside the body to store urine. These more complex procedures aim to mimic the bladder’s natural storage function. One primary option is the Orthotopic Neobladder, which uses a longer segment of the patient’s intestine, often 50 to 60 centimeters of the ileum, to construct a new spherical pouch.
This neobladder is connected directly to the urethra, allowing the patient to void through the usual route. However, the patient must learn to empty the pouch by relaxing pelvic floor muscles and increasing abdominal pressure, as the neobladder lacks the muscle contractions of a native bladder. Nighttime leakage can be common, though many patients achieve good daytime continence through intensive retraining.
The other major internal method is the Continent Cutaneous Pouch, such as an Indiana Pouch, which creates an internal reservoir but does not connect to the urethra. Instead, a valve mechanism is engineered, and the opening is brought to the abdominal wall to form a small, flat stoma. The patient keeps this pouch continent and empties it by inserting a catheter through the stoma a few times a day, generally every four to six hours. This method eliminates the need for an external collection bag but requires periodic self-catheterization.
Long-Term Life and Management
Living with a urinary diversion requires adjustment, but most patients successfully transition back to a high quality of life. The initial post-operative recovery period is typically several weeks, during which specialized nurses teach the patient how to manage their specific diversion. Patients with an ileal conduit learn to size and change their external collection appliance to prevent skin irritation. Those with a neobladder undergo pelvic floor muscle rehabilitation and timed voiding schedules to maximize continence and ensure complete emptying.
Ongoing management involves regular monitoring for potential long-term complications, such as urinary tract infections or metabolic changes due to the use of intestinal tissue. The intestinal segment used in the diversion naturally produces mucus, which patients learn to flush out of the system.
Regular follow-up appointments check kidney function and screen for issues like stoma narrowing or stone formation within the internal pouch. With proper care and support, individuals successfully manage these diversions and resume activities like work, travel, and exercise. Advances in surgical techniques and ostomy products have made managing life without a bladder a routine and sustainable process.