The bladder is a hollow, muscular organ that serves as a reservoir for urine produced by the kidneys, allowing for temporary storage and controlled release. When a serious medical condition requires the removal of this organ, a procedure known as a cystectomy is performed. Surgeons create new pathways for urine to exit the body through a reconstructive process called urinary diversion, making it possible to live without a bladder.
Primary Reasons for Bladder Removal
A cystectomy is often required when diseases cannot be managed through less invasive treatments. The most frequent indication for complete bladder removal is muscle-invasive bladder cancer, where malignant cells have penetrated the deeper layers of the organ wall. Removal offers the best chance for a cure in these advanced cases.
Non-cancerous conditions may also compromise bladder function, requiring surgical intervention. These include severe, chronic inflammatory disorders like interstitial cystitis, which causes pain and tissue damage unresponsive to medication. Chronic injury from pelvic radiation therapy, resulting in persistent bleeding or contracted capacity, may necessitate removal. Additionally, certain neurological disorders causing irreversible neurogenic bladder dysfunction, leading to unmanageable incontinence or severe infections, are sometimes treated with a cystectomy.
Methods for Urinary Diversion
When the bladder is removed, the surgeon creates a new system for urine elimination called urinary diversion. This reconstruction uses a segment of the patient’s gastrointestinal tract to establish a functional pathway. Diversion methods are categorized based on whether the patient requires an external collection appliance.
Incontinent Diversion: Ileal Conduit
One common method is the incontinent diversion, typically the ileal conduit. A small section of the ileum is isolated and used as a channel to bridge the ureters to the abdominal wall. Urine flows continuously through this conduit and exits the body through a stoma, a small opening. Since there is no valve, urine must be collected constantly in a specialized pouching system worn externally over the stoma.
Continent Diversion: Orthotopic Neobladder
Continent diversions store urine inside the body, allowing the patient control over emptying. The orthotopic neobladder uses a segment of bowel tissue to construct a new reservoir, surgically placed where the original bladder was located. This new pouch connects directly to the urethra, allowing the patient to void through the natural channel. Voiding requires using abdominal pressure to push the urine out, as the mechanism differs from natural urination.
Continent Diversion: Cutaneous Reservoir
Another type is the continent cutaneous reservoir, or internal pouch. This pouch is created from the bowel inside the abdomen to hold urine, but it connects to a stoma on the skin. A specialized valve maintains continence, meaning no external bag is required. The patient must empty the reservoir several times daily by inserting a catheter through the stoma into the internal pouch.
Long-Term Adaptation and Quality of Life
Recovery following cystectomy and urinary diversion involves several weeks of healing and adjustment to the new anatomy. Patients must learn to manage their specific type of diversion for long-term health. Those with an ileal conduit learn proper appliance care, including cleaning the stoma and ensuring a secure seal to prevent skin irritation.
Patients with a continent cutaneous reservoir or neobladder follow a strict schedule for drainage or voiding to prevent overstretching and minimize infection risk. Neobladder patients learn to use abdominal muscles to empty the reservoir, as the nerve reflex signaling fullness is absent. Regular self-catheterization may be necessary for both continent diversions to ensure complete emptying.
Long-term health considerations relate to the section of bowel used for diversion. Since the ileum is often utilized, decreased absorption of nutrients, particularly Vitamin B12, may occur, requiring monitoring and supplementation. All diversions carry an increased risk of urinary tract infections compared to a healthy system, making consistent hydration and proper care routines important. Despite the challenges, most individuals report a good quality of life after recovery and successfully adjust to their new reality.