A cystectomy is a major surgical procedure involving the full or partial removal of the urinary bladder, the organ responsible for storing urine. When the entire bladder is removed (radical cystectomy), surgeons must create a new pathway for the body to store and pass urine. This necessary reconstructive step is called a urinary diversion, and it represents the most significant change a person experiences after the operation. The decision to remove the bladder requires substantial adjustment to daily life and is reserved for severely compromised health situations.
Primary Reasons for Bladder Removal
The most frequent reason for undergoing a cystectomy is bladder cancer, particularly when the disease has invaded the muscle layer of the bladder wall. This procedure is also performed if high-risk, non-muscle-invasive bladder cancer persists or recurs despite treatments like immunotherapy. A radical cystectomy aims to prevent cancer spread, often involving the removal of nearby lymph nodes and sometimes reproductive organs (e.g., the prostate and seminal vesicles in men, or the uterus and part of the vagina in women). While cancer is the primary indication, cystectomy is sometimes necessary for severe, non-malignant conditions that failed other therapies. These include interstitial cystitis causing chronic pain, neurogenic bladder dysfunction leading to severe infections, or chronic radiation cystitis resulting in persistent bleeding. In these non-cancer cases, a simple cystectomy, which removes only the bladder, may be sufficient.
Types of Urinary Diversion Procedures
Following complete bladder removal, the surgeon constructs a new system for urinary drainage, typically using a segment of the patient’s small or large intestine. Diversion procedures fall into two main categories: incontinent diversions, where urine drains continuously, and continent diversions, which allow voluntary control over when urine is passed. The choice depends on the patient’s overall health, manual dexterity, and personal preference.
Ileal Conduit
The ileal conduit is the most common type of urinary diversion, valued for its simplicity and lower complication rates. In this procedure, a segment of the ileum (part of the small intestine) is isolated and used as a channel to divert urine. The two ureters, which carry urine from the kidneys, are connected to one end of this intestinal segment. The other end is brought through the abdominal wall to create a stoma. Urine flows continuously out of the stoma and is collected in a specialized external pouch, or ostomy bag, that adheres to the skin. This incontinent method requires the patient to wear an appliance that must be emptied several times daily.
Continent Cutaneous Reservoir
A continent cutaneous reservoir (e.g., Indiana Pouch) creates an internal storage pouch from a segment of the bowel, typically using the large and small intestines. The reservoir is constructed as a low-pressure system where urine can be stored safely inside the body for several hours. This internal pouch connects to a small, continent stoma on the abdomen that does not leak urine. No external bag is required. To empty the pouch, the patient must insert a catheter into the stoma at regular intervals throughout the day, a process called intermittent self-catheterization. This option is favored by patients who wish to avoid wearing an external appliance but requires motivation and the manual dexterity to perform the catheterization.
Neobladder
The neobladder is the most complex form of continent diversion, aiming to recreate function similar to the original bladder. A pouch is constructed from a section of the small intestine and connected directly to the urethra, allowing the individual to pass urine naturally. Since the new reservoir lacks the original nerve connections, the patient must learn to empty it by relaxing the pelvic floor muscles and using abdominal pressure, often voiding on a set schedule. The neobladder avoids an external stoma or self-catheterization through the skin. However, some patients, particularly women, may still need to use a catheter to ensure complete emptying. Daytime continence rates can be high, though nighttime leakage is more common, and the risk of needing to catheterize long-term is higher than in men.
Immediate Post-Surgical Recovery
A radical cystectomy with urinary diversion is a major operation, requiring a hospital stay typically lasting five to fourteen days. The initial recovery focuses on pain management, often accomplished through patient-controlled analgesic pumps or continuous local anesthetic delivery. Early mobilization is encouraged, with patients helped to sit up and walk shortly after surgery, as this promotes wound healing and helps restore normal bowel function. Patients will have several tubes and drains in place during this acute phase to manage healing. These include surgical drains to remove excess fluid from the surgical site, and specialized tubes called ureteral stents, which ensure the newly connected ureters drain properly into the diversion. If an ileal conduit was created, the stoma will initially be swollen, and specialized nurses teach the patient how to care for the stoma and manage the collection pouch. Temporary dietary restrictions are common until normal bowel function returns.
Adapting to Life with a Urinary Diversion
The long-term reality of life after a cystectomy involves significant, yet manageable, lifestyle adjustments and a commitment to ongoing self-care. For those with an ileal conduit, daily life revolves around managing the external collection pouch, which includes regular emptying and scheduled changes of the skin barrier and bag. Patients with a continent cutaneous reservoir or a neobladder must adhere to a strict schedule of intermittent self-catheterization or timed voiding to prevent complications like infection or pouch over-distension. This routine is a fundamental part of managing the new urinary system, ensuring the kidneys remain protected. Maintaining a high quality of life requires attention to potential long-term issues, such as metabolic changes due to the use of bowel segments for the diversion. Dietary modifications and consistent hydration are important for general health and to help prevent the formation of stones, which are more common in continent diversions than in an ileal conduit. Addressing body image concerns and discussing intimacy with partners is an important part of the emotional adjustment, as the surgery can affect sexual function and self-perception. Regular follow-up appointments with a urologist are necessary to monitor kidney function and check for late complications like ureteral strictures, ensuring the long-term success of the urinary diversion.