Radical cystectomy with urinary diversion and pelvic lymph node dissection is the gold standard treatment for muscle-invasive bladder cancer.

It involves removing the entire bladder with surrounding lymph nodes and recreating the urinary system from intestine. In men, the surgery also involves removal of the prostate and seminal vesicles. In women, the surgery also involves removal of the uterus, ovaries and part of the vagina. The most common urinary diversion (ileal conduit) routes urine to a stoma on the abdominal wall that continuously drains into an ostomy appliance. Continent urinary diversions that do not involve a drainage bag are possible but risk additional future complications.

When to Ask a Urologist about Radical Cystectomy with Urinary Diversion

You should speak with a Urologist about Radical Cystectomy with Urinary Diversion if you have muscle-invasive bladder cancer or recurrent, high-risk non-muscle-invasive bladder cancer.

Cost

Typically covered by most insurances (although coinsurance and deductibles may apply). Coverage will be verified prior to proceeding. If you do not have insurance, our office will be able to give you an out-of-pocket cost estimate.

Effectiveness

Systemic recurrences following cystectomy vary based on stage and lymph node status. Bladder cancer limited to the muscle has a 25% recurrence; bladder cancer extending beyond the bladder wall has a 40% recurrence; and, bladder cancer that has moved to lymph nodes has a 70% recurrence. Systemic recurrences typically cannot be cured with current chemotherapy treatments. Five-year overall survival is around 60% after radical cystectomy.

Possible Side Effects

The risks associated with radical cystectomy with urinary diversion include bleeding, infection, failure to remove all of the cancer, damage to adjacent structures, urine leak, bowel obstruction, hernia, stroke, heart attack, blood clot, and the possibility of death. It is important to understand that treatments can have a significant quality of life impact with changes in continence, sexual function, bowel function and metabolic parameters. It is also important to understand that surgery entails a difficult postoperative period. About 60% of patients experience some complications within 90 days, 20% experience a serious complication and about 30% are readmitted to the hospital. The risk of mortality around surgery is about 4%.

Alternative Approaches

A treatment alternative for patients who desire to avoid or are too frail to undergo surgery involves sparing the bladder and undergoing both chemotherapy and radiation with very close regular surveillance with cystoscopy and CT scans every 3-6 months. About 40% of patients progress to cystectomy. Bladder sparing is typically reserved for patients with a single tumor that can be totally resected on TURBT. Bladder sparing has been shown to reduce 5-year survival relative to surgery (28% vs 47%).

What to do to Prepare for Surgery

Attention to maintaining good nutrition and smoking cessation are critical to improving outcomes and minimizing surgical risks. Routine exercise is strongly recommended to improve fitness before surgery.

You will receive detailed instructions from the surgical schedulers regarding any necessary testing or appointments prior to surgery. In general, you should temporarily stop blood-thinning medications prior to surgery (when to stop depends on the type of blood thinner). Prescription blood-thinning medications should be stopped following clearance from the doctors that prescribed them though other medications that thin the blood including fish oil and pain relievers such as ibuprofen should be stopped as well.

On the day before surgery, you will receive a phone call alerting you to the time that you should arrive, and you should wash the surgical area with an antibacterial soap. You may be instructed to drink one bottle of magnesium citrate to evacuate the bowels in preparation for the procedure.

You should not eat or drink anything after midnight on the day of surgery, but you may take approved home medications in the morning before surgery with a small sip of water.

What to Expect after Surgery

There will be an incision in the lower center of your abdomen. The surgery typically requires prolonged hospitalization. Your diet will be slowly advanced as bowel function returns. For patients following ileal conduit, there will be two small tubes within the ostomy bag to help drain the kidneys. There will be an additional external surgical drain that is removed prior to discharge. Light activity, including walking, under nursing supervision is recommended. The nursing staff will also provide teaching to use a breathing device called an incentive spirometer that helps encourage patients to take deep breaths.