Most patients are candidates for bladder removal. Chemotherapy before surgery should be considered for any patient with clinical stage T2 (muscle invasive bladder cancer). Bladder removal is one of the most effective ways to treat bladder cancer to stop
it from growing and spreading beyond the bladder. If a patient with bladder cancer is not a candidate there can be alternatives to bladder removal. At the University of Colorado we perform around 100 of these operations per year.
Everyone recovers differently from surgery. Some patients are back to work in two weeks and some it takes many months to get back to normal life. Recovery is often associated with some days that are good and some that are not so good, but overall improvements are made over time.
Bladder removal can be done through a bigger incision in the abdomen or with a robotic approach through many small incisions. First, the bladder is removed with all the surrounding tissue. Next lymph nodes in the pelvis are removed. Last, a urinary diversion is created through which urine will take a new path to exit the body. Urinary diversion is done three common ways, an ileal conduit (where patient is left with a “bag” externally), a neo-bladder (“normal” plumbing), or a continent cutaneous diversion (no bag, but catheter (or soft hollow tube) is used to expel urine) is created. There are three choices of diversions used for urinary storage after cystectomy.
A neobladder can be created for most patients. A detailed discussion with the surgeon is the best way to discuss the risks and benefits of a neobladder. Every patient is different and urinary diversions are individualized to each patient who has bladder cancer.
The neo-bladder is drained with a catheter after surgery, one through the urethra. It will take some time for the new bladder to work, but ultimately works quite well during the day, but at night because the brain is not connected to the neobladder like it was with the native bladder leaks in about 50% of patients.
Patients may be incontinent during the day or night. During bladder removal, we remove the internal sphincter at the bladder neck and leave behind the external sphincter, which prevents the urine from leaking. This sphincter and the pelvic floor have to be strengthened before and after surgery with Kegel exercises. In addition, it takes time for the neobladder to stretch to the full capacity potential. If incontinence persists, physical therapy and artificial sphincters are also available. Sometimes the leakage can mean that the bladder is not fully emptying. Approximately 10% of patients (and more women than men) need to catheterize to keep their bladder emptying completely.
The hospital stay is approximately 3-5 days if there are no complications. We ask patients to get up and walk the day after surgery as this helps the bowel function progress, which is the hardest part after surgery. Patients are generally allowed to have liquids right after surgery.
Most people feel like getting through this surgery is one of the hardest things they have ever done. That said, when completely healed, there is not much one cannot do with a neo-bladder, continent cutaneous diversion, or ileal conduit. Sexual function is maintained with a combination of “nerve-sparing,” medications, injections and even surgery. Penile rehab can be an important part of recovery after surgery.
Women can also have some change in sexual function; however, with certain local creams and dilation, most women will be able to return to normal sexual function.
This depends on the cancer stage. Once the bladder is removed, a full staging evaluation is completed. Treatment after surgery depends on the cell types causing cancer and stage. Chemotherapy and radiation are sometimes recommended for patients with bladder cancer after they recover from surgery. There are also clinical trials available in this area her at the University of Colorado.
It is hard for a family member to see someone they love go through a cancer diagnosis and surgery. . Support truly does help recovery; hopefully they can stay involved and try to stay positive during the experience.
There are a few things to do in the first few weeks after surgery such as irrigating or removing mucous the neo-bladder or cutaneous continent diversion will now make. Our stomal therapist will stop by while you are in the hospital and make sure that you and your family members are aware of this process.
Often a visiting nurse makes the transition from the hospital to home easier.
Yes, and it is encouraged. It helps pump blood through the veins in the legs, helping prevent blood clots.
Support can be helpful from a patient who has been through this surgery. You may ask your physician for a name of someone who has been through the same surgery whom you can contact. You can also go to www.bcan.org for more information from patients.
Small frequent meals are the best way to meet the calorie needs, usually about 5 to 6 small meals a day. Staying hydrated is very important after surgery, you should try to drink 1 liter (300oz) at least daily. Some patients need more than the 1 liter.
Neobladder training does take time and patience. When the sphincter muscle is strong, there is little leakage. When it is weak, leakage happens. The external sphincter needs to be strengthened in order to control the urine. At first, this takes conscious focus. With time, it will become automatic. The external sphincter is a muscle much like any other. It becomes strengthened through repetition. We recommend you start Kegel exercises as early as possible. Kegel exercises consist of tightening the sphincter for a few seconds and then release. This should be performed at least 10 times per hour while you are awake. Most patients find that the pelvic floor muscles get notably stronger around 4 to 6 weeks. Generally, continence is gained in the morning first, followed by the afternoon, followed by with coughing or sneezing.
Nighttime continence is difficult because there is no nerve that sends a message from your new bladder to the sphincter telling it to tighten when the neobladder gets full. This is what happened with the original bladder. The more full the neobladder gets the more likely it might leak. The keys to staying dry at night include cutting back on fluids during and after dinner, and getting up at least once in the middle of the night to keep the neobladder empty. Some patients need to set alarms to get up before bladder leakage. The bladder cancer advocacy network chat room bcan.org) may also have helpful suggestions.
Yes. Everything but smoking in moderation is reasonable. You should not smoke or chew tobacco to keep your chances of cancer coming back to a minimum.
You may shower after surgery. Hot tubs are ok if all wounds are closed and all tubes have been removed.
You can do anything you feel up to doing with just two exceptions. No lifting anything greater than 10 pounds until 6 weeks after surgery.
Once you have lost all of your hardware from surgery, you will start to feel better. Expect to feel tired—being free from tubes is a big step forward in your new life. There is a chance you can get an infection after your tubes are removed, so keep an eye out for fever greater than 101°, heavy mucous, foul-smelling or very cloudy urine. If you are worried about infection, you can call our clinic nurse (720-848-0170), email your provider through MyHealthConnection or call the resident on call after hours (720-848-0000). If you experience leg swelling on one side, unfamiliar acute chest pain, or shortness of breath, visit the nearest emergency room or call 911.
There is often genital swelling that will resolve over the next few months. Mild lower extremity swelling may be seen after surgery that also generally resolves with time. Expect to feel quite tired even months after your surgery. Walking is important. Walking also keeps the intestines working as well. Gas, constipation, and even diarrhea are all expected changes right after surgery. Things tend to settle down to somewhat normal around three months.
Sex should wait until general healing is secure at 6 weeks. Most patients prefer to wait until they have regained urinary control as well (12 weeks average). In men, even with nerve-sparing procedures, the nerves are traumatized by surgery and have less-than-ideal functioning for at least six months after surgery. For men, the sooner aids for erectile function are used, the better then long-term result. Women should discuss when the right time is with the surgeon, generally 6 weeks is okay.
Neobladders made out of intestine will generally always have bacteria inside of them. If the urine is checked when there are no symptoms of infection, there will be bacteria present. However, fever, malaise, cloudy or foul-smelling urine with more mucous, are signs of significant infection. Bladder infections are not uncommon after surgery. Many patients get an infection every few years. This is not something to be anxious about, but something to keep in mind if you just are not feeling well. You may email your provider, call our clinic, or talk to a resident on call if you feel you may have an infection. Oftentimes we will give you a standing order for antibiotics you may fill as needed if you have already experienced an infection in the past.
Patients with a history of Ta, T1, or CIS urothelial cancer of the bladder will typically follow this schedule:
Cystoscopy every 3 months for two years followed by
Cystoscopy every 6 months for two years followed by
Annual cystoscopy indefinitely
Cytology is sent as part of each cystoscopy for high-risk cancer
For any recurrence, patients start again at 3-month cystoscopy above
For every recurrence CT IVP should also be obtained
For patients with high-risk disease (CIS, T1, or high-grade) patient are generally treated with intravesical treatments to decrease recurrence. The general schedule for this is once weekly for 6 weeks at first diagnosis followed by once weekly for 3 weeks after the first 3-month cystoscopy, then once weekly for 3 weeks every 6 months for a total of 3 years after negative cystoscopy around the same time. In general, patients need to wait until bleeding has subsided before starting intravesical therapy after a biopsy (average 2-6 weeks).
On occasion, there may be a catheter placed with surgery. The catheter is usually temporary and supports the bladder to drain as needed. You can usually remove the catheter yourself a few days after surgery. You will receive more detailed information from your provider once you are at the hospital.
Expect to see blood in your urine after surgery. It is usually the worst the first few days after surgery, but sometimes it clears and then starts up again a few hours or weeks later when scabs fall off. The amount of blood is less than what it looks like. Drinking a fluid helps keep the blood dilute in the urine. Your body will make more and in general, blood in the urine is not cause for alarm. Call or come in if you are making clots that are clogging the catheter
Expect for your bladder to be irritated after surgery. This means the urethra may burn or ache. You may have to go to the bathroom more often – even every half hour. This should clear up within a few weeks, but everybody recovers differently. . If your symptoms are not better or intolerable, you may have an infection. Please email your provider through MyHealthConnection (720-848-0000), call the clinic nurse between 8am and 430pm (720-848-0170), or call the Urologist on call on evenings or weekend.
Sometimes patients diagnosed with invasive bladder cancer benefit from chemotherapy and/or radiation. This will be determined usually after surgery depending on the final pathologic diagnosis from surgery.