Cystectomy is a surgical procedure to remove the urinary bladder and create a new way to store urine. In females, cystectomy usually involves the removal of the uterus, ovaries, fallopian tubes, and some parts of the vagina. Sounds scary, right? Yes, surgeries can be frightening. But knowing a bit about the procedure can make it less overwhelming. This article will explore what cystectomy is, its risks, and how it can be helpful, and chances of pelvic organ prolapse post cystectomy.

What is Cystectomy?

Cystectomy, or bladder removal surgery, is a complex surgical procedure that requires extensive preoperative evaluation and postoperative care. It is a surgery to remove the urinary bladder, either partially or entirely. The urinary bladder is a pouch-like organ located below the kidneys and above the urethra. It collects urine before you excrete it from your body. Cystectomy procedure is typically performed to treat bladder cancer. However, surgeons sometimes perform this procedure to treat other benign or malignant conditions affecting the urinary system.

The removal of the bladder has significant implications on the patient's quality of life, including the need for lifelong urinary diversion or reconstruction. That is why careful patient selection and counseling is crucial to achieving optimal outcomes and improving the patient's overall health and well-being.

What Conditions does Cystectomy treat?

Your physician may recommend cystectomy to treat:

• Malignancy (cancer) of the bladder, also cancer which have metastasized (or spread) to the bladder
• Congenital abnormalities of the urinary system
• Neurological or inflammatory disorders affecting the urinary system

Risks of Cystectomy

As cystectomy involves the manipulation of several internal organs, there remains some risk of complication. Some of the complications of cystectomy include:

• Bleeding
• Blood clots in the legs
• Blood clots that may move to the lungs or heart
• Infection
• Poor wound healing
• Damage to surrounding organs or tissues
• Sepsis
• Rarely, death 

Your surgeon will have to perform urinary diversion so that in the absence of the bladder, the urine can accumulate in a new place. Risks associated with the urinary diversion procedure include:

• Dehydration
• Kidney failure
• Imbalance in essential minerals
• Vitamin B-12 deficiency
• Urinary tract infection
• Kidney stones
• Urinary incontinence
• Bowel Obstruction
• Ureter blockage

The Procedure of Bladder Removal Surgery

The procedure for cystectomy begins with pre-op (before the surgery) preparation. Your surgeon will probably advise you to clear your liquid diet at least 48 hours before surgery. Then you might also be asked to stop taking your prescription and non-prescription medication, dietary supplements, etc. Your doctor will also ask you to stop smoking cigarettes and consuming alcohol and caffeine.  

Urinary Diversion Procedure:

Your doctor will talk you through the procedure to familiarize you with the new way the urine will be stored and exit from your body after the surgery. This procedure typically involves various tubes and urine-collecting bags that need proper care. Your healthcare provider will also train you and your caregiver to use and clean the device.  

Cystectomy procedure:

Cystectomy is performed one of the three procedures:

• Open surgery: A single incision is done on the abdomen to access the pelvic organs.
• Minimally invasive surgery: The surgeon makes a small incision in the abdomen, and special surgical tools are inserted to access the organ. It is also called laparoscopic surgery.
• Robotic surgery: An advanced minimally invasive procedure that uses robots to do the surgery.

During the surgery, you will be under general anesthesia, so you will not feel any pain. Once you are asleep, the surgeon will make an incision in your abdomen and use different surgical instruments to remove the bladder from the surrounding tissues. If the surgery is to treat bladder cancer, your surgeon will have to remove the nearby lymph nodes. After the bladder removal surgery, your surgeon will create a urinary diversion.  

Life After Cystectomy Procedure

After the surgery, it will take some time for you to come back from under general anesthesia. The recovery from a cystectomy will take some time. Your healthcare team will help you walk and move around. Walking will promote the healing process, improve circulation, and prevent blood clot formation. You will likely be kept under observation in the hospital for 5-7 days. After that, you will have to return to the hospital or clinic a few times for follow-up.  

You must avoid certain activities like lifting heavy objects, driving, and returning to work the first six weeks after the surgery. Cystectomy and urinary diversion can also affect your sexual experience. The removal of the vaginal tissues in women during the procedure can make sex painful and uncomfortable after the surgery. Nerve damage during the surgery can also impair arousal and the ability to experience an orgasm.

When is Bladder Removal Surgery Necessary? 

To determine if a cystectomy is necessary, it will depend on the condition that is being treated and well as other factors including the severity of the condition, the patients overall quality of life and symptoms present.

In cases of bladder cancer, a partial or radical cystectomy may be performed depending on the extent and stage of the cancer. During a partial cystectomy, only the cancerous part of the bladder is removed, preserving as much healthy bladder tissue as possible. In a radical cystectomy, it involves removing the entire bladder, surrounding lymph nodes, and sometimes nearby organs if the cancer has spread.

For non-cancerous conditions like congenital abnormalities of the urinary system or neurological or inflammatory disorders affecting the urinary system, if conservative treatments, therapies, and lifestyle changes do not effectively manage the symptoms or improve the condition, then a cystectomy may be considered to help improve the patients quality of life. 

Removal of the bladder is a complex procedure that has many potential risks and side effects. It is important to carefully discuss with your surgeon and specialists to evaluate the patients’s medical condition, overall health status, and preferences before determining the most appropriate course of action. 

Risks of Pelvic Organ Prolapse after Radical Cystectomy

After undergoing cystectomy combined with hysterectomy (removal of the uterus), female patients may develop pelvic organ prolapse. It can happen due to the weakening of the pelvic structures from removing pelvic organs during the surgery. Studies show that although pelvic organ prolapse after radical cystectomy is not common, it has a high chance of creating potential risks and significant challenges for pelvic reconstruction.

For patients who experience pelvic organ prolapse post cystectomy, there are different treatment options available. Pelvic floor exercises like Kegels exercises are commonly done to strengthen pelvic floor muscles. Medical devices like pessaries are frequently prescribe by doctors to provide structure support to the pelvic area. Pessaries are prosthetic devices inserted into the body through the vaginal canal. However, not all women are suitable for pessary use and it may be more difficult for women who have undergone cystectomy to use pessaries.

Non-invasive solutions like FemiCushion are also available to help with painful prolapse symptoms. FemiCushion is medical device that features a silicone cushion to provide the necessary support to the prolapsed pelvic organs and prevent them from slipping down into the vaginal canal and out of the body.

Supervising Doctor of This Article

Koichi Nagao, MD PhD

Professor, Department of Urology, Toho University Faculty of Medicine
Director of Urinary tract reconstruction center, Toho University Omori Medical Center
Director of Reproduction Center, Toho University Omori Medical Center

Professor Nagao specializes in plastic surgery in the field of reproductive medicine. He completed eight years of plastic surgery training at Showa University before majoring in urology at Toho University. With his meticulous surgical techniques and careful examinations that combines urology and plastic surgery, Professor Nagao became a Board Certified Specialist with multiple associations including the Japanese Urological Association, the Japan Society for Reproductive Medicine, and the Japanese Society for Sexual Medicine.

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