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Friday, June 6, 2008

Surgery for invasive bladder cancer

If a tumour is too large to be removed by cystoscope, or if it has started to grow through the bladder wall, it may be necessary to remove all or part of the bladder. Your doctor can discuss with you which is the most appropriate type of operation for your particular situation.

Partial cystectomy

If part of the bladder is removed, the operation is called a partial cystectomy. After this operation you will be able to pass urine as usual, but as your bladder will be smaller, and will hold less urine, you may need to pass urine more often.

Cystectomy

If the whole bladder is removed, the operation is called a complete cystectomy. In men, the prostate gland, part of the urethra, and the lymph nodes close to the bladder are also removed. In women, as well as the bladder, the womb, cervix, nearby lymph nodes and part of the urethra are removed. After a cystectomy women will not be able to have children.

Men usually become impotent (are unable to get or maintain an erection) and women may find that sensations during sexual intercourse are different from before the operation. The effects of surgery on your sex life are explained in more detail later on this section.

A new storage place for urine will need to be created using a urostomy, bladder reconstruction, continent urinary diversion or uro-rectal conduit.

Urostomy

The most common way of making a new drainage channel for urine is to make a urostomy. While you are under a general anaesthetic, the doctor will remove a section of your small bowel, join the two ureters to one end of it and bring the other, open end out through the skin of your abdomen.

This operation makes an ileal conduit. It is called this because the piece of small bowel (ileum) acts as a channel (conduit) to take the urine from the ureters and bring it to the surface of the abdomen. The small hole on the surface of the abdomen, through which the urine now passes out of the body, is called a stoma.

A flat, watertight bag is placed over the opening on the abdomen (stoma) to collect the urine. It is kept in place with a special type of glue. The bag will fill with urine and will need to be emptied regularly.

See further information on living with a urostomy.

Bladder reconstruction

Sometimes the bladder can be replaced by using a piece of the small or large intestine to make a completely new bladder. This operation is known as bladder reconstruction, and it can be done in different ways.

Usually your doctor will remove a piece of your bowel, make it into a balloon-shaped sac and stitch it to the top of your urethra. The ureters are stitched into this new bladder so that urine drains directly into it from the kidneys. It is then possible for most people to learn how to pass urine through the urethra, rather than needing to wear a stoma bag or use a catheter.

The new bladder is emptied by flexing your abdominal muscles, but you will need to remember to empty it, as you will have lost the nerves that tell you when your bladder is full. Sometimes this nerve loss can lead to incontinence (leaking of urine), especially when you are asleep. Twenty to 30% of patients (2 or 3 out of every 10 people) will have some incontinence.

Bladder reconstruction is not suitable for everyone. Your doctor can advise whether it is possible for you to have bladder reconstruction. Most people are able to learn how to pass urine through the urethra. However, some people find it difficult and need to drain the urine regularly by passing a catheter into the urethra.

Continent urinary diversion

Sometimes, a continent urinary diversion can be made. During an operation a pouch is made in the abdomen, using a piece of bowel. The ureters are attached to the piece of bowel. The pouch holds the urine. The end of the piece of bowel is brought out onto the surface of the abdomen to create a stoma. A small plastic tube (catheter) can be passed through the stoma into the pouch about 4 or 5 times a day to drain the urine. This is called self-catheterisation. Although this can feel daunting at first, most people manage very well with self-catheterisation and care of their stoma. The main advantage of this type of surgery is that it is not necessary to wear a stoma bag.

Uro-rectal conduit

It is sometimes possible to divert the urine into the rectum so that both the urine and the stool are passed through the rectum (back passage). If this is done the person does not need a urostomy bag, or to pass a catheter to drain the urine.

After surgery

After your operation you will have a drip (intravenous infusion) going into a vein in your arm. Depending on the operation you have had, you may have one or more wounds, which may have small tubes (drains) coming out of them to drain any excess fluid that is produced. After your operation you may have some pain or discomfort which may continue for a few weeks, particularly when you are walking around. Regular painkillers should help to ease this, so let the staff on the ward know if you are still in pain.

You will probably be ready to go home from 7 to 10 days after your operation. Arrangements can be made for a district nurse to visit you at home, and if you have any problems you should contact your doctor as soon as possible.

Change in body appearance

You may be worried about adapting to changes in how your body looks, and how you may feel about your body after any surgery. This is a normal reaction, as over the years we all develop an image in our minds about what our bodies look like. Although we may not be completely satisfied with that image, most people are used to the way they see themselves. It can be upsetting to have that image changed permanently by surgery, especially if you have a stoma.

You may also be very concerned about the effect that the surgery may have on your personal relationships and lifestyle. You may be worried about rejection, continuing to have sex with your partner, or starting a new relationship. Many people find that once they have found the courage to talk about their fears with a partner, their minds are set at ease. Just talking about your feelings can help to clarify your fears and also gives other people the chance to understand how you are feeling. You can talk to your doctor or nurse about your fears and support organisations can also give support.

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