Overview
Definition:
Radical cystectomy is the surgical removal of the entire bladder, seminal vesicles, prostate, and vas deferens in men, and the uterus, cervix, ovaries, fallopian tubes, and anterior vaginal wall in women
It is typically performed for invasive bladder cancer, and involves pelvic lymphadenectomy and urinary diversion.
Epidemiology:
Muscle-invasive bladder cancer (MIBC) accounts for approximately 25% of all bladder cancers
Incidence increases with age, with a higher prevalence in males
Smoking is the leading risk factor
Radical cystectomy is the gold standard surgical treatment for eligible patients with MIBC.
Clinical Significance:
Radical cystectomy is a major oncologic surgery with significant implications for patient morbidity, mortality, and quality of life
Understanding the perioperative surgical role is crucial for residents preparing for DNB and NEET SS examinations, as it encompasses pre-operative optimization, meticulous surgical technique, and comprehensive post-operative care.
Indications
Absolute Indications:
T2-T4a urothelial carcinoma of the bladder unresponsive to or progressing after intravesical therapy
Carcinoma in situ (CIS) refractory to conservative management
Salvage surgery for bladder cancer recurrence after other primary treatments.
Relative Indications:
Selected cases of T1 high-grade bladder cancer with aggressive features (e.g., lymphovascular invasion)
Persistent or recurrent hematuria with suspicious bladder lesions not amenable to TURBT or intravesical therapy
Certain pelvic malignancies extending into the bladder.
Contraindications:
Distant metastatic disease
Unfit for major surgery due to severe comorbidities
Poor performance status (ECOG 3-4)
Patient refusal of surgery or urinary diversion.
Preoperative Preparation
Patient Evaluation:
Comprehensive history and physical examination
Assessment of comorbidities (cardiac, pulmonary, renal)
Nutritional status evaluation
Smoking cessation counseling
Thorough explanation of surgical procedure, risks, benefits, and alternatives, including urinary diversion options.
Staging Investigations:
Cystoscopy with biopsy
Computed tomography (CT) scan of abdomen and pelvis with contrast for local staging and nodal assessment
Chest X-ray or CT chest for distant metastasis
Bone scan if indicated
MRI pelvis for detailed local staging, especially for T3/T4 tumors.
Optimizing Patient Health:
Management of anemia and nutritional deficiencies
Optimization of glycemic control in diabetic patients
Antibiotic prophylaxis (e.g., fluoroquinolones, cephalosporins) based on institutional protocols
Deep vein thrombosis (DVT) prophylaxis with heparin and/or compression devices.
Urinary Diversion Planning:
Discussion and choice of urinary diversion (ileal conduit, continent cutaneous diversion, orthotopic neobladder) based on patient factors (age, comorbidities, manual dexterity, cognitive function, sex)
Patient and family education regarding stoma care or voiding mechanics.
Surgical Management
Surgical Approach:
Open radical cystectomy via midline or Pfannenstiel incision
Minimally invasive approaches including laparoscopic or robotic-assisted radical cystectomy (RARC), which offer potential benefits in reduced blood loss and faster recovery but require specialized expertise.
Procedure Steps:
Pelvic lymphadenectomy (standard template or extended template)
Mobilization of the bladder, prostate/uterus, seminal vesicles/vagina
Ureteral transection and isolation
Division of bladder pedicles and vascular attachments
Excision of the bladder en bloc with surrounding organs
Specimen retrieval
Urinary diversion construction (e.g., Bricker ileal conduit, Studer neobladder).
Lymphadenectomy Extent:
Standard template lymphadenectomy typically includes obturator, external iliac, and internal iliac lymph nodes
Extended template lymphadenectomy may include presacral and common iliac nodes, often considered in cases of positive lymph nodes or high-risk disease, but the oncologic benefit and optimal extent are subjects of ongoing research.
Urinary Diversion Techniques:
Ileal conduit: A segment of ileum is isolated and used to create a conduit to the skin surface for urine collection via a stoma bag
Continent cutaneous diversion: Uses intestinal segments to create a continent reservoir with a stoma, requiring intermittent catheterization
Orthotopic neobladder: A new bladder is constructed from intestinal segments and anastomosed to the urethra, allowing for voluntary voiding.
Postoperative Care
Immediate Postoperative Period:
Hemodynamic monitoring
Pain management (epidural, PCA, IV analgesics)
Fluid management and electrolyte balance
Nasogastric tube if indicated
Urinary catheter drainage for initial post-op period or monitoring of diversion
Early mobilization to prevent DVT and pulmonary complications.
Urinary Diversion Management:
Stoma site assessment for skin integrity and appliance adherence
Education on stoma care for ileal conduits or continent diversions
Monitoring for signs of pouch leakage, infection, or dehydration
Management of potential complications such as ureteroileal anastomotic leak or stricture.
Nutritional Support:
Early enteral feeding as tolerated
Adequate protein and caloric intake to promote wound healing
Management of potential malabsorption with intestinal diversions
Hydration is critical for all diversion types to prevent stasis and infection.
Complication Monitoring:
Vigilant monitoring for surgical site infection, anastomotic leaks (bowel, ureteral), ileus, DVT, pulmonary embolism, wound dehiscence, electrolyte imbalances, and urinary tract infections
Regular laboratory monitoring (CBC, electrolytes, renal function) and imaging as needed.
Complications
Early Complications:
Hemorrhage requiring transfusion or reoperation
Wound infection or dehiscence
Pelvic abscess
Ureteroenteric anastomotic leak or stricture
Ileus
DVT/Pulmonary embolism
Myocardial infarction
Stroke
Acute kidney injury.
Late Complications:
Stoma-related issues: retraction, stenosis, hernia, skin irritation
Ureteral stricture leading to hydronephrosis
Bladder outlet obstruction or incontinence with neobladder
Vitamin B12 deficiency and metabolic acidosis with ileal conduits
Bowel obstruction due to adhesions
Incisional hernia.
Prevention Strategies:
Meticulous surgical technique, appropriate antibiotic prophylaxis, early mobilization, DVT prophylaxis, vigilant monitoring, and patient education are key
Careful patient selection and optimization preoperatively are paramount
Use of stapled anastomoses can reduce leak rates.
Key Points
Exam Focus:
Radical cystectomy is indicated for MIBC
Perioperative management involves optimization, meticulous surgery, and specialized diversion care
Robotic-assisted surgery is increasingly common
Common complications include leaks, infections, and stoma issues.
Clinical Pearls:
Always consider the patient's overall health and functional status when discussing urinary diversion options
Early mobilization and adequate hydration are critical postoperatively
Involve stoma nurses early for patient education and support.
Common Mistakes:
Inadequate preoperative assessment or staging
Failure to optimize comorbidities
Incomplete lymphadenectomy
Poor stoma siting or management
Underestimating the risk of perioperative complications
Lack of thorough post-operative monitoring and follow-up for diversion-specific issues.