Bladder cancer is the second most common cancer after prostate cancer, and is usually manifested by blood in the urine. Removing the bladder can help cure bladder cancer when the disease has penetrated beyond the bladder lining into the muscle of the bladder wall. After the resection, the surgeon reconstructs a bladder, typically of small bowel tissue.  

When should the bladder be removed?

When the patient undergoes primary diagnostic trans urethral resection of bladder tumor (TURBT) surgery, and the pathological results show that cancer has penetrated the bladder muscle, the entire bladder should be removed. This is recommended because, at this stage, the disease is multifocal, tending to return elsewhere in the bladder. In addition, data shows that when cancer has penetrated the muscle, metastases may occur in up to 50% of cases.

When the tumor spreads, it can manifest in numerous ways: obstruction of the ureters, enlarged lymph nodes in the pelvis, or metastases to the liver or bones. Therefore, before surgery to potentially remove the bladder, the patient will undergo CT imaging of the abdomen, pelvis, and chest, and a bone scan will be performed to rule out metastases. If a metastasis is found, the patient is referred to an oncologist for chemotherapy.
 

Preparation before surgery

A specialist Assuta Hospital urologist performs an evaluation before the patient undergoes the bladder resection and reconstruction. During the evaluation, the surgeon determines the type of reconstruction to be performed based on the disease condition, the surgeon's assessment, and the patient's preferences. The patient undergoes a pre-surgical evaluation with an anesthesiologist and also fasts according to surgeon instructions.

Surgery objectives

The objectives of the bladder resection surgery are as follows:

• Remove the bladder cancer along with a margin of healthy tissue to make sure the cancer has been removed in its entirety
• Remove the pelvic lymph nodes (for diagnosis and possibly for treatment)
• Divert the urine from the ureters, while trying to preserving sexual function
• Diversion options include: running the diversion from the small intestine to outside the abdominal wall or creating a newly reconstructed urine bladder made from intestinal tissue, which diverts to a reservoir with the option to drain via a catheter

About the surgery

The operation is performed under general anesthesia. The surgeon makes an incision longitudinally along the midline, from the pelvis to above the navel.

For men, the bladder, prostate, seminal vesicles and pelvic lymph nodes are removed. In men with a normal erection before surgery, the Assuta surgeons try to preserve the erectile nerves.

For women, physicians recommend removing the uterus and ovaries because the tumor commonly spreads to these organs. It is usually possible to preserve the vagina so that the woman can continue having sexual intercourse.

After the bladder resection, it is necessary to divert the urine from the kidneys to drain outside the body. The usual method of diverting urine is by connecting the ureters to a pouch made from a section of small intestine removed from the patient’s gastrointestinal tract.

The surgeon attaches the ureters to one end of the pouch while the other end of the pouch is directed outside the lower abdomen. This round or elliptical, pinkish-red opening in the abdomen to divert waste out of the body is called a stoma.
 

Urinary elimination after the surgery

After the surgery, urine will be excreted through the stoma into a special plastic bag designed to attach to the stoma.

Tubes (stents) that were inserted into each ureter will exit the stoma and drain the urine into the bag.

Immediately after surgery, the stoma can appear swollen, but it will shrink to its final size within a few weeks. The stoma will secrete mucus (sticky white matter), which is normal. As the patient recovers, prepares for hospital discharge, and feels ready to learn about urinary elimination, the care team will gradually provide instruction on taking care of the stoma independently.

Potential complications from resection of the bladder

Bladder resection is a major, complex operation, requiring several weeks’ recovery. Surgery requires the experience and accuracy of an expert surgeon to completely remove the tumor along with a small margin of non-cancerous tissue, while preventing possible complications and promoting the patient’s post-surgery function, including optimal control of urinary function and the ability to maintain an erection.