Classic surgery with reconstruction
Through a midline incision, a cystoprostatectomy with extended lymphadenectomy is performed, then a reservoir is formed from 50–60 cm of the ileum 20–25 cm from the ileocecal angle: orthotopic (connected to the urethra) with a intact urethra and the absence of a tumor in it, or a conduit with a urostomy. Open access facilitates the intestinal stage and anastomoses, and therefore remains important in difficult cases. Recovery 2–3 months; neocystis requires training, conduit requires stoma care; Monitor electrolytes and B12 for life.
When is the bladder removed?
- muscle-invasive bladder cancer (T2–T4a) without distant metastases is the mainstay of cure, often after neoadjuvant chemotherapy;
- high-risk non-invasive cancer that recurs after BCG therapy, carcinoma in situ that does not respond to treatment;
- extensive tumors that cannot be removed endoscopically, intractable bleeding;
- tumors of neighboring organs with germination into the bladder (cancer of the cervix, rectum - with the appropriate specialists).
Urine diversion options
After the bladder is removed, the urine needs a new path. Ureterocutaneostomy - the ureters are exposed to the skin of the abdomen with urostomy bags; the fastest and most gentle option for weakened patients. Bricker conduit - a segment of the ileum connects the ureters to one stoma on the abdomen (reliable, standard). Orthotopic reservoir (neocystis) - a new bladder is formed from 50–60 cm of intestine, sewn to the urethra: the patient urinates naturally, without a stoma, with a preserved urethra and the absence of a tumor in it. The choice depends on the stage, age, renal function and wishes of the patient.
Recovery and life after
The operation is large: 10–14 days in the hospital, 2–3 months of recovery, training in stoma care or neocystis training (urination by the hour, bedwetting in the first months). The intestinal reservoir requires monitoring of electrolytes and vitamin B12. Five-year survival rate for a localized tumor is 60–80%, for lymph node involvement — 30–40%; observation with MSCT every 3–6 months.
